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.


name: Teach patient or significant other to care for airway (consistent with ability).


name: Include airway care, maintenance in discharge plan.


name: Note centimeter level of endotracheal tube at lip level.


name: Provide care for tracheostomy or endotracheal tube.


name: Change oral endotracheal tube side to side.


name: Maintain endotracheal tube or tracheostomy cuff pressure greater than 14 millimeters mercury but less than 20 millimeters mercury.


name: Keep spare tracheostomy tube at bedside.


name: Extubate patient as indicated or ordered.


name: Provide care related to mechanical ventilation.


name: Monitor ventilator settings, function, alarm system.


name: Utilize CPAP mechanical ventilation as indicated or ordered.


name: Follow protocol for management of patient with continuous pulse oximetry.


name: Follow protocol for management of the patient requiring oxygen therapy.


name: Follow the protocol for the infant in an oxygen hood.


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


name: Follow protocol for care of the patient experiencing pleural effusion.


name: Follow protocol for care of the patient with inhalation injury.


name: Follow protocol for pulmonary care of the spinal cord injured patient in rehabilitation.


name: Follow protocol for management of patient in respiratory distress.


name: Follow protocol for management of the patient with acute bronchospasm.


name: Follow protocol for management of the patient with an artificial airway.


name: Follow protocol for management of patient with an endotracheal tube.


name: Follow protocol for management of the patient with mechanical ventilation.


name: Follow protocol for management of the critically ill patient with mechanical ventilation (acute).


name: Follow protocol for management of the non-critically ill patient with mechanical ventilation (non-acute).


name: Follow protocol for management of the patient with CPAP mechanical ventilation.


name: Follow protocol for management of the patient receiving nocturnal nasal positive pressure ventilation (NNPPV).


name: Follow protocol for weaning the patient from mechanical ventilation.


name: Follow protocol for discharge planning of ventilator dependent patients.


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


name: Follow the protocol for the patient having thoracic surgery.


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


name: Follow protocol for care of pneumonectomy patient.


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


name: Follow protocol for care of the pre and post lung biopsy patient having undergone lung transplantation.


name: Follow protocol for care of the patient undergoing bronchoscopy at the bedside.


name: Follow protocol for care of the pediatric out-patient post-bronchoscopy in the Surgical Admission Suite.


name: Implement patient education plan for chronic obstructive pulmonary disease (COPD).


name: Implement patient education plan for patient with asthma.


name: Implement patient education plan for cystic fibrosis.


name: Implement patient education plan for bronchoscopy.


name: Implement patient education plan for tracheostomy.


name: Implement patient education plan for inhalation injury.


name: Implement patient education plan for pediatric patient with apnea monitor.


name: Implement patient education plan for infant with bronchopulmonary dysplasia.


name: Implement patient education plan for patient with nose and sinus surgery.


name: Role of Family Relationships in Patient Care


name: Contact family to gather information and establish rapport.


name: Allow family to spend time with patient.


name: Involve family in patient's care and teaching.


name: Encourage family activities as much as possible.


name: Address sexuality concerns of patient or significant other.


name: Assess factors surrounding altered sexuality.


name: Provide appropriate educational or counseling resources related to sexuality: such as sexually transmitted diseases, disability.


name: Assess communication abilities and limitations.


name: Provide simple, direct commands, demonstrations, gestures.


name: Assist communication by sentence completion.


name: Provide supplies to facilitate communication.


name: Label intercom system at nurses station to note patient's inability to speak.


name: Promote restoration of verbal communication.


name: Consult speech therapist; encourage patient's participation in speech therapy.


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


name: Follow protocol for management of the patient with expressive aphasia.


name: Implement patient education plan for safer sex.


name: Assess for conditions which pose a risk to safety.


name: Assess for the presence of sensory deficits.


name: Examine infant or child for signs and symptoms of previous injury.


name: Assess patient and family knowledge of safety precautions.


name: Protect patient from injury to self or others.


name: Supervise patient closely or conduct security checks as needed (such as at all times, while smoking, etc.)


name: Institute precautions as needed (such as, seizure, suicide, etc.).


name: Assess need for additional staff for clinical emergencies (such as, Call to Assist, Code, etc.).


name: Restrain or seclude patient, using least restrictive means or setting, as ordered.


name: Apply protective devices as needed, such as, helmet, splints, arm sling, etc.


name: Remove from environment sharp or blunt objects that could be used to injure patient or others.


name: Instruct patient or family in regard to safety issues or restrictions.


name: Post sign regarding safety precautions at patient bedside as needed.


name: Identify patient by an armband that includes patient name.


name: Feed or assist as needed for all meals; monitor for problems related to swallowing difficulties.


name: Observe and document difficulty swallowing.


name: Consult speech therapy for difficulties swallowing.


name: Position after feeding to minimize risk of aspiration from regurgitation.


name: Dispose of needles and syringes according to policy.


name: Provide special nurse or doctor to transport patient as needed.


name: Use appropriate safety precautions for infants and children.


name: Use only manual beds in the pediatric unit.


name: Keep sharp objects out of children's reach at all times.


name: Maintain supervision of children in the play room.


name: Use bubble tops for cribs of active toddlers.


name: Close and lock all windows on the pediatric units.


name: Do not allow parents to prop bottle when the infant is in the crib.


name: Orient patient to nurse call system; keep bell in reach at all times.


name: Orient patient or family to hospital and or room environment.


name: Orient patient or family to over-bed lighting system.


name: Orient patient or family to bed controls.


name: Orient patient or family to use of kitchen facilities.


name: Place objects patient needs (bedside table, light, TV, telephone, etc.) in easy reach, according to patient's positioning needs.


name: Assure use of non-slip slippers when patient is out of bed.


name: Use enough personnel when moving patient.


name: Keep patient's bed in low position when unattended.


name: Maintain side rails according to policy.


name: Use precautions with equipment according to policy.


name: Use only electrical devices properly grounded and approved by the responsible department (Physical Plant, Engineering Services, etc.)


name: Assess and report electrical hazards to the responsible department (Physical Plant, Engineering Services, etc.)


name: Keep at bedside special equipment needed for safety.


name: Maintain readiness and accessibility of emergency equipment.


name: Follow protocol for prevention of suicide.


name: Follow protocol for the management of patients at high risk for falls.


name: Follow protocol for management of the psychiatric patient at risk of falling.


name: Follow protocol for patient in seclusion.


name: Follow protocol for the management of the patient in restraints.


name: Follow protocol for the management of allergic reactions.


name: Implement patient education plan for drug overdose.


name: Implement patient education plan for orientation of patient or family.


name: Assess ability to perform activities of daily living or self-care.


name: Assess impact of sensory or motor deficits on ability to perform ADL's.


name: Promotion of Activities of Daily Living (ADL's)


name: Assist patient to resume activities of daily living (ADL's).


name: Provide ample time for patient to do self-care activities.


name: Provide instruction for effective oral hygiene.


name: Provide instruction for effective personal hygiene.


name: Assist with adapting activities of daily living (ADL's) to sensory or motor deficits.


name: Assist as needed with basic hygiene, bathing, dressing.


name: Assess for, and obtain occupational therapy consult.


name: Follow recommendations from occupational therapist related to activities of daily living (ADL's).


name: Follow protocol for the patient unable to perform activities of daily living (ADL's).


name: Follow protocol for management of psychiatric patient unable to perform activities of daily living (ADL's).


name: Implement patient education plan for self-catheterization.


name: Promote patient's self-esteem by establishing trusting relationships.


name: Assist patient in acceptance of altered body image.


name: Encourage patient and family to look at altered body parts.


name: Be truthful and convey acceptance of altered body appearance.


name: Encourage patient and family to discuss feelings related to altered appearance.


name: Follow protocol for care of the patient experiencing acute body image disturbance.


name: Assess patient's beliefs and attitudes about pain and pain relief.


name: Assess and identify sources of patient discomfort.


name: Administer medications to increase comfort.


name: Premedicate patient for comfort related to procedure or therapy.


name: Utilize non-pharmacological comfort measures.


name: Teach patient or significant other about pain, pain relief.


name: Work with patient to develop a pain management plan.


name: Include pain management in discharge planning.


name: Provide appropriate visual stimulation for patient with limited visual field.


name: Position self within patient's view to talk, and encourage others to do so.


name: Place objects of interest within patient's view.


name: Assure appropriate sensory stimulation; auditory, visual, tactile, vestibular, olfactory.


name: Assist patient in avoiding over-stimulation.


name: Provide care related to sensory or motor deficits.


name: Monitor symmetry of sensory or motor function of extremities.


name: Follow protocol for management of the patient with acute pain.


name: Implement patient education plan for patient taking oral pain medication for pain control.


name: Implement patient education plan for patient with outpatient cataract surgery.


name: Identify potential risk factors for skin breakdown.


name: Inspect skin of entire body; document significant changes.


name: Inspect skin pressure points before and after sitting and with turning; document significant changes.


name: Assess perianal area for skin breakdown.


name: Determine percentage and depth of burns by means of clinical appearance.


name: Notify physician of changes in skin integrity.


name: Assess patient or family knowledge of risk factors and prevention measures related to skin breakdown.


name: Provide device to minimize skin breakdown.


name: Institute topical therapy as needed or ordered to maintain or restore skin integrity.


name: Administer Lacrilube or artificial tears as indicated.


name: Avoid excessive use of tape; use duoderm or Montgomery straps as needed.


name: Assess effectiveness of topical therapy and modify care as indicated.


name: Have patient wear shoes for specified times each day.


name: Instruct patient or family regarding prevention and treatment of skin breakdown.


name: Instruct patient or family on risk factors for skin breakdown.


name: Instruct patient or family on rationale of pressure relief.


name: Instruct patient or family on measures to reduce shearing, friction and moisture on patient's skin.


name: Note dimensions and depth of pressure ulcer.


name: Note presence of granulation tissue or epithelialization.


name: Note presence or absence of sinus tract formation.


name: Note presence or absence of necrotic tissue, slough, eschar.


name: Promote maintenance or restoration of integrity of oral mucosa.


name: Administer oral care, with adjustments to patient needs.


name: Assess for potential or actual stomatitis.


name: Note oral cavity condition or potential for alteration and any changes that may occur.


name: If bleeding occurs with brushing teeth or flossing gums, discontinue, and use a soft cleanser.


name: Use soft nylon bristle toothbrush or toothette which is soaked in warm water before use and rinsed in warm water during use.


name: Keep dentures out except at meal time, as tolerated.


name: Assess condition of wound, surrounding tissue.


name: Observe for and report any swelling, hematoma, or fistula.


name: Observe and document appearance of skin or muscle flap.


name: Instruct patient to notify nurse if any bleeding occurs.


name: Observe for leakage at suture line or Kyle leak.


name: Document burn or wound appearance and notify physician of any changes.


name: Obtain Polaroid photograph of wounds and place in chart.


name: Prevent or detect early signs of infection to surgical incision or wound.


name: Assess incision or wound for redness, swelling, drainage.


name: Treat impending infection early and appropriately.


name: Notify physician of signs of impending infection.


name: Monitor and cleanse all drainage tubes and catheter sites.


name: Provide appropriate treatment for each wound stage.


name: If no drainage to surgical incision, leave open to air; if drainage, replace dry sterile dressing.


name: Cleanse incision or wound with soap and water.


name: Cleanse incision or wound with recommended solution.


name: Demonstrate methods of incisional support.


name: Assess for compliance with patch and shield to operative eye.


name: Provide specific care for electrical injury or chemical burn.


name: Remove all clothing, brush away solid material.


name: Flush exposed skin with copious amounts of cool water, use eyelid retractors if needed, and utilize appropriate neutralizing agent if indicated.


name: Debride loose tissue with sterile instruments during irrigation.


name: Dress with pluronic on coarse mesh gauze (fine mesh to face, hands, feet, and perineum).


name: Leave donor site wrapped in Xeroform for 24 hours post surgery, then remove outer dressing.


name: Leave Biofrane site wrapped for 24 hours.


name: Allow Xeroform or Biofrane to fall off on its own, then keep skin moist with Eutracream.


name: Check splints for proper fit; readjust as necessary.


name: Keep splints on at all times except during exercise, eating, or bathing.


name: Debride wounds and wash with Shurcleanse.


name: Apply topical anti-microbial agent and gauze as indicated and dress occlusively.


name: Wrap new graft with Vaseline gauze for 2-3 days post graft takedown.


name: Clean graft edges with daily gentle debridement of nonadhered skin.


name: Avoid mechanical and chemical trauma to freshly grafted areas.


name: Assess trauma to torso; chest and abdomen.


name: Monitor for signs, symptoms of gastrointestinal bleeding.


name: Monitor all stools, emesis, or gastric drainage for guaiac.


name: Clean around nasal balloon and check for any areas of pressure.


name: Follow protocol for care of a patient on a specialty bed.


name: Follow protocol for the management of the patient with a Jackson-Pratt drain.


name: Follow protocol for management of the patient with a drainage tube (T-tube).


name: Follow protocol for management of the patient with an alteration in skin integrity.


name: Follow protocol for the adult patient at risk for developing skin impairment due to pressure or irritation.


name: Follow protocol for the pediatric patient at risk for developing skin impairment due to pressure or irritation.


name: Follow protocol for management of the patient with an intravenous extravasation.


name: Follow protocol for management of the patient with an alteration in skin integrity requiring a skin graft.


name: Follow protocol for patient with split-thickness skin graft (STSG) after takedown.


name: Follow protocol for care of the patient with a muscle or skin graft.


name: Follow the protocol for the pediatric patient with an Abdominal Silo.


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


name: Follow protocol for skin management for the spinal cord injured patient in rehabilitation.


name: Follow protocol for stump care management: Patient with prosthesis fitting and gait training (PFGT) or Rehabilitation Phase.


name: Follow protocol for stump care management: Patient with prosthesis fitting and training (upper extremity) or Rehabilitation Phase.


name: Implement patient education plan for patient at high risk for impaired skin integrity.


name: Implement patient education plan for patients with potential or actual alteration in tissue integrity.


name: Implement patient education plan for repair of decubitus ulcer of sacrum, trochanter, or ischium.


name: Implement patient education plan for patient with wound care or dressing changes.


name: Implement patient education plan for the patient with a drainage tube (T- tube) or a Jackson-Pratt drain.


name: Implement patient education plan for the patient with a skin flap.


name: Implement patient education plan for the patient with a burn injury.


name: Implement patient education plan for wound care at home.


name: Implement patient education plan for patient with breast biopsy.


name: Monitor tissue perfusion of extremities and report changes as indicated.


name: Assess and monitor skin color and temperature.


name: Monitor pulses of affected extremities utilizing Doppler as needed.


name: Monitor and record SaO2 of circumferentially burned extremities.


name: Notify physician of SaO2 are less than 90%, decreasing or absent pulses, or increasingly sluggish capillary refill.


name: Discuss with physician possible need for escharotomy or fasciotomy.


name: Prepare patient and family for escharotomy or fasciotomy if indicated.


name: Monitor for edema secondary to increased cellular permeability.


name: Assess neurovascular status; color, temperature, movement and sensation.


name: Perform neurovascular checks to upper extremities.


name: Perform neurovascular checks to lower extremities.


name: Perform neurovascular checks to affected extremity.


name: Teach patient and family to perform neurovascular checks.


name: Institute thermal therapy as ordered or indicated.


name: Apply ice or cool compress as ordered or indicated.


name: Apply moist or dry heat as ordered or indicated.


name: Assess tissue perfusion of transplanted kidney.


name: Monitor urine output hourly while Foley catheter is in place.


name: Follow protocol for the patient requiring close extremity observation due to neurovascular impairment from injury, disease or surgery.


name: Monitor for previous and current patterns of voiding.


name: Monitor frequency and volume of voiding.


name: Promote and assist with return to normal urinary function.


name: Provide access to bathroom or bedpan or urinal.


name: Cleanse catheter and surrounding tissues.


name: Teach patient and family care related to Foley catheter.


name: Follow generic bladder management protocol related to spinal cord injured persons in rehabilitation.


name: Follow protocol for management of the patient requiring a Foley catheter.


name: Follow protocol for management of the patient requiring a Texas catheter.


name: Follow protocol for management of patients with suprapubic, ureteral or nephrotomy catheters.


name: Follow protocol for bladder management (not related to spinal cord injury).


name: Implement patient education plan for patient with radical retropubic prostatectomy.


name: Implement patient education plan for patient with suprapubic catheter placement.


name: Implement patient education plan for pediatric patient with suprapubic catheter placement.


name: Implement patient education plan for pediatric patient with hypospadias repair.


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


name: PRE- OR INTRA- OR POST-PROCEDURE COMPONENT


name: Perform multi-system nursing assessment.


name: Conduct complex admission screening or assessment.


name: Conduct complex discharge screening or assessment.


name: Perform an initial and ongoing assessment; pre-, intra-, and post-procedure or surgery.


name: Assess the patient's response to interventions and adjust care accordingly.


name: Consult physician or service as indicated.


name: Teach patient or significant other(s) about procedure using appropriate means and media.


name: Provide educational materials: handouts, booklets, tapes, etc.


name: Emphasize importance of patient's or significant other's participation.


name: Teach what to expect before, during, after procedure.


name: Teach skills, use of equipment related to procedure.


name: Assess learning; reinforce teaching as needed.


name: Encourage questions; provide clear answers.


name: Educate patient and or family related to expected results.


name: Prepare patient for procedure, with respect for patient rights.


name: Assess patient's knowledge and expectations of procedure.


name: Assess patient's experience with surgery, anesthesia, this procedure.


name: Explain and ensure dietary restrictions as ordered.


name: Administer medications, enemas, skin preparation, intravenous infusion fluids, etc. as ordered.


name: Complete pre-operative or pre-procedure checklist.


name: Facilitate safety and effectiveness of procedures.


name: Collaborate with physician as needed: Assist, consult, report adverse signs and symptoms, obtain orders.


name: Prepare and monitor operating or procedure room environment.


name: Maintain lines, tubes, catheters used to administer substances to patient or to monitor patient condition.


name: Provide care related to patient transfer or transfer patient.


name: Monitor safety and effectiveness of regional anesthesia.


name: Assess patient vital signs before, during and after administration of regional anesthesia.


name: Observe for adverse effects of anesthesia, report findings.


name: Assess effect of blood patch on pain of spinal headache.


name: Follow the protocol for the preadmission assessment center visit.


name: Follow protocol for care of the patient who is having a surgical procedure (preoperative).


name: Follow protocol for care of the pre-operative thoracic cardiovascular surgery (TCV) patient.


name: Follow protocol for admission of a patient to the surgical admission suite (SAS) and Breast Center. (breast biopsy)


name: Follow the interdependent protocol and patient care plan for the adult pre operative and general surgery patient.


name: Follow protocol for care of the intraoperative patient.


name: Follow protocol for care of the patient who had a surgical procedure (postoperative).


name: Follow protocol for the patient with monitored conscious sedation for minimally depressing the level of consciousness while providing analgesia for procedure.


name: Follow protocol for patient who has had monitored sedation.


name: Follow the protocol for the management of the patient in a Post Anesthesia Care Unit.


name: Follow protocol for post anesthesia patient (general).


name: Follow protocol for the patient who has had regional anesthesia.


name: Follow the protocol for the patient with an epidural catheter.


name: Follow the protocol for the patient who is receiving intrathecal anesthesia.


name: Implement patient education plan for pre-operative teaching.


name: Implement patient education plan for pre-operative ambulatory or outpatient surgery patients.


name: Implement patient education plan for generic Emergency Department patients.


name: Implement patient education plan for admitting generic Emergency Department patients.


name: Implement patient education plan for discharging generic Emergency Department patients.


name: Mobility, exercise, and activity will increase to optimal or return to baseline.


name: Patient's activity tolerance will increase or progress.


name: Patient will conserve energy and avoid fatigue.


name: Patient will utilize orthotic or assistive devices correctly to optimize independence in activity.


name: Patient will attend school as appropriate, when able.


name: Musculoskeletal function will be maintained or restored at best feasible level.


name: Muscle tone will be maintained or restored.


name: Range of motion will be maintained or restored to the level prevailing prior to current illness, injury, or surgery.


name: Patient will maintain correct body alignment.


name: Patient will maintain required positioning and comply with activity restrictions.


name: Patient will recall and follow hip precautions.


name: Immobilization requiring the use of devices or traction will be maintained as ordered.


name: Patient will avoid complications or injury associated with immobility.


name: Patient will acquire mobility via wheelchair.


name: Patient will tolerate progressively extended periods of mobilization to wheelchair without orthostatic hypotension, skin impairments, excessive fatigue, or intolerable discomfort.


name: Patient will be functionally or verbally independent in wheelchair preparation, transfers, and mobilization on the unit.


name: Patient will regain or maintain or progress toward independence in ambulation.


name: Patient will progress toward ambulation with or without assistive devices on level surfaces on the unit.


name: Patient will experience adequate rest and sleep.


name: Patient will demonstrate satisfaction or comfort with level of sleep or rest achieved.


name: Patient will experience uninterrupted 60-90 minute sleep cycles to allow for adequate rest.


name: Patient will incorporate rest periods into daily activity.


name: Patient will regain pre-hospitalization sleep patterns.


name: Normal bowel elimination pattern will be maintained or restored


name: Patient will demonstrate age-appropriate stooling patterns.


name: Patient will resume or maintain optimal gastric motility or pass flatus.


name: Patient will maintain or return to best feasible bowel function within constraints of the disease or surgical procedure.


name: Fluid loss through stools will not be excessive.


name: Bowel incontinence will be rare or absent.


name: Abdominal distension will be minimal or absent.


name: The spinal cord injured (SCI) patient will develop safe and effective bowel management routines (which will assure adequate emptying of the colon, minimize incontinent emptying of the bowel, avoid constipation, avoid mucosal irritation or injury, and avoid dysreflexic episodes).


name: Patient will maintain optimal gastrointestinal functioning.


name: Patient will experience adequate and comfortable digestive processes.


name: Patient will experience minimal nausea and vomiting.


name: Patient will exhibit evidence of adequate cardiac output.


name: Fetal heart rate will remain within normal patterns.


name: Patient will develop optimal cardiac tolerance.


name: Patient will maintain or achieve hemodynamic stability.


name: Cardiac electrophysiology will return to normal.


name: Patient will demonstrate resolution of electrocardiogram (EKG, ECG) changes.


name: Normal sinus rhythm will be maintained or restored.


name: Patency of vascular system will be maintained.


name: Patient will remain free of pulmonary emboli.


name: Patient will remain free of deep vein thrombosis.


name: Patient will experience minimal circulatory complications or sequelae.


name: Chest X-ray will show no evidence of pulmonary edema.