ࡱ>  gbjbjR|R| 4n00_ t.0 Hhhh-------$/V2f..h..h--h|p5&.$-D.0t.2w2`2&..t.2 :  HYPERLINK "http://lms.elsevierperformancemanager.com/ContentArea/NursingSkills/GetNursingSkillsDetails?skillid=ZZ_003&skillkeyid=639&searchTerm=medication&searchContext=nursingskills" CheckList Alert It is the policy of the hospital that specific IV medications are given on specific units listed in the Reference Sheet-see Quick Sheet or Extended Text. Units listed on the Reference Sheet are considered able to take Stepdown patients and the staff working on these units have received special training to deliver these medications. If a unit is not listed on the Reference Sheet, the medication cannot be administered on that unit. All of the medications listed in the Reference Sheet may be given in the Intensive Care Units. All IV medications noted in this policy will be administered via the Alaris IV pump using the Medication Safety System Guardrails Software. Bypassing the dose-checking component of the IV pump technology is discouraged to assure patient safety. For more information specific to Deaconess Hospital, see extended text.  Step Down/Telemetry Units and Allowed Medications Reference Sheet Caution - Read Carefully! The units below are listed because they are Step-Downand/or TelemetryUnits and their nursing staff have received additional training and competencies to administer these medications. If a unit is not listed in the table below, the medication cannot be administered on that unit. All ICUs may give medications listed in Reference Sheet. MedicationCVCC/ CVSS/GW Tele StepdownGW Short StayMRCC/ GW Med TeleNTCASMCCPRECAUTIONS/ MONITORINGEXCEPTIONSAbciximab (Reopro)YESYESYESNONOINITIATE DOUBLE CHECK PER P&P 40-04Activase (tPa)NONONONONOINITIATE DOUBLE CHECK PER P&P 40-04NOT APPLICABLE TO CATHFLO.AdenosineYESYESYESYESNONOT APPLICABLE TO CODE SITUATIONS. REFER TO P&P 40-39.Alcohol 10%NONONONONOMONITOR FOR EXTRAVASATION IF USING PERIPHERAL ACCESS. CENTRAL LINE ACCESS MUST BE CONSIDERED AS SOON AS POSSIBLE.Alprostadil (Prostin VR)NONONONONOAmiodaroneYESNOYESYESYESMONITOR FOR EXTRAVASATION IF USING PERIPHERAL ACCESS. CENTRAL LINE ACCESS MUST BE CONSIDERED AS SOON AS POSSIBLE.NOT APPLICABLE TO CODE SITUATIONS. REFER TO P&P 40-39.AtropineYESYESYESYESYESNOT APPLICABLE TO CODE SITUATIONS. REFER TO P&P 40-39.Bivalirudin (Angiomax)YESYESYESNONOINITIATE DOUBLE CHECK PER P&P 40-04Cisatracurium (Nimbex)NONONONONOMedicationCVCC/ CVSS/GW Tele StepdownGW Short StayMRCC/ GW Med TeleNTCASMCCPrecautions/MonitoringExceptionsDexmedeto-midine (Precedex)NONONONONODiltiazemYESYESYESYESYESDobutamine (rate >10 mcg/Kg/min)YESNONONONOMONITOR FOR EXTRAVASATION IF USING PERIPHERAL ACCESS. CENTRAL LINE ACCESS MUST BE CONSIDERED AS SOON AS POSSIBLE. VASOPRESSOR ORDER SET SHOULD BE USED WITH INITIATION OF VASOPRESSOR DRUGSDobutamine (rate < or = 10 mcg/Kg/minYESYESYESYESYESMONITOR FOR EXTRAVASATION IF USING PERIPHERAL ACCESS. CENTRAL LINE ACCESS MUST BE CONSIDERED AS SOON AS POSSIBLE. VASOPRESSOR ORDER SET SHOULD BE USED WITH INITIATION OF VASOPRESSOR DRUGS SHOULD NOT BE TITRATED ON FLOORS.Dopamine (rate > 3 mcg/Kg/min)YESNONONONOMONITOR FOR EXTRAVASATION IF USING PERIPHERAL ACCESS. CENTRAL LINE ACCESS MUST BE CONSIDERED AS SOON AS POSSIBLE.VASOPRESSOR ORDER SET SHOULD BE USED WITH INITIATION OF VASOPRESSOR DRUGSDopamine (rate < or = 3 mcg/Kg/min)YESYESYESYESYESMONITOR FOR EXTRAVASATION IF USING PERIPHERAL ACCESS. CENTRAL LINE ACCESS MUST BE CONSIDERED AS SOON AS POSSIBLE.SHOULD NOT BE TITRATED ON FLOORS. VASOPRESSOR ORDER SET SHOULD BE USED WITH INITIATION OF VASOPRESSOR DRUGSDOPAMINE MAY BE GIVEN ON ANY UNIT IF THE DOSE DOES NOT EXCEED 3 MCG/KG/MIN AND TITRATION IS NOT REQUIRED.MedicationsCVCC/ CVSS/GW Tele StepdownGW Short StayMRCC/GW Med TeleNTCASMCCPrecautions/MonitoringExceptionsEpinephrineNONONONONOINITIATE DOUBLE CHECK PER HIGH RISK P&P 40-04 VASOPRESSOR ORDER SET SHOULD BE USED WITH INITIATION OF VASOPRESSOR DRUGS. MONITOR FOR EXTRAVASATION IF USING PERIPHERAL ACCESS. CENTRAL LINE ACCESS MUST BE CONSIDERED AS SOON AS POSSIBLE. NOT APPLICABLE TO CODE SITUATIONS. REFER TO P&P 40-39EpoprostenolNONONONONOEptifibatide (Integrilin)YESYESYESNONOINITIATE DOUBLE CHECK PER HIGH RISK P&P 40-04Esmolol (Brevibloc)NONONONONOFentanyl infusion NONONONONONOT APPLICABLE TO PCAS OR EPIDURALS. FENTANYL INFUSIONS MAY BE ADMINISTERED ON OPCC (5100) AND GATEWAY SURGICAL-ONCOLOGY. NOT APPLICABLE TO PROCEDURAL IVP FENTANYL GIVEN FOR MODERATE SEDATION. REFER TO P&P 40-28 MEDICATION ADMINISTRATION: SEDATION.Hydro- morphone infusion NONONONONONOT APPLICABLE TO PCAS OR EPIDURALS HYDOMORPHONEINFUSIONS MAY BE ADMINISTERED ON OPCC (5100) AND GATEWAY SURGICAL-ONCOLOGY.MedicationCVCC/ CVSS/GW Tele StepdownGW Short StayMRCC/ GW Med TeleNTCASMCCPrecautions/MonitoringExceptionsIbutilide (Corvert)YESNOYESYESYESIsoproterenolNONONONONOLabetolol - IV infusionNONONONONOLabetolol (Normodyne) IVPYESYESYESYESYESMAXIMUM TOTAL DOSE 300 MGLidocaineYESYESYESYESYESNOT APPLICABLE TO CODE SITUATIONS. REFER TO P&P 40-39LORazepam (Ativan) infusionNONONONONOIVP DOSES OF ATIVAN ARE OKMetoprolol (Lopressor) IVPYESYESYESYESYESMidazolam (Versed)NONONONONOVERSED IM MAY BE GIVEN ON ANY UNIT IF BEING USED AS A ONE TIME PRE-OP MEDICATION AND THE DOSE IS LESS THAN OR EQUAL TO 2 MG. VERSED IVP MAY BE UTILIZED FOR MODERATE SEDATION ON ANY UNIT BY FOLLOWING P&P 40-28 MEDICATION ADMINISTRATION:SEDATION. *Versed IV may be administered as pre-op medication in SDCC and Holding AreaMedicationCVCC/ CVSS/GW Tele StepdownGW Short StayMRCC/ GW Med TeleNTCASMCCPrecautions/MonitoringExceptionsMilrinone (Primacor)YESYESYESYESYESMorphine InfusionNONONONONONOT APPLICABLE TO PCAS OR EPIDURALS MORPHINEINFUSIONS MAY BE ADMINISTERED ON OPCC (5100) AND GATEWAY SURGICAL ONCOLOGY. IVP DOSES FOR PAIN ARE OKNicardipine (Cardene)YESNOYESNONONitroglycerinYESNONONONONitroprusside (Nipride)NONONONONOINITIATE DOUBLE CHECK PER HIGH RISK P&P 40-04Nor- epinephrine (Levophed)NONONONONOMONITOR FOR EXTRAVASATION IF USING PERIPHERAL ACCESS. CENTRAL LINE ACCESS MUST BE CONSIDERED AS SOON AS POSSIBLE.VASOPRESSOR ORDER SET SHOULD BE USED WITH INITIATION OF VASOPRESSOR DRUGS INITIATE DOUBLE CHECK PER HIGH RISK P&P 40-04MedicationCVCC/ CVSS/ GW Tele StepdownGW Short StayMRCC/ GW Med TeleNTCASMCCPrecautions/MonitoringExceptionsPancuronium (Pavulon)NONONONONOINITIATE DOUBLE CHECK PER HIGH RISK P&P 40-04PentobarbitalNONONONONOPhenylephrine (Neo- synephrine)NONONONONOMONITOR FOR EXTRAVASATION IF USING PERIPHERAL ACCESS. CENTRAL LINE ACCESS MUST BE CONSIDERED AS SOON AS POSSIBLE.VASOPRESSOR ORDER SET SHOULD BE USED WITH INITIATION OF VASOPRESSOR DRUGS INITIATE DOUBLE CHECK PER HIGH RISK P&P 40-04Procainamide (Pronestyl)YESNOYESYESYESNOT APPLICABLE TO CODE SITUATIONS. REFER TO P&P 40-39.Propranolol (Inderal)YESNOYESYESYESPropofol (Diprivan)NONONONONOINFUSE VIA DEDICATED LINE. CHANGE TUBING/BOTTLE EVERY 12 HOURSNOT APPLICABLE TO USE FOR RSI PROCEDURES. REFER TO P&P 40-51. DIPRIVAN IVP MAY BE UTILIZED BY CREDENTIALED PHYSICIANS FOR DEEP SEDATION ON ANY UNIT BY FOLLOWING P&P 40-28 MEDICATION ADMINISTRATION:SEDATION. DIPRIVAN INFUSIONS BY NOT BE UTILIZED ON NON-MECHANICALLY VENTILATED PATIENTS UNLESS THE PHYSICIAN IS PRESENT DURING THE INFUSION.MedicationCVCC/ CVSS/GW Tele StepdownGW Short StayMRCC/ GW Med TeleNTCASMCCPrecautions/MonitoringExceptionsRocuronium (Zemuron)NONONONONOINITIATE DOUBLE CHECK PER HIGH RISK P&P 40-04NOT APPLICABLE TO USE FOR RSI PROCEDURES. REFER TO P&P 40-51.Sodium Chloride 3%YESNOYESYESYESINITIATE DOUBLE CHECK PER HIGH RISK P&P 40-04SuccinylcholineNONONONONOINITIATE DOUBLE CHECK PER HIGH RISK P&P 40-04NOT APPLICABLE TO CODE SITUATIONS. REFER TO P&P 40-39Tirofiban (Aggrastat)YESYESYESNONOINITIATE DOUBLE CHECK PER HIGH RISK P&P 40-04VasopressinNONONONONONOT APPLICABLE TO CODE SITUATIONS. REFER TO P&P 40-39Vecuronium (Norcuron)NONONONONOINITIATE DOUBLE CHECK PER HIGH RISK P&P 40-04NOT APPLICABLE TO USE FOR RSI PROCEDURES. REFER TO P&P 40-51.VerapamilYESNOYESYESYES Alert It is the policy of the hospital that specific IV medications are given on specific units listed in the Reference Sheet-see Quick Sheet or Extended Text. Units listed on the Reference Sheet are considered able to take Stepdown patients and the staff working on these units have received special training to deliver these medications. If a unit is not listed on the Reference Sheet, the medication cannot be administered on that unit. All of the medications listed in the Reference Sheet may be given in the Intensive Care Units. All IV medications noted in this policy will be administered via the Alaris IV pump using the Medication Safety System Guardrails Software. Bypassing the dose-checking component of the IV pump technology is discouraged to assure patient safety. For more information specific to Deaconess Hospital, see extended text.  ALERT For more information regarding High Alert Medications at Deaconess Hospital, see  HYPERLINK "http://dweb.deaconess.com/CMSPages/GetFile.aspx?guid=f21772c6-5ce2-4187-83c2-86b36b494a09&versionhistoryid=8485" \t "_blank" Hospital P&P 40-04. For information regarding Medication Disposal at Deaconess, see  HYPERLINK "http://dweb.deaconess.com/CMSPages/GetFile.aspx?guid=585fc8e0-247b-4b3e-8a79-d62dd09b659a&versionhistoryid=1704" \t "_blank" Hospital P&P 40-82. For information regarding Dose Expressions and Unacceptable abbreviations at Deaconess, see  HYPERLINK "http://dweb.deaconess.com/CMSPages/GetFile.aspx?guid=285f80f6-a67c-455b-8887-48ee96250e01&versionhistoryid=6330" \t "_blank" Hospital P&P 40-48. HYPERLINK "http://dweb.deaconess.com/CMSPages/GetFile.aspx?guid=285f80f6-a67c-455b-8887-48ee96250e01&versionhistoryid=6330" \t "_blank"   Step Down/Telemetry Units and Allowed Medications Reference Sheet arelisted in the QUICK SHEET. OVERVIEW IV medications included in the Medication Safety System Guardrails Software are categorized into seven separate medication profiles (Critical Care, Adult Telemetry, Med-Surg, Adult Oncology, Pediatrics less than 10 Kg, Pediatrics greater than 10 Kg but less than 35 Kg, and Pediatrics greater than 35 Kg). Typically, IV medications not listed in this policy may be given on any nursing unit according to existing skills and hospital policies using appropriate written or computer drug references. Ifa medicationis not listed in this document or an existing hospital document whendrug references indicate that special precautions and monitoring should be taken, consult the Deaconess Pharmacist and/or Nursing Administration for advice. If advised by the Pharmacist or Nursing Administrator that special precautions are needed, Nursing Administration will determine the specific location where the drug should be administered. Administration guidelines for drug doses and rates can be altered by a physician's specific order or upon the recommendation of the Deaconess Pharmacist; however, specific unit location for administration of medications cannot be altered. Nursing Service and Pharmacy will review these guidelines ANNUALLY. SUPPLIES AND EQUIPMENT  HYPERLINK "http://lms.elsevierperformancemanager.com/ContentArea/NursingSkills/GetNursingSkillsDetails?skillid=ZZ_003&skillkeyid=639&searchTerm=medication&searchContext=nursingskills" Click here for a list of supplies and equipment. MEDICATION GUIDELINES Phenergan will be interchanged for other like medications unless given by anesthesia. If administering Phenergan, the following criteria must be met: Use central line if available. DO NOT administer through hand veins - May require starting an appropriate IV site. If appropriate IV site unattainable, may give promethazine (Phenergan) IM X 1, then contact phsician for further orders. Dilute with minimum of 10 ml Normal Saline. Run Normal Saline flush bag throughout administration if continuous IV fluids not infusing, or if IV fluids not compatible. 50 ml maximum dose of Normal Saline flush. Instill through port furthest from the patient. Do not use syringe pumps. Administer IV promethazine (Phenergan) slowly over 10-15 minutes. Observe patient continuously throughout administration. All Med Surg Units can infuse Dopamine at 3 mcg/kg/min or less using the following criteria: Dopamine will be administered via the Alaris IV pump using the Medication Safety System Guardrails Software. Bypassing the dose-checking componenent of the IV pump technology is prohibited to assure patient safety. Low-dose Dopamine infusion will be ordered by the physician. Dopamine will not be titrated to maintain blood pressure, but RN may tritrate to wean to off as follows: When the physician writes the order to discontinue Dopamine, it is required that the dosage of Dopamine be decreased by 1 mcg/Kg/min per hour. Vital signs should be taken with each dose change and 15 minutes after each dose change. The physician's order will identify actual start dosage. No other vasoactive or vasopressor infusions will be administered to the patient receiving low-dose Dopamine on the Medical/Surgical units. The Dopamine infusion will be infused at a lower port into a compatible primary IV line. Patients requiring vasopressor infusions who do not meet these criteria will be transferred to the appropriate unit for treatment (i.e.CVCC, NTCA, SMCCor ICU at Main campus. Medical Telemetry, Telemetry Stepdown or ICU at Gateway campus). The Registered Nurse will be responsible for hanging, monitoring, regulating and discontinuing the Dopamine infusion. Dose calculations will beperformed by a Registered Nurse and double-checked by a pharmacist and/or a Registered Nurse every shift and documented. See Mosby Skill: Intravenous Infusion: Dose and Flow Rate Calculation. Vital signs are monitored and documented every 15 minutes for the first hour. Then every four hours. Check intake and output every shift. Monitor IV site hourly forsigns and symptoms ofinfiltration and check for blood return. Change IV forany questionable sites, reddened areas, or if no blood return observed. If infiltration has occured, do not remove IV. Stop infusion immediately and see treatment of Dopamine extravasation. Document in EPIC: Condition of patient prior to infusion, blood pressure and pulse, weight, I&O, hourly IV site monitoring and condition of site, response of patient to treatment. Notify physician of any change in blood pressure and/or pulse. IV push and infusion medication with specific high risks should be given on nursing units with trained staff and EKG monitoring. Certain medications will be limited to the critical care units only to assure closer monitoring. IV push and infusion medications with specific high risks may be given on a regular unit initially if the patient is attached to a crash cart monitor and either the ordering physician OR an ACLS certified Registered Nurse is present at the bedside. If the medication is to be continued, Nursing Administration will arrange for appropriate placement (that includes EKG monitoring and appropriately trained personnel) of the patient. Treatment of Extravasation: Stopthe flowof the IV immediately butDO NOTREMOVE the IV cannula. Aspirate as much of the infiltrated drug as possible. Attach a 5ml syringe to the IV cannula and aspirate gently. After prepping skin with a Chloraprep, using TB syringe with 25 ga 5/8" needle to gently aspirate subcutaneously. Dilute 5 mg of Regitine with 10-15 ml of normal saline and infuse through the retained IV cannula. The Regitine and normal saline solution may also be instilled subcutaneously using a 25 ga 5/8 needle. Remove the IV needle. Maintain warm compresses to the affected area for a minimum of 4 hours. Elevate the affected extremity. Notify the physician. Document in detail the occurrence of the infiltration and its treatment in EPIC. Complete an incident report. Check the site each shift. Document the status of the involved area until resolution occurs. For the purposes of this skill, Critical Care profile units include: Deaconess Main Campus 4800-Cardiovascular Surgical Trauma ICU, 2900-Cardiovascular ICU, 3900 Neuro/Medical ICU, ED-Emergency Department, CVL-Cardiovascular Lab, Surgery, PACU Deaconess Gateway Hospital MS ICU,PICU,ED,Surgery, PACU, Neuro ICU Heart Hospital Heart Unit orCath Lab Nursing units with adult telemetry monitoring and training may give certain high-risk medications upon physician's order without the physician being present. These units include: Deaconess Main Hospital 2500/2600 Cardiovascular Care Center Cardiovascular Short Stay 5500-5600-Medical Renal Care Center 3500-3600-Surgical Medical Care Center 3800 Neuro Transitional Care Center (NTCA) Deaconess Gateway Hospital General Medical Telemetry Telemetry Stepdown Heart Hospital Short Stay Unit Heart Floor PROCEDURE All initial drip rates are to be validated and documented by cosigning the initial titration graph that is attached to an EKG monitor record. The order set for vasopressors in EPIC should be used with any initiation of vasopressor drugs when the physician has not included concentration, starting dosage, and maximum dosage. This includes extravasation management. Narcotic infusions that are administered in a large volume (not PCA or Epidural) may be given in any critical care unit OR the Oncology Pulmonary Care Center (OPCC-Unit 5100 OR GW Surgical Oncology). Due to the high risk for medication errors associated with very high risk medications, as outlined by the Institute of Safe Medication Practice and the CAPS, double signatures and validation of Orders prior to medication administration is required at any location throughout the hospital for intravenous medications as noted in Policy and Procedure 40-04High AlertMedications. This policy is NOT applicable for Emergency Resuscitation or Rapid Sequence Intubation. Refer to Policy and Procedure 40-39 Code Blue Process, Roles, and Responsibilites and P&P 40-28 Medication Administration-Sedation. If a medication listed below is used during a procedure, refer to P&P 40-28 Medication Administration: Sedation (Conscious Sedation Guidelines) for administration guidelines. Do not use the Medication Administration: Sedation Policy as the guideline for administration of these medications if no procedure is being done. ALL MEDICATIONS LISTEDIN THEREFERENCE SHEET TABLEARE APPLICABLE FOR CRITICAL AREAS (LISTED ABOVE UNDER MEDICATION GUIDELINES). Use theREFERENCE SHEET to determine what other units may administer IVP and IV drip medications. EXCLUSIONS: Chemotherapy drugs are considered hazardous agents. See P&P 40-34 Administration, Handling and Disposal of Hazardous Drugs for administration guidelines and  HYPERLINK "http://healthbookshelf.deaconess.com/webopac/report/b026a626-fb0b-4725-a4fe-f8ade948ace8.pdf" P&P 40-04 High Alert Medications. Concentrated electrolytes are high-risk medications. Potassium chloride guidelines should be followed as outlined by the Pharmacy Department. Oral potassium replacement therapy is suggested as the first option. Injectable potassium should never be admininistered IM, SC, IVP or in an undiluted form. The routine use of lidocaine to decrease pain associated with potassium administration is not recommended, as the appropriate rate of administration and dilution of potassium should lessen/eliminate pain associated with administration. However, if lidocaine is thought to be necessary, the recommended dose should not exceed 20 mg/bag. Patients should not recieve potassium at a rate >200mEq/24 hours. Small Volume Potassium IV Supplementation (Max volume 500 ml)RateDilutionCentral LineIf concentration equals or exceeds 0.15 mEq K+/ml, dilute to 20 mEq/ 100 ml or 40 mEq/ 250 mlNon Monitored10 mEq/hRemote Monitored/Telemetry20 mEq/hPeripheral Line10 mEq/hIf concentration is less than 0.15 mEq K+/ml, dilute to 20 mEq/ 250 ml or 40 mEq/ 500 ml*Doses exceeding 40 mEq should be administered in divided doses Note: 1mmol KPhos = 1.46 mEqK+ For Large Volume IV Supplementation (greater than or equal to 500ml):RateDilutionPotassiumPotassiumCentral LineNon-Monitored10 mEq/h60 mEq/LMonitored20 mEq/h80 mEq/LPeripheral Line10 mEq/h60 mEq/LNote: Concentrations and rates exceeding those listed above MUST be administered through a central line and the patient MUST be on an EKG monitor. Updated May 2016 Alert It is the policy of the hospital that specific IV medications are given on specific units listed in the Reference Sheet-see Quick Sheet or Extended Text. Units listed on the Reference Sheet are considered able to take Stepdown patients and the staff working on these units have received special training to deliver these medications. If a unit is not listed on the Reference Sheet, the medication cannot be administered on that unit. All of the medications listed in the Reference Sheet may be given in the Intensive Care Units. All IV medications noted in this policy will be administered via the Alaris IV pump using the Medication Safety System Guardrails Software. Bypassing the dose-checking component of the IV pump technology is discouraged to assure patient safety. For more information specific to Deaconess Hospital, see extended text.  No supplies or equipment required. Alert It is the policy of the hospital that specific IV medications are given on specific units listed in the Reference Sheet-see Quick Sheet or Extended Text. Units listed on the Reference Sheet are considered able to take Stepdown patients and the staff working on these units have received special training to deliver these medications. If a unit is not listed on the Reference Sheet, the medication cannot be administered on that unit. All of the medications listed in the Reference Sheet may be given in the Intensive Care Units. All IV medications noted in this policy will be administered via the Alaris IV pump using the Medication Safety System Guardrails Software. Bypassing the dose-checking component of the IV pump technology is discouraged to assure patient safety. For more information specific to Deaconess Hospital, see extended text.  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