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1. AUGUST JANUARY AUGUST JANUARY AUGUST JANUARY AUGUST JANUARY AUGUST aunt Liar UNIVERSITY OI NOTRE DAME V Y HEALTH SERVICES SUBJECT DIETARY SERVICE AT UNIVERSITY HEALTH CENTER AUTHORIZATION Assistant Director Clinical Services DATE March 2011 PURPOSE University Health Services will provide dietary services to infirmed students with the cooperation of University Food Services and North Dining Hall PROCEDURE AND OR GUIDELINES A B C The name of the student and ND ID number will be provided on the menu Food Services will insure that all meals are delivered Health Services staff will dispose of unused food and disposable products and food Services will be responsible for picking up dirty dishes and carts and washing them at the North Dining Hall within 24 hours Meals ordered will include food plated to order utensils and napkins Health Services employees will provide a beverage served in paper or Styrofoam which will be stored at the Health Center Food Services will be responsible for maintaining a stock of supplies and food items for Health Services throughout the school year according to prescribed inventory Two Grab n Go lunches are kept in stock at the Health Center by Food Services for nourishment in betwee
2. Reviewed Reviewed o Reviewed j Confidential Report of Communicable Disease THIS FORM CONTAINS CONFIDENTIAL INFORMATION PER 410 IAC 1114 10 DISTRIBUTION Who idana Deparimaer Canary Loca Heath Oct Pint Reporte Rubel Gecnan Mares set daou fer congenital mouere onse Dome Hepatis Vial A B Data A Non Herpes 5 aunt Liar SUBJECT AUTHORIZATION PURPOSE DATE UNIVERSITY OI NOTRE DAME V Y HEALTH SERVICES HYDROCOLLATOR Assistant Director Clinical Services Provide moist heat therapy March 2012 EQUIPMENT SUPPLIES Hydrocollator heating unit Hydrocollator pack 4 bath towels Thermometer PROCEDURE AND OR GUIDELINES Note Hydrocollator heating unit to be checked q shift for water level to the fill line and clarity Fill tank with distilled water only Water temperature to be checked daily and recorded on log Contraindictions Acute injuries areas of impaired circulation or sensation anesthetized areas over keloid skin peripheral vascular disease 1 Prepare patient a Assess for fever or severe pain radiating distally or impaired circulation or sensation If so consult physician prior to therapy b Explain procedure to patient 2 Prepare equipment a Use tongs to obtain Hydrocollator pack from not water bath b Wrap pack in at least four
3. 2 188 5096 Dextrose 25gm 0 5g ml 50ml 1 Surgipad 2 8 4 Sodium Bicarbonate 50mEq 1mEq ml 50ml 1 Scalpel 1 Epinephrine 1 10 000 1mg o 1mg ml 10ml 1 Tape 1 adhesive 1 paper 1 transpore 168 Adrenaline 1 1000 1mg ml 1ml 2 Tongue blades 2 Benadryl 50mg ml 1ml single dose syringe 1 Scissors 1 Decadron Dexamethesone 20mg 4mg ml 1 Towel drape non fenestrated sterile 3 Glucagon ER kit 1 Gloves sterile sizes 6 6 1 2 7 7 v 8 1pr ea Glutose 15 Oral Gel 15gm of Glucose 2 Unsterile 3pr Lanoxin 500ug 0 5mg in 2 ml 1 Sutures 3 0 Silk FS 1 8 4 0 Ethilon P 3 1ea Lasix 40mg 10mg ml 4 ml 1 Narcan 0 4 0 4mg ml 1 Naloxone HCL 1 DRAWER 4 SUPPLY AMT BASE Nitrostat 0 4mg 1 150gr Multiple tablet bottle 1 IV SOLUTIONS 1000CC 5 Dextrose 1 Nubain 10mg ml 1ml Nalbuphine 1 1000cc 0 9 Sodium Chloride NaCl 1 Solu Cortef 100mg 1 1000cc 5 Dextrose and 0 45 NaCl 1 Solu Cortef 250mg 1 IV Tubing primary set 2 Valium Diazepam 10mg 2ml 2 ml 2 DRAWER 5 SUPPLY AMT DRAWER 2 SUPPLY AMT DATE O2 mask Adult Ped Nasal cannula 1ea SYRINGES BD Brand 3ml 22gX 1 12 3ea Bitestick 1 23g X 1 25g X 5 8 3ea Suction set amp refill unit 1 5cc 10cc catheter tip 1ea Plastic gown 1 NEEDLES 18g X 1 22g X 1 1 2 25g X 1 2ea Face Shield 1 IV CATHETERS Insyte 22g 1 20g 1 16g 2ea Laceration tray 1 Tegaderm 3 Alcohol pads 10 DRAWER 6 SUPPLY AMT mm Betadine preps Airway kit
4. AUTHORIZED PERSONS RN Test performance RN or PCA Equipment Cleaning ADDITIONAL CONSIDERATIONS Other documents to reference other approval needed etc This facility uses the ONE TOUCH Ultra system Meters brought in by patients may be used for that individual only Manufacturers guidelines for use will be followed unless otherwise defined FORMS or REFERENCES One Touch owners manuel see next page ANNUAL REVIEW Signature Reviewed ge pM Hg Signature Reviewed Reviewed Reviewed Reviewed Reviewed Reviewed Reviewed Reviewed Reviewed DATE TIME CODE HIGH CONTROL STRIP LOW RN SIGNATURE SAMPLE OF LOG UNIVERSITY OF NOTRE DAME UNIVERSITY HEALTH SERVICES March 2011 Issued Approved by Office of Student Affairs Director University Health Services Medical Director SUBJECT BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN POLICY All employees of University Health Services will comply fully with the Bloodborne Pathogen Standard requirements as part of their continuing commitment to health and safety in the workplace It is the responsibility of the Department of Risk Management and Safety to initiate and revise the University s Exposure Control Plan The Clinical Services Adm
5. Turn the green cap or wrench handle clockwise to close the pressure regulator Turn the flowmeter knob clockwise until the pressure regulator and flowmeter read zero Turn knob counter clockwise until tight To Remove Cylinder Bleed the system Remove green cap lift off or wrench handle from the cylinder Unscrew pressure regulator and remove Remove the plastic or metal gasket O ring from the valve and discard Loosen the set screw on the side of the tank holder frame Remove cylinder and place on floor lying down on side Label the tank as empty and take to O2 storage area located in UHS Pharmacy general supply area Transport tank by cart or wheelchair secured to avoid falling OXYGEN DELIVERY AND CYLINDER CHANGE NOTE NEVER place oxygen cylinder upright without support of a stand or in a storage unit Handle cylinder with care Avoid damage to the valve tip as severe injury may result To Replace Cylinder 1 2 3 4 ANNUAL REVIEW puer Reviewed Reviewed Obtain unopened cylinder from Pharmacy general supply area Remove protective covering and save gasket O ring Using green cap or wrench handle open cylinder for one second to remove any dirt from the valve Place gasket into valve at top of cylinder Place regulator on cylinder and seat the three metal prongs into valve Tighten screw until regulator is snug Open cylinder one full turn and check pressure gauge to determine amount of
6. with start and discard time and RN initials or discarded after initial use C DOCUMENTATION 1 Nurse Notes Documentation is required for initiation of IV Therapy Rational for restarts and when the expected outcome is not met a b C 2 IV Date and time Number of insertion attempts Reference use IV Therapy Record eg 7 19 07 0800 IV started x 2 attempts Tolerated See IV Therapy Record Therapy Record See Exhibit Documentation in Nurses Notes is required when expected outcome is not met The RN must initial and sign IV Therapy Record D REMOVAL OF IV DEVICE 1 Equipment 2 Gloves unsterile Alcohol prep pad Gauze sponges or cotton ball Tape or bandage Sharps container rocedure Wash hands wear gloves Stop IV infusion when applicable Remove site dressing being careful not to dislodge catheter Remove catheter 1 Place gauze sponge over insertion site and carefully remove catheter and inspect integrity of catheter 2 Apply pressure over site until bleeding stops E F 3 Apply tape or bandage e Cleanse any dried blood on skin f Document on IV Therapy Record Additional entry is necessary in Nurses Notes if site does not meet expected outcome ADDITION OF MEDICATIONS TO IV SOLUTIONS gt ND Mixing should be done in a low traffic area Wipe countertop with alcohol or germicidal solution Wash hands Check ph
7. Document in patient medical record Complete incident report NEBULIZER TREATMENTS L Cleaning and Maintenance a Discard disposable nebulizer and tubing after each treatment b When necessary wipe the outside of the compressor cabinet with a clean damp cloth to keep it dust free c Change air inlet filter routinely or when the filter turns gray in color Small filters every month Remove filter retaining cap by turning counterclockwise Remove dirty filter with a toothpick and discard Replace with the new filter and reattach retaining cap by turning clockwise Large filters every six months Remove filter cap by grasping it firmly and pulling it out of the front of the unit Remove fulter with fingers and discard Replace filter and push retaining cap into position M Document completely on Nurses Notes for inpatient on Clinic Data Record for outpatient May use Respiratory Flow Sheet a Date and time of treatment b Medication name dose C Length of treatment d Pulse respirations and breath sounds pre and post treatment e Patient response to treatment f Cough effort g Amount and type of sputum h Any other significant information i Charges ANNUAL REVIEW urguet d Reviewed __ Reviewed Reviewed Reviewed Reviewed Reviewed Reviewe d d NAME 1 0 Pre TreatmentAssessment EE Post Treatment Assessment MEDS vs COMMENTS
8. Manufacturer s guidelines will be followed for any of the three acceptable devices Water Pik machine OR Elephant Ear OR WelchAllyn Ear Wash System Otoscope Ear lavage basin Towels Plastic drape PROCEDURE AND OR GUIDELINES A Before Procedure 1 Refer to Medical Directives before initiating procedure Manufacturer s guidelines will be followed for any of the three acceptable devices Consider use of a wax softener prior to irrigation Explain procedure to patient Drape patient with plastic drape and towel Position patient near sink Have patient hold ear basin under ear Test for comfortable water temperature by running water over lobe of ear Ideal water temperature is 98 6 F Water that is too hot or cold can stimulate the inner ear and cause dizziness T Pulltop of ear up and back 55 wh EAR IRRIGATION B Procedure 1 WelchAllyn Ear Wash System a Prepare equipment b Begin water flow through the system adjust to an approximate body temperature If water temp exceeds 110 water will stop flowing from the eartip Reduce adjust the faucets If water temp is too cool the thermal sensor is blue Adjust the faucet c Attach eartip to the handle with the tab side up and the ridge on the inside lining up with the grooves on the handle d Insert the eartip into the ear canal pulling gently up and back on the pinna e Continually assess water temperature by checking the thermal sensor and
9. PROCEDURE 1 Obtain urine specimen from patient according to procedure for collection of urine See Laboratory Manual 2 Open bag and remove transfer device and vacutainer tube Tube contains a white freeze dried preservative to stabilize the specimen 3 Submerge straw of transfer device below the surface of urine to the bottom of the urine container 4 Place vacutainer tube in holder portion and advance tube over puncture point to pierce the stopper 5 Holdin position until urine stops flowing into the tube 6 Remove the tube from the device and set aside leaving transfer device in the container T Lifttransfer device and allow the urine to drain from the straw Discard into sharps container 8 Shake vacutainer tube to dissolve the preservative 9 Label specimen with name social security number date and time Complete lab requisition Send to SBMF in biohazard bag NOTE Refrigerate specimen until lab pick up VACUTAINER URINE CULTURE KIT EQUIPMENT SUPPLIES Urine Specimen Vacutainer kit Disposable gloves AUTHORIZED PERSONS RN or PCA ANNUAL REVIEW Signature Date Signature Date Reviewed Reviewed Reviewed Reviewed
10. UNIVERSITY HEALTH SERVICES Clinical Services Policies and Procedures Reviewed June 2014 Please Note Clicking on a title in the following Table of Contents will take you to that page Table of Contents Clinical Services Statement ADDVantage Med Policy Allergy Injections Policy Blood Glucose Testing One Touch Ultra Procedure Bioodborne Pathogens Policy Conjunctivitis Test Kit Cryo Cuff Procedure Dietary Services Procedure Ear Irrigation Procedure EKG Procedure Eye irrigation Procedure HIV Testing Procedure Hydrocollator Procedure Immunization VAERS Pr r Injectable Training Arm Procedure Instrument Processing and Sterilization Procedure International Travel Consult Procedure Itradermal Injection Simulator Procedure Isolation of Patients Policy Isotretinoin Accutane Therapy Policy IV Thera Procedure Kinetic Performa CPM Procedure Liquid Nitrogen Procedure Medical Directives Procedure Medical Emergency Hesponse Emergency Carts Policy Medical Emergency Cart Procedure Narcotic Counts in Inpatient Unit Nebulizer Treatment Procedure Notification of Laboratory Test Results On Call HC Staff Policy Oxygen Delivery amp Cylinder Change Procedure Pain Management Policy Pulse Oximeter Procedure uction Hand He es G Vac Procedure TB Screening for International Students Procedure Vacutainer Urine Culture Procedure UNIVERSITY OF NOTRE DAME UNIVERSITY HEALTH SE
11. 2 Any item with packaging material that is damaged torn stained or heavily Wrinkled should be considered contaminated D STERILIZATION PROCESS Sterilization provides the highest level of assurance that an item is free of viable microbes Manufacturer s directions will be followed INSTRUMENT PROCESSING AND STERILIZATION T 8 9 Reservoir Fill reservoir using distilled water to reach the base of the safety valve without covering it Preparation of Materials Clean and package instruments following protocol as above Load Place packages on the tray s in the chamber one level deep only CAUTION Never overload or crowd chamber Do not let packages come in contact with door or sides of chamber Close the door securely and check that the DOOR CLOSED light is on Turn on the ROCKER SWITCH on the bottom right front panel Press the START key The dress symbol should be lit on the top row of the control panel WATER INLET is displayed until the correct volume of water is automatically introduced into the chamber The sequence of operations fill heat steam vent and dry happen automatically The time and temperature and pressure parameters are pre programmed When the cycle is complete a TONE will sound for five seconds and the START light will turn off Open the door and remove the contents using thick cotton gloves Turn off the ROCKER SWITCH front lower right E BIOLOGICAL INDICATORS
12. Biohazard Infectious waste shall be disposed of in accordance with applicable regulations Infectious waste generated in the Health Center is removed by the Dept Of Risk Management and Safety All contaminated sharps and potential sharps must be discarded immediately after use or as soon as possible into containers which meet the following requirements a Closeable and not able to be opened except by use of tools b Puncture resistant C Leak proof on bottom and sides to prevent leakage of contaminated liquids d Labeled using the universal biohazard symbol and the word biohazard Sharps containers must be easily accessible for use maintained in an upright position during use and replaced routinely so that they are not overfilled When moving containers of contaminated sharps the containers must be closed so that their contents do not spill or protrude If leakage of the primary container is possible it must be placed into a secondary container which is closeable labeled and shall safely contain all contents without leaking Reusable containers should not be opened emptied or cleaned manually or in any manner which would expose employees to the risk of injury Regulated waste shall be placed in containers which are closeable and labeled using the universal biohazard symbol and the word biohazard Containers must be constructed to contain all contents and prevent leakage of fluids during handling storage transport or
13. Cautions 1 DO NOT use dull or burred needles as these will cause leaks in the system burred needles will cause permanent damage Use smaller needles 20 25 gauge 2 Use only 500cc of Infusion Fluid as a larger amount will increase the pressure of the venous system resulting in leaks 3 DO NOT clean the simulator with solvents or corrosive material as they will damage it 4 DO NOT use the subcutaneous injection INJECTABLE TRAINING ARM SPECIAL INSTRUCTIONS A Use 20 25 gauge needles only to prolong the life of the skin and veins B Not to be used for Intradermal injection practice C For IM injections use air as the injectant since distilled water cannot be drained D Treat with care and follow care instructions to prolong use E Arm may be used for practice without the setup of fluid F Arm to be kept with clinical services training materials ANNUAL REVIEW d Reviewed Signature Revewed O Reviewed Reviewed Reviewed Reviewed O Reviewed Reviewed Reviewed UNIVERSITY OI NOTRE DAME UNIVERSITY HEALTH SERVICES SUBJECT INSTRUMENT PROCESSING AND STERILIZATION AUTHORIZATION Assistant Director Clinical Services DATE March 2011 POLICY Sterilization of reusable sharps and other equipment having contact with blood or other potentially infectious materials OPIM is an important aspect of infection control Steam sterilization will be used fo
14. DATE March 2011 PURPOSE To provide fast reliable Sp02 and pulse rate measurements EQUIPMENT SUPPLIES Oximeter PROCEDURE AND OR GUIDELINES 1 Attach the sensor to the oximeter 2 Attach the finger sensor to the patient s index finger allowing the cable to lay across the palm of the hand and parallel to the arm of the patient 3 Press the 1 key the oximeter will go through its power sequence Verify that all LED s on the display light up upon start up of the device 4 After a few seconds the Sp02 value pulse rate and pulse strength bar graph should be shown 5 Press the 0 key to turn off oximeter Whenever the oximeter is on it stores one Sp02 and pulse rate reading every 30 seconds The stored readings are called spot check data The oximeter Remembers spot check data for up to 99 patients and 17 of run time Clearing all Spot Check Data Press and hold the 1 key for about 6 seconds while the oximeter is on to clear all spot check data and reset the patient number to P1 Cleaning Oximeter and Sensor Clean or disinfect the sensor before attaching a new patient Clean the sensor with a soft cloth moistened in water or a mild soap solution To disinfect the sensor wipe the sensor with isopropyl alcohol Do not allow any liquid to enter any of the oximeter openings PULSE OXIMETER Unplug the sensor from the monitor before cleaning or disinfecting Do not autoclave ethylene oxide sterilize or immerse the sensors i
15. Remove and discard exam table paper that has been in contact with patient Remove and discard all items used for patient care exam a Discard biohazard items in red waste container Spray all potentially contaminated horizontal surfaces with disinfectant Allow to remain wet for at least 10 seconds Wipe dry with paper towels Discard paper towels and gloves in proper waste container Revewed Reviewed __ Reviewed Reviewed UNIVERSITY OI NOTRE DAME aunt Liar SUBJECT Conjunctivitis Test Kit Adeno Detector AUTHORIZATION Assistant Director Clinical Services DATE November 2011 PURPOSE To aid the rapid differential diagnosis of acute adenoviral conjunctivitis EQUIPMENT SUPPLIES RPS Adeno Detector test kit Gloves Timer PROCEDURE AND OR GUIDELINES 1 Tear open each foil pouch in the kit package Do not touch the collector pad to any surface except the collection site conjunctiva and the sample transfer window 2 Locate the sample pad on the underside of the sample collector the pad will appear yellow prior to testing Apply examination gloves Gently lower the patient s lower eyelid to expose the inside pocket inferior fornix 4 Swab or dab the sampling pad inside the lower eyelid 6 8 times around the conjunctiva Allow the sampling pad to rest against the conjunctiva for an additional 3 seconds to ensure saturation of the sampling pad with the eye fluid The pad will turn red upon saturation with
16. When injections can be given more than once a week please note specific time frame between doses 5 Dosage adjustment instructions for missed late injections reactions and new vials Please note if local reaction is defined by size of induration and or erythema 6 Aphysician s signature authorizing the therapy hon gt INCOMPLETE INFORMATION WILL RESULT IN A DELAY IN TREATMENT Injections will be given only when a physician is on the premises All patients will be expected to remain in our clinic for 30 minutes following the injection s Any significant reaction and its treatment will be reported to you If the patient has had a previous systemic reaction please share that information with us Optimum results of therapy depend on patient compliance plus clear and concise guidelines from you Together we can provide the best possible patient care Should you have any questions regarding our policy and procedure for allergy injections at University Health Services please feel free to contact the allergy nurse at 574 631 3738 U niversity H ealth Services U niversity of Notre Dame Pre Therapy Questionnaire Sample NDID To be completed at each immunotherapy visit Student Name DOB Any fever in last 24 Yes hours Any SOB in last 2 Yes days Any current beta Yes Yes No Yes N Yes blockers Any change in Yes Yes No Yes N Yes medication Any problems with Yes previous injection Any increase in Yes a
17. aunt Liar SUBJECT Conjunctivitis Test Kit Adeno Detector AUTHORIZATION Assistant Director Clinical Services DATE November 2011 PURPOSE To aid the rapid differential diagnosis of acute adenoviral conjunctivitis EQUIPMENT SUPPLIES RPS Adeno Detector test kit Gloves Timer PROCEDURE AND OR GUIDELINES 1 Tear open each foil pouch in the kit package Do not touch the collector pad to any surface except the collection site conjunctiva and the sample transfer window 2 Locate the sample pad on the underside of the sample collector the pad will appear yellow prior to testing Apply examination gloves Gently lower the patient s lower eyelid to expose the inside pocket inferior fornix 4 Swab or dab the sampling pad inside the lower eyelid 6 8 times around the conjunctiva Allow the sampling pad to rest against the conjunctiva for an additional 3 seconds to ensure saturation of the sampling pad with the eye fluid The pad will turn red upon saturation with tear fluid 5 Begin the test by gently placing the sampling pad of the sample collector into the sample transfer window of the test cassette body 6 Press firmly where indicated until the test feels secure A double click means that test is properly assembled 7 Open the buffer vial and remove the protective cap from the test Do not allow any portion of the cassette besides the absorbent tip to touch the buffer vial Immerse the absorbent tip into the buffer vial
18. 3 Insertion of device a Technique is dependent infusion device selected See attached procedures for catheters currently in use Exhibit I amp III Always use aseptic technique Always inspect the needle for integrity Change sites every 72 hours If venipuncture is unsuccessful after two attempts ask another RN or physician or ND Fire Department staff to assist Upon completion discard stylet into sharps container discard gloves and supplies appropriately and wash hands Document in Nurses Notes amp IV Therapy Record per procedure 1 IV site a Label Tegaderm dressing with date and time the IV is started the gauge length and type of IV device and initials of the person starting the IV Change site routinely every 72 hours 2 Tubing a Label tubing with start and discard date and time an RN initials Change tubing every 72 hours Tubing used for intermittent administration of IV meds should be changed every 72 hours b If patient is an outpatient designate and label tubing and pump for re use for individual patient Change tubing prn and q 72 hours IV Bag a Label bag with start and discard date and time rate of flow and RN initials IV bags must be changed at least every 24 hours b Any medications added to the IV bag must be identified Label IV bag with name of medication amount date time and initials of RN c IV solution used for intermittent medication administration must be labeled
19. 5693 or FAX to 574 631 6047 Thank you Allergy Nurse 574 631 3738 0 UNIVERSITY OF NOTRE DAME UNIVERSITY HEALTH SERVICES March 2011 Reviewed Approved by Office of Student Affairs Director University Health Services Medical Director SUBJECT BIOMEDICAL EQUIPMENT AND MAINTENANCE POLICY University Health Services ensures that all biomedical equipment function properly y scheduling annual maintenance with a reputable vendor PURPOSE ensure accurate and consistent diagnostic results and patient care support and to comply with all applicable standards of maintenance of biomedical equipment GUIDELINES A Inspection and maintenance of biomedical equipment is ordered annually and on an as needed basis throughout the year B Records of scheduled maintenance inspections and repairs are kept on file in the office of the Director of University Health Services for at least the current and previous year PROCEDURE 1 Equipment used by UHS for the provison of patient care shall be maintained by TriMedx 6325 Digital Way 400 Dan Swain BMET3 Indianapolis IN 46278 574 224 1288 317 275 1591 572 241 2890 fax 877 874 3339 TriMedx com BIOMEDICAL EQUIPMENT AND MAINTENANCE 1 Annual inspection is provided in January of each year 2 Itis the using person s responsibility to notify their immediate supervisor or the UHS pharmacy when there is an equipment failure or malfunction 3 Ifthe user s
20. If this happens please contact Premier Customer Service at 8881 773 6872 FROSTED EXTERIOR OR EXTREMELY COLD EXTERIOR OF THE VACUUM CONTAINER This can be caused by partial or complete deterioration of the container vacuum insulation due to age or mechanical damage dropped con tainer dents The container must be replaced with a new one Please con tact Premier Customer Service at 868 773 6872 DELAYED SHUT OFF OR SPRAY WON T SHUT OFF AFTER RELEASE OF TRIGGER This can be caused by foreign matter in the trigger valve mechanism or mechanical problems with the trigger valve stem or spring If you notice any af the above contact Premier Customer Service at 888 773 6872 Do nat attempt to perform any repairs on the Nitrospray Plus units All repairs should be handled by our authorized personnel only Please contact Premier Customer Service at 888 773 6872 if you experience any problems with your unit Unauthorized repairs will void warranty and will absolve PREMIER MEDICAL PRODUCTS of any claims for injury caused by an unauthorized repaited unit If necessary it is acceptable to refill your unit during the course of the day whether the container is stilt cold or warm Jf difficulty is encountered when removing the top cap of a cold unit activation of the trigger will help relieve the internal pressure Holding the container at an ange during treatment is both clinically practical and assists in creating appropriate ag
21. J Beview Revewed Reviewed Reviewed j Reviewed j UNIVERSITY OI NOTRE DAME aunt Liar SUBJECT MEDICAL EMERGENCY RESPONSE EMERGENCY CARTS AUTHORIZATION Assistant Director Clinical Services DATE March 2011 PURPOSE To provide prompt efficient medical response to emergency situations To assure that appropriate supplies and equipment are readily available in the event of a medical emergency EQUIPMENT SUPPLIES Emergency Cart Automatic External Defibrillator PROCEDURE AND OR GUIDELINES Health Center staff will respond immediately to a medical emergency When a physician is available he she will direct emergency care A physician must be contacted for specific orders not covered in the Medical Directives or provided by emergency support personnel Responding to 911 1 Call for help have the Emergency Cart brought to the location of the patient 2 Assess the patient 8 Check Airway Breathing Circulation ABC s b Initiate CPR as needed c Monitor vital signs d Maintain safe environment 3 Call 911 a Inform Security Department of the emergency situation b Request ambulance 4 Initiate O per nasal cannula mask or ambu bag as needed 5 Suction as needed 6 Notify the following a Physician b Administrator on call MEDICAL EMERGENCY RESPONSE EMERGENCY CARTS c Family unless appropriate for physician or Administrator to notify d Rector 7 Accurately document
22. Squeeze the handle of the suction device repeatedly to provide suction m Apply suction as you withdraw the tip using a sweeping motion if possible u Suction for no more than 15 seconds at a time for an adult 10 seconds for a child and 5 seconds for an infant Suction Portable Hand Held Res Q Vac ANNUAL REVIEW Reviewed Reviewed Reviewed Reviewed o o Reviewed Reviewed J C Reviewed Reviewed unt SUBJECT AUTHORIZATION DATE PURPOSE UNIVERSITY OI NOTRE DAME V Y HEALTH SERVICES TB SCREENING OF INTERNATIONAL STUDENTS Assistant Director Clinical Services March 2011 To provide screening surveillance and appropriate referral to Notre Dame students at risk for Tuberculosis TB Tuberculosis continues to be a highly infectious potentially life threatening disease Because of the increase in tuberculosis worldwide and in response to the Center for Disease Control and Prevention s CDC recommendation regarding strategies and along with Indiana Statues for TB control the University of Notre Dame is initiating this policy PROCEDURE AND OR GUIDELINES 1 All new international students foreign born U S citizens who are not U S permanent residents enrolled for on campus coursework must be screened before the first semester of attendance at the university New graduate students who were previously enrolled as underg
23. can be left in place or disconnected e Rest cooler on floor or table o Rechill the water in the cuff once an hour or as needed Initially rechill after 15 30 minutes to quickly cool the area a Connect the tube lower the cooler and the water will drain from the cuff b Aftera minute or two for mixing with the ice elevate the cooler and repeat the filling process Contraindications Cryotherapy should not be used if a patient has Reynaud s or other vasospastic disease cold hypersensitivity or compromised local circulation Care a After use drain water from the tube by pressing spring on quick disconnect and elevating tube b Spray cuff with approved disinfectant and allow to dry c Store jug with top off to allow drying d Clean cuff tube and cooler routinely every 6 months January and August using a few ounces of liquid soap added to hot water in the cooler Recycle water between cooler and cuff a few times to clear tube May be cleaned more often when necessary RN or PCA CRYCO CUFF ANNUAL REVIEW Reviewed Bewiewwa Reviewed Reviewed o Reviewed Reviewed Reviewed o Reviewed Bwewa j SAMPLE reduced size CRYOCUFF CLEANING SCHEDULE 1 COT RM A SIGNATURE 2 COT RM A SIGNATURE 3 IOU TREATMT RM SIGNATURE DATE DATE DATE JANUARY AUGUST JANUARY AUGUST JANUARY AUGUST JANUARY AUGUST JANUARY
24. chemical cleaner Do not place simulator on any kind of printed paper or plastic Do not use ball point pen on simulator Do not use dull or burred needles as these will cause leaks NOOR W ND SPECIAL INSTRUCTIONS A The arm features eight 8 spots for practicing injections B Use distilled water as the injection fluid C Simulator to be stored with other clinical teaching materials in original case INTRADERMAL INJECTION SIMULATOR ANNUAL REVIEW Reviewe Reviewed sM d Signature Reviewed Reviewed Reviewed Reviewed uM Reviewe Reviewed UNIVERSITY OI NOTRE DAME zem Liam March 2011 Reviewed Approved by Office of Student Affairs Director University Health Services Medical Director SUBJECT Isolation of Patients POLICY Patients who are suspected to be contagious to others will be separated from the rest of the University Health Services patient population PURPOSE prevent the transmission of infectious contagious illness GUIDELINES Visual alerts are posted in waiting and reception locations requesting patients with symptoms to sit in designated and separate area Inpatients and observation patients with known or suspected contagious illness will be placed in single patient rooms on IOU Patient education is posted in common areas on topics of respiratory hygiene practices Hand hygiene products and tis
25. documented before HIV testing can be performed Exhibit VI Consents and requested lab tests shall be obtained at UHS as soon as possible All testing for source and exposed employees will be done confidentially using number coded specimens and the Requisition Anonymous Laboratory Tests SBMF form no 13111 Exhibit VII Additionally affix the numbered label to the Exposure Incident Report for reference Lab tests should be drawn within 24 48 hours of exposure A copy of the test results for the exposed employee and source individual shall be forwarded to the referral doctor Test results must be identified with case number and whether it is the exposed employee A or the source B Additional sources will be identified as C D etc Each individual has the right to refuse testing The employee should be informed that worker s compensation benefits may be jeopardized if testing is refused If the employee consents to baseline blood collection but does not give consent at that time for HIV serologic testing the sample shall be preserved for at least 90 days If within 90 days of the exposure incident the employee elects to have the baseline sample tested such testing will be done as soon as possible NOTE Under Indiana Code 16 1 9 5 7 it is unlawful for any person to disclose medical information involving a communicable disease without a release Therefore when consent is sought from a source individual the source individual must b
26. employee b All documents pertaining to the employee s Hepatitis B vaccination status c All information which was provided to the healthcare professional making a post exposure evaluation d Results of examinations medical testing and follow up procedures related to a specific occupational exposure e Healthcare professional s written opinion for post exposure evaluation and follow up 2 Medical records must be kept confidential and maintained for at least the duration of employment plus thirty 30 years The record will be identified by the placement of an orange sticker on the file Medical records shall not be disclosed or reported without the employee s written consent to any person within or outside the workplace except as required by this plan or by law 3 The medical record will be maintained separate from the personnel file 4 Training records will be maintained for three 3 years and include a Training dates b Content or summary of the training c Name s and qualifications of the trainer s d Names social security numbers and positions of employees attending each session A contaminated sharps injury record shall be established and maintained to record percutaneous injuries from contaminated sharps and to serve as a tool for identifying high risk areas and evaluating devices Exhibit IX The contaminated sharps injury record will be recorded and maintained in such a manner to protect the confidentiality of the inju
27. for 15 seconds 9 Remove the absorbent tip from the buffer vial Replace the protective cap and place the test cassette horizontally on a flat surface for 10 minutes Do not interpret test prior to completing 10 minutes of development time 10 Once the background of the result window is white again it may be pink during testing time and 10 minutes has elapsed the test may be accurately read If there is a streaky pink background e eo after 10 minutes allow an additional 5 minutes of running time 11 Results are indicated through two lines which appear in the result window the result line and the control line The control line appears as a red line the control line zone It indicates the correct application and performance of the test and must appear for the test to be valid a Negative result only the control line appears A negative result should be reported as a presumptive negative for the presence of adenovirus antigens b Positive result the result line appears as a red line in the result window It indicates a positive result An uneven or incomplete result line is due to an uneven distribution of eye fluid on the sample pad Even if the result line is faint in color incomplete over the width of the test strip or uneven in color it must be interpreted as positive for the presence of adenovirus antigens c Invalid result if the control line does not appear the test must be discarded and the patient retested by re sampl
28. ice line for a 30 minute treatment to the top for 6 to 8 hours c Allow 5 minutes with agitation to chill water 2 Minimize underdressings if any Use stockinette to protect the skin a Apply underdressings with minimal tension particularly around the popliteal and pretibial area b Do not use with elastic wraps because the pressures are cumulative 3 Apply cuff always apply with cuff empty KNEE a Adjust infrapatellar opening so the cuff conforms to the slightly flexed knee b Secure the proximal strap tight but not constrictive Filling provides the compression c Apply distal strap loosely To minimize upper calf constriction do not stretch the elastic The distal strap can be quite loose A tight distal strap may cause constriction AUTHORIZED PERSONS CRYCO CUFF ANKLE a Disengage Velcro on bottom so flaps lay open Slide foot through and zip up b Close bottom flaps together for a comfortable but snug fit Velco can be adjusted to control the width and angle of the sole from heel to toe c Fasten top strap Fill and pressurize cuff a Connect tube to cuff Open air vent on the cooler c Elevate the cooler about 15 inches 30mm hg and hold for about 30 seconds to pressurize the cuff Avoid pressures above 30mm hg Reduce pressure with any sense of discomfort numbness or tingling of the limb d Press the metal tab on the quick disconnect while cooler is elevated to seal the pressure The tube
29. limited to the following a Sodium hypochlorite common household bleach in 10 concentration in water Thesolution shall be labeled with date and time of preparation and shall not be used if it is more than 24 hours old b Isopropyl alcohol rubbing alcohol at a seventy percent 7096 concentration by volume Indiana State Board of Health 410 IAC 1 4 8 Precautions Oct 6 1989 c Other chemical agents which have an Environmental Protection Agency EPA registration number and that meet hospital level disinfection standards 4 Patient beds tables phones etc shall be cleaned with a hospital grade detergent disinfectant between patient use or more frequently as needed 5 Trash cans shall be inspected daily and decontaminated weekly However when contamination is visible clean and decontaminate receptacles immediately or as soon as possible 6 All hard surface floors shall be cleaned daily and as needed with a hospital grade detergent disinfectant T Carpeted areas shall be vacuumed daily and thoroughly cleaned yearly more frequently as needed 8 Blinds shall be cleaned yearly or when visibly soiled SUBJECT BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN 9 Walls shall be cleaned when visibly soiled 10 Equipment shall be decontaminated prior to servicing or shipping Otherwise it must be appropriately labeled 11 Reusable utility gloves shall be decontaminated after each use 12 Broken glassware shall be picked up by
30. matter it must be fiitered prior to use or locate a supplier of clean cryogen Ice crystals can accumulate in the cryagen if the filled container is exposed to air without the cap in place These partictes will reduce the spray especially when using smail diameter tips Allowing the tips to warm will melt the particulate ice crystals and normal spray will resume Ckhibrt Storage of the unit is very important When not in use the container should be stored with the cap on even when empty to prevent build up of condensation inside Condensation will freeze and could lead to clogging of the outflow track and valve assembly SPUTTERING OF SPRAY Check that the container has not been overtilled Check that the top cap is correctly tightened to the container Sputtering can be caused by low internal pressure in the container Please see section Insufficient Spray for causes and remedies NOTE Pulsating spray is considered normal operation HISSING SOUND FROM PRESSURE SAFETY VALVE The sound is the vent ing of excess internal gas pressure built up in the container It is normal and occurs periodically during use Agitating the container will increase the pressure and the frequency of venting Continuous and uninterrupted sound may be a sign of relief valve malfunction This can be caused by foreign matter an the valve gasket or seat this situation you may also experience very short holding times as the gas evaporates continuously
31. of transmitting infectious particles and the surface or item is rendered safe for handling use or disposal 4 Exposure Incident A specific eye mouth other mucous membrane non intact skin or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee s duties 5 Occupational Exposure Reasonably anticipated skin eye mucous membrane or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee s duties 6 Other Potentially Infectious Materials OPIM The following human body fluids semen vaginal secretions cerebrospinal fluid synovial fluid pleural fluid pericardial fluid peritoneal fluid amniotic fluid saliva in dental procedures any body fluid that is visibly contaminated with blood and all body fluids in situations where it is impossible to differentiate between body fluids Any fixed tissue or organ other than intact skin from a human living or dead SUBJECT BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN T Parenteral Piercing mucous membranes or the skin barrier through such events as needlesticks human bites cuts and abrasions 8 Personal Protective Equipment PPE Specialized clothing or equipment used by workers to protect themselves from direct exposure to blood or OPIM 9 Regulated Waste Liquid or semi liquid blood or OPIM contaminated items that would release blood or
32. order iPLEDGE first visit form Exhibit I Clinic data sheet with Isotretinoin Transcription Label Exhibit I ISOTRETINOIN ACCUTANE THERAPY e Isotretinoin label placed on front of medical record lower left corner 2 Appropriate gender specific labs are ordered per Exhibit Il a Diagnosis code Acne 7060 is noted on lab requisitions with comment return q month 3 Physician marks diagnosis Acne on Isotretinoin on encounter form a Diagnosis code V5869 entered into Medicat by Front Office staff 4 Labresults a Reviewed by UHS physician Annual Review Revewed O pH uM gp Signature Reviewed Reviewed Reviewed Reviewed Reviewed p Revewed Reviewed Reviewed tS Revewed O iPLEDGE d PRESCRIBING CHECKLIST FIRST OFFICE VISIT For Male Patients And Female Patients Who Cannot Get Pregnant 55 First Visit Patient Registration Information Firstmame Last name o MI Address State ZIP Phonenumber J E mail Date of birth Social Security number Last 4 digits Patient has no Social Security card J I have obtained the signed Patient Information Informed Consent form 2 1 have supplied the patient with an iPLEDGE program identification card Identification card Confirmation information 2 1 have counseled this patient on the following Drug should not be shared with anyone Blood should not be don
33. patient instructions Distend the vein before venipuncture is attempted Apply B LABELING tourniquet 6 8 inches above insertion site or apply BP cuff and inflate it to approximately 80 90mm HG Apply tight enough to occlude venous return while maintaining arterial flow To further distend the vein when necessary have the patient open and close fist lower the patient s arm and gently pat the skin over the vein wet the skin well with alcohol or apply warm moist compress for 10 15 minutes Examine the arm and select possible infusion site Place a drape under the arm Using friction cleanse site with Povidon iodine and allow to dry for 30 seconds If necessary for visibility wipe away partially with alcohol and dry completely Work in circular motion from the center outward Do not touch the site prepped Note If the patient has an allergy to Povidone iodine use only alcohol swabs 2 3 Use a vigorous scrub for at least one 1 minute Start the IV at the distal end of the vein if possible Avoid veins that feel hard or have nodules above the intended site previously used veins or areas distal to previous sites Refer to picture of accessible sites in the hand and arm metacarpal cephalic basilica or median Do not shave over the insertion site Shaving may cause micro abrasions exposing the skin to bacteria The antiseptic will clean the skin effectively Shaving however may be necessary where the tape is applied
34. retract lower lid and hold position b Slide the lens out Terminate flow c Reassess and document response to treatment Annual review Reviewed Reviewed Reviewed j Reviewed o Reviewed Reviewed j Reviewed Reviewed d Reviewed o Reviewed o Reviewed o Reviewed UNIVERSITY OF NOTRE DAME UNIVERSITY HEALTH SERVICES Saint Liam Hall 74 631 7497 Notre Dame Indiana 4 46556 USA b http uhs nd edu March 2011 Issued Approved by Office of Student Affairs Director University Health Services Medical Director SUBJECT HUMAN IMMUNODEFICIENCY VIRUS HIV TESTING POLICY The University Health Services provides confidential HIV antibody testing to Notre Dame students Included in this service are pre and post test counseling by a University Health Services physician PURPOSE It is important to provide on campus confidential HIV testing and counseling due to the increase of occurrence of HIV disease in the United States and more specifically among young adults PROCEDURE A The student must see a physician to request HIV testing B Pre and post test counseling will be done by a UHS physician if testing is done at the Health Center It is expected that counseling would include discussion of 1 Determination of whether the student is at high risk risk factors for HIV infection risk reduction strategies 2 Determine whether
35. supervisor determines that a repair is required the UHS pharmacy shall be contacted The pharmacy shall serve as a resource for department managers in evaluating service needs 4 TriMedx shall be contacted for service and be responsible for documenting service on equipment for which they are responsible Documentation shall include e Equipment description manufacturer model and serial e Location Description of repairs e Description of maintenance and preventive maintenance 5 TriMedx shall be responsible for compliance with laws and regulations governing the performance of equipment and shall be able to provide documentation of compliance Annual Review Reviewed Reviewed Reviewed Reviewed o Reviewed Reviewed Reviewed Reviewed Reviewed Reiewd Reviewed Reviewed aunt Liar UNIVERSITY OI NOTRE DAME V HEALTH SERVICES SUBJECT Blood Glucose Testing ONE TOUCH Ultra System AUTHORIZATION Assistant Director Clinical Services DATE March 2011 PURPOSE To establish safe accurate bedside capillary blood glucose results that are used in decision making for patient care PROCEDURE A B RON Testing NOTE Prior to patient testing be sure that the system has been checked Reference Quality Control Tests procedure 1 Explain the purpose of the test and the procedure to the patient 2 Perform test procedure follo
36. swab to remove excess extract e Change needle e Apply firm pressure over the injection site for 15 20 seconds e Avoid rubbing or scratching the area of injection 4 Atthe first appointment for injections Have the student sign a Patient Information sheet Exhibit Ic Place a copy with their Allergy Folder and provide a copy for the patient 5 Schedule and or confirm next appointment with patient and in Medicat B Withholding of Injections The RN will withhold an injection if the patient e Is taking a beta blocker medication i e Inderal Inderide Timoptic Lopressor Corgad Tenormin etc Has a fever of 100 or more in the past 24 hours Has severe asthma or hay fever symptoms Has received immunizations excluding influenza in the past 24 hours Has any swelling remaining from the previous injection Is acutely ill e 5 overheated from strenuous physical activity These items are addressed on the Pre therapy Questionnaire Exhibit IX Injections that are withheld are documented on the Allergy Injection Schedule C Observation Time 1 All patients are required to remain in clinic for 30 minutes following their injections and to have the site of injection inspected before leaving the clinic 2 Non compliance will result in discontinuation of services at UHS ALLERGY INJECTIONS D Treatment of Reactions The immediate measures for treatment are directed by the allergist s protocol and UHS Medical Directives and may inclu
37. the event on an Emergency Medical Report form Exhibit a Date and time b Circumstances status of the patient c Vital signs d Treatment provided patient response to treatment e Notification of security physician Administrator family rector f Arrival time of Emergency Support persons and treatment provided g Disposition of patient h Charges Maintenance of Emergency Cart 1 An inventory sheet listing contents and the expiration of dates of medications and IV fluids will be maintained on each cart Exhibit II and III 2 Each cart will be sealed with a device that can be readily released when needed 3 Each cart will be checked once a day by the Night Shift RN or designated RN 4 A log listing date time and signature of the RN checking the cart will be maintained Exhibit IV Signing the log indicates that a the cart is sealed b the medications and supplies in the cart have not expired and are present C IV pole backboard and sharps container are present O tank is present and psi is checked for minimum sufficient volume of tank d the AED is present and working on the 13 floor cart e the ER Cart Log Exhibit IV will be monitored by the Assistant Director Clinical Services and maintained for three years 5 Immediately after use or if the seal is unlocked or absent the cart must be inventoried restocked prn and sealed Sign the cart log when complete or communicate the status of the cart to the nex
38. this is an appropriate time period to be tested 3 Education about HIV disease 4 Explanation of HIV testing purpose procedure for paying performing and reporting results type of test performed i e ELISA Western Blot interpretation and safer sex practices 5 Availability of treatment for HIV infection HUMAN IMMUNODEFICIENCY VIRUS HIV TESTING 6 Possible psychological and socioeconomic consequences of testing and results T Information to ensure that the student understands the risks benefits and alternatives to testing 8 Information that anonymous testing is available at the Health Department C The physician must document on the chart whether or not the student has consented D A confidential lab requisition form will be utilized when results of the testing are not recorded in the student s medical record The top copy of the form noting patient name and code number and the lab report noting a corresponding code number may be stored in a file maintained by the ordering physician or placed in the student s medical chart A standard lab requisition form will be used when the student requests a name identified HIV test Results will be placed in the student s medical chart E All test results must be obtained in person from the physician F A Release of Information form must be signed prior to any copy of the test leaving the Health Center even if the results are given to the student G The student will be directed
39. to maintain confidentiality may result in disciplinary action up to and including termination of employment In addition stringent confidentiality provisions are included in Indiana law which provides for disciplinary action and Class A misdemeanor penalties for those who divulge confidential medical or epidemiological information except fewer than three specified circumstances as follows 1 If the information is for statistical purposes and does not identify any individual 2 If all individuals identified in the information give written consent If the information is necessary to enforce public health laws certain criminal sentencing provisions or to protect the health or life of named party Source IC 16 1 9 5 7 Senate Enrolled Act 9 D HIV Reporting Indiana law requires the reporting of cases of Human Immunodeficiency Virus HIV to the State Board of Health except for anonymous counseling and testing sites certain research projects and other providers approved by the Board for exemption from name reporting Even if a site is exempt from HIV reporting confirmed cases of AIDS must be reported to the State Board of Health which must in turn report to the Centers for Disease Control Source IC 16 1 9 5 2 Senate Enrolled Act 9 429 Annual Review 0 Signature Date Reviewed Reviewed Signature Das Rweek ooo Reviewed Reewt Rwewt rReviewe lT Reewt
40. 4 large bath towels to cover the pack with a minimum of six layers on both sides c Use tape to close towel wrapped pack d You may place towel wrapped pack in a pillowcase 3 Treatment a Apply towel wrapped pack to patient as ordered indicated b Adjust position of patient to maintain contact of pack to affected area c For application to lower back have patient lie on their side or sit upright in HYDROCOLLATOR a chair and apply pack to designated area Use pillows to support pack DO NOT ALLOW PATIENT TO LIE ON HYDROCOLLATOR PACK the packs are filled with sand and they maintain their heat for long periods of time d Recheck patient and Hydrocollator pack frequently for placement and skin response e Limit treatment to 30 minutes q 2 hours or as ordered by a physician f Assess and document patient s response to treatment 4 Remove pack a Unwrap hydrocollator pack from towels return pack to hot water bath Maintainence 1 Use distilled water to fill Hydrocollator heating unit 2 Maintain water level in Hydrocollator heating unit to designated line Check this level every shift 3 Clean heating unit at the end of each semester December May and August and as needed e Shut off Hydrocollator Heating Unit and unplug it e Remove packs from unit e Place packs in a plastic bag and place in the freezer to maintain moisture Do not allow them to dry out Allow water to cool then empty unit Cleanse inside of unit with a
41. 55 u1 55 o 55 55 co 55 N N 55 N N N w N B N N Oo N N N N w w 55 Completed monthly log to Assistant Director Clinical Services UNIVERSITY OF NOTRE DAME UNIVERSITY HEALTH SERVICES SUBJECT NARCOTIC COUNTS IN INPATIENT UNITS AUTHORIZATION Medical Director DATE June 2014 PURPOSE To maintain an exact inventory and dispensing record of controlled drugs dispensed at the Health Center PROCEDURE AND OR GUIDELINES Controlled drugs are kept in double locked cabinets in the Inpatient Unit Two nurses or a nurse and a pharmacist count controlled drugs verify with the logged inventory and sign the log book This is done every shift during the academic year Signature logs and inventory sheets are returned to the Pharmacy for storage at the end of each month and when more medication is required respectively ANNUAL REVIEW Reviewe Signature pom Reviewed Reviewed dl Reviewe dl Reviewed Reviewe Reviewed Reviewe Reviewed Reviewe d d amt Liar UNIVERSITY OI NOTRE DAME UNIVERSITY HEALTH SERVICES SUBJECT NEBULIZER TREATMENTS AUTHORIZATION Assistant Director Clinical Services DATE March 2011 PURPOSE To deliver medications directly into the respiratory tract To provide
42. A biological indicator is a highly resistant bacterial endospore Biological indicators are used to monitor mechanical function and operator technique to determine sterilization efficiency If the culture does not grow the autoclave was effective in sterilization 1 The adequacy of the autoclave is checked by having Autoclave Check Cultures performed monthly on ampules of bacterial spores that have been subjected to the sterilization process 2 The kits are stored in the 1 floor dirty utility room at room temperature 3 Follow the procedure for Autoclave Check Culture A Means of Verifying Sterilization Equipment Adequacy Exhibit I 4 Complete a lab requisition form to process the Check Culture Exhibit Il Keep the pink copy of the requisition in UHS Medical Director orange lab folder until results are returned 5 A print out from the autoclave of that sterilization cycle which includes the biological testing date length of timing and temperature for the sterilization cycle should be kept with the pink copy above 6 When results of the autoclave culture return from South Bend Medical Foundation document on the Autoclave Maintenance Record P Nursing NursingForms Autoclave Maintenance Record in the cabinet in the autoclave room Then forward the results and pink copy of the requisition to the Assistant Director Clinical Services INSTRUMENT PROCESSING AND STERILIZATION 1 Records of all autoclave check c
43. CEDURE Explanation of Procedure given Consent signed for Procedure Release of Information consent form signed optional Specimen sent to Pathology SITE I hereby give my permission for the above listed Procedure to be performed on me by the physician M D I have identified the operative area wound as gt the location for the procedure as LEFT RIGHT The proposed Procedure and the expected outcome risks and reasonable alternative of the proposed pro cedure have been explained to me I have had the opportunity to obtain answers to all questions I have regarding the Procedure Other medication used DATE TIME ALLERGIES Local Marcaine 1 Xylocaine 1 w epinephrine 2 Xylocaine 2 w epinephrine Topical Liquid Nitrogen AgNo Sticks Patient Signature Date and Time Witness Physician or RN POST PROCEDURE INSTRUCTIONS Follow up appt WOUND CARE Hand out R LC E Other Instructions MD or Ns signature UNIVERSITY OI NOTRE DAME aunt Liar SUBJECT CRYCO CUFF AUTHORIZATION Assistant Director Clinical Services DATE March 2012 PURPOSE To provide safe compression to minimize swelling and cold to minimize pain EQUIPMENT SUPPLIES Cryo cuff which includes cuff ankle or knee cooler and tube Stockinette PROCEDURE 1 Prepare cooler a Add water to the appropriate line indicated inside the cooler b Add ice to the minimum
44. Date and initial receipt in lower right hand corner Note patient name status Frosh Soph Jr Sr and contact phone number on the Allergy Patient List Exhibit Il Initiate Allergy Injection Schedule Exhibit VI and Immunotherapy checklist Exhibit IV See procedures for reference The patient does not need to wait while this is done Initiation of these forms will expedite their first visit If information is missing from Allergist s instructions items checked on checklist initiate letter to the doctor Exhibit VIII Highlight the areas of importance on the Allergist s instructions Place all forms and instructions in a plastic folder File in Allergy Room cabinet Provide student business card with Allergy Office contact information Instruct student to call Allergy Office phone line to set up and request changes in appointment times Plan first appointment for student if the student knows their schedule Otherwise remind the student that it is their responsibility to contact the Allergy nurse to make their appointment G Extract Pick up Document pickup of extracts on the Allergy Injection Schedule Their original injection schedule and or doctor s guidelines may be given upon request Make a copy of their schedule for our chart After giving the packet to the student note it on the Allergy Injection Schedule Exhibit VI Also note whether or not they are expecting to return for allergy injections when they return
45. HECKLIST FIRST OFFICE VISITS For Female Patients Of Childbearing Potential Patient name __ nm ID8 First Visit Patient Registration Information Tisi conn L MI Address City __ _ _ _ _ _ _ _ sue ZIP Phone number B Date of birth Social Security number Last 4 digits J Patient has no Social Security card JI have obtained the signed Patienr Information Informed Consent form I have supplied the patient with an IPLEDGE program identification card Identification card Confirmation Information 1 have counseled this patient on the following Requirement to use 2 forms of birth control every time she has intercourse Drug should not be shared with anyone Blood should not be donated while taking isotretinoin Patient program requirements First Pregnancy Screening Initial pregnancy test serum or urine must be negative for patient to enter the PLEDGE program Dae Results Positive J Negative Follow up Visit Contraception Counseling OT have provided contraception counseling to this patient OR O This patient was referred to and obtained contraception counseling from another healthcare professional Date of contraception counseling 0 0 O 1 have obtained a signed Patient Information Informed Consent About Birth Defects form from this parent Confirmation Information 12 acceptable forms of contraception used simultaneously for 30 days prior to second pregnancy test Contraceptio
46. OPIM in a liquid or semi liquid state if compressed items that are caked with dried blood or OPIM and are capable of releasing these materials during handling contaminated sharps and pathological and microbiological waste containing blood or OPIM 10 Universal Precautions An approach to infection control According to the concept of Universal Precautions all human blood and certain human body fluids are treated as if known to be infectious for HIV HBV and other bloodborne pathogens METHODS OF PROTECTION COMPLIANCE A Universal Precautions Universal Precautions is an approach to infection control See Terminology There is no practical way to determine the health status of all patients who may be sources of bloodborne pathogens Using this assumption when dealing with infectious materials eliminates the need for decision making to determine the extent of actual or potential disease hazards and establishes minimum standards for contamination control which will effectively control bloodborne pathogens if they are present This approach includes the use of barrier precautions by employees to prevent direct skin parenteral or mucous membrane contact with blood or other body fluids that are visibly contaminated with blood Universal precautions shall be observed to prevent contact with blood or other potentially infectious materials In situations where differentiation between body fluid types is difficult or impossible all body fluids sha
47. R IRRIGATION ANNUAL REVIEW Reviewed o Reviewed Reviewed o Reviewed Reviewed Reviewed o Reviewed Bwewa j amt Liar UNIVERSITY OI NOTRE DAME UNIVERSITY HEALTH SERVICES SUBJECT EKG Electrocardiogram AUTHORIZATION Assistant Director Clinical Services PURPOSE To provide information concerning the electrical activity of the heart valuable in the diagnosis of abnormal cardiac rhythm and myocardial damage DATE March 2012 PROCEDURE 1 Explain procedure to the patient 2 Turn machine on Program patient data if patient stable or document demographic information on the printout after the procedure 3 Lead Placement see diagram Exhibit 1 Place sensors and attach leads as indicated RA LA RL LL leads match to appropriate extremity V1 lead 4th intercostal space at right sternal border V2 lead 4th intercostal space at left sternal border V3 lead midway between V2 and V4 V4 lead 5th intercostal space on left midclavicular line V5 lead on left anterior axillary line at the same level as V4 V6 lead on left mid axillary line at same level as V4 Note For patients with chest hair that interferes with good contact of the sensors any one of the following techniques may be used a Spread the hair between thumb and forefinger apply the sensor to the exposed skin b Usea water dampened tow
48. RVICES Saint Liam Hall Notre Dame Indiana 46556 USA CLINICAL SERMCES STATEMENT It is the policy of University Health Services at the University of Notre Dame to provide professional and quality nursing care to qualified students Nursing personnel meet the requirements of their position descriptions and demonstrate knowledge and skill attained through formal training education and experience Nursing procedures are performed according to best practice guidelines and equipment specific recommendations for use Clinical policies and procedures are reviewed by the Assistant Director Clinical Services on an annual basis Revisions and updates are made as necessary and communicated to appropriate staff Medical records are reviewed annually for compliance with standards of nursing documentation The Procedure Manual does not represent an all inclusive list of nursing procedures but serves as a reference for those procedures that are considered high volume and or high risk potential UNIVERSITY OI NOTRE DAME UNIVERSITY HEALTH SERVICES March 2011 Issued Approved by Office of Student Affairs Director University Health Services Medical Director SUBJECT ADD VANTAGE INTRAVENOUS MEDICATION POLICY Whenever financially and clinically advisable the Ad Vantage Intravenous Administration System will be used particularly in administration of antibiotic solutions PURPOSE To reduce waste and reduce nursing time necessar
49. Signature Albuterol O Clear Non Temp 2 5mg 3ceNS O Clear Non p LI Rales productive P u Other LI Rales productive R Rhonchi 11 Productive EC M Rhonchi __ 11 Productive goga Wheezes __ PeakFlow 0 Wheezes __ PeakFlow ___ Diminished___ Diminished 11 Non 11 Albuterol Non Clear productive Temp 2 5mg 3ccNS O Clear productive p Rales O Productive f o Other O Rales D Productive R Rhonchi RI O Rhonchi O2sat O2sat PeakFlow _ Wheezes __ PeakFlow LI Wheezes __ eaKFiow Diminished O Diminished 11 Non 11 Albuterol LI Non Clear A productive Temp 2 5mg 3ccNS Clear productive Rales m O Productive P Us o Other Rales D Productive R Rhonchi n Rhonchi O2sat O2sat PeakFlow _ Wheezes __ PeakFlow__ Wheezes __ Diminished EI Diminished___ O Non Albuterol 0 Non Clear LL productive Temp 2 5mg 3ccNS Clear productive p LI Rales __ _ lU Productive P _ f o Other LI Rales U Productive R I Rhonchi __ __ ___ Re I Rhonchi __ __ ___ O2sat O2sat PeakFlow O wheezes __ __ __ PeakFlow Owheezes __ __ PAKCIOW Diminished__ 11 Diminished___ __ Insp Exp Loc O Non m Albuterol Insp Exp Loe m N
50. a sage and effective method of administration of therapy EQUIPMENT SUPPLIES Pulmo Aid compressor Nebulizer Kit Unit Dose medication packet per physician order PROCEDURE AND OR GUIDELINES A B C D m RN to perform Wash hands Assemble equipment following package instructions for assembly of the Nebulizer Kit Place medication as ordered by physician into nebulizer bottle Order must include name dose and frequency of medication Place compressor onto a steady level surface With power switch in the off position plug cord into outlet Position patient for comfort in sitting position Instruct patient a Place mouthpiece between teeth With mouth closed inhale deeply and slowly through mouth as the aerosol begins to flow then exhale slowly through the mouthpiece Breathing through the nose will reduce the quantity of drug delivered to the lungs It will also prevent the drug from deeply penetrating the airways b Encourage the patient to drop their shoulders and relax Encourage inspiratory holds if possible About every 10 breaths or approximately one minute encourage the patient to take a slow deep breath hold for 5 10 seconds then exhale slowly This will help the drug reach the lower e NEBULIZER TREATMENTS airways Advise the patient to continue the treatment until the medication in the nebulizer has been aerosolized This should take approximately 15 20 minutes If the treatment n
51. al purpose utility gloves e g rubber household gloves for housekeeping chores involving potential blood contact and for instrument cleaning and decontamination procedures Utility gloves may be decontaminated and reused but should be discarded if they are peeling cracked discolored punctured torn or if there is other evidence of deterioration or leakage Gloves shall be changed under the following circumstances a Between patient contacts b If visibly contaminated with blood or body fluids although certain repetitive tasks in laboratory settings may be completed before gloves are changed i e wiping the probe on a whole blood analyzer SUBJECT BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN c When physical damage to the integrity of the glove is observed i e tearing surface defects Employees with known minor skin defects i e cuts abrasions burns dermatitis or exudative lesions on arms hands face or neck must cover these areas with a water resistant bandage in addition to the use of PPE Employees with weeping or exudative lesions or dermatitis which cannot be Securely covered shall refrain from direct patient care and handling clean or soiled patient equipment Indiana State Board of Health 410 IAC 1 4 8 Precautions 2 Face Shields This barrier device is intended to protect eyes nose and mouth from coming in contact with blood or body fluid droplets Employees shall wear protective face shields whenever spla
52. and up to twenty 20 minutes 5 Inspect and manually clean each instrument to remove any residual soil Instruments should be cleaned underwater using a nonabrasive brush Spatter or aerosols generated during hand scrubbing must be minimized Rinse instruments thoroughly Wear utility gloves face shield and a protective gown 6 Place instruments on an absorbent towel Allow to dry thoroughly 7 Lubricate hinged instruments with spray lube 8 Decontaminate utility gloves cleaning brush and containers for transporting and soaking instruments each evening B PACKAGING Packaging will permit sterilization to take place and provide delivery of its contents without contamination Cleaned instruments are still considered contaminated Wear gloves 1 Place dried instruments into pre labeled packages Place with the handle towards the end which opens Place a small gauze square over any sharp edges Hinged instruments must be held in an opened position with gauze Place the gauze and sharp edge toward the opaque side allowing view of the instrument through the clear side This should keep the package from being punctured and contaminated 2 Seal the bags following the package instructions C SHELF LIFE Sterilized instruments have a shelf life of one 1 year unless the integrity of the package has been compromised 1 Sterile items dropped into any type of liquid or items with liquid spots anywhere should be considered contaminated
53. ars as a red line in the result window It indicates a positive result An uneven or incomplete result line is due to an uneven distribution of eye fluid on the sample pad Even if the result line is faint in color incomplete over the width of the test strip or uneven in color it must be interpreted as positive for the presence of adenovirus antigens c Invalid result if the control line does not appear the test must be discarded and the patient retested by re sampling the eye using a new test kit i Note if a second sampling is required eye fluid may be reduced and inadequate for testing If both eyes are affected and second sample needed use other eye If only one eye is affected the sample may be repeated immediately if adequate secretions are available or it may be repeated several hours later 12 Refer to package insert for color photographs and illustrations on proper use of test kit 13 Document results of test in medical record notify physician as indicated 14 Document charge for test on encounter form FORMS or REFERENCES Conjunctivitis label for assessment Encounter form ANNUAL REVIEW Signature Date Signature Date Reviewed Reviewed Reviewed Reviewed Reviewed Reviewes Reviewed Bewiewwa Reviewed Reviewed j UNIVERSITY NOTRE DAME UNIVERSITY HEALTH SERVICES March 2011 Reviewed A
54. aslin At a minimum complete numbers 1 2 3 6 and 7 Keep the mailing containers Store them in the bin under the sink ALLERGY PATIENT LISTING Name Last First Phone Number Year in school UNIVERSITY HEALTH SERVICES Student Health Center Telephone 574 631 7497 Notre Dame Indiana 46556 Facsimile 574 631 6047 TO Date Fax Number Dear Doctor University of Notre Dame Health Services has received instructions and schedule for Patient Name DOB Please provide the following information for our records as we provide continued allergy injections for your patient while they are attending the University of Notre Dame Type of extract or dilutions of extract Recommended interval of injections Recommended maintenance dose or dose schedule Expiration date of extract Guidelines for reactions including dose adjustments due to any reactions Method we should use to obtain new extract when needed Guidelines for dose adjustments due to lapses in therapy LILILILILILILI LI Signature of Prescribing Doctor authorizing therapy Other University Health Services will await your written clarification of these matters before attempting to provide care for your allergy patient Please send your recommendations to University Health Services University of Notre Dame Notre Dame Indiana 46556
55. assessing the patient s comfort f Release the actuator and keep the eartip in the canal for 5 10 seconds to vacuum any remaining water 2 Water Pik a Fill Water Pik container with warm water Prime tubing b Insert tip of Water Pik at the opening of the ear canal c Turn on Water Pik to allow water to flow freely into ear Keep dial on 2 3 no higher than 4 5 If the patient experiences discomfort adjust water pressure If discomfort continues stop procedure d Refill water and empty ear basin prn Elephant Ear Wash System a Fill Container with warm water May use small amount of shampoo soap b Install disposable tip to tubing c Squeeze trigger After Procedure a Document patient s response to treatment b Examine ear to assess ear status Refer to physician if e Painful irrigation e Redness or pus in ear canal e Tympanic membrane invisible e Unable to remove cerumen Clean equipment a Rinse and dry device b Wash ear basin and irrigation tip in warm soapy water Rinse c Drain water from plastic tubing d Store equipment and cover with a towel NOTE To remove lime build up in tubing place full strength vinegar in reservoir turn machine on and flush tubing until scale is removed Repeat prn Flush well with tap water To disinfect the tubing rinse with 10 bleach solution or soak tubing in disinfectant e R Maintenance Breakdown Notify Assistant Director Clinical Services EA
56. ated while taking isotretinoin Patient program requirements lJ E have prescribed maximum 30 day supply of isotretinoin USE REVERSE SIDE FOR MONTHLY VISITS Ether Jd O iPLEDGE amore m Prague y Prem PRESCRIBING CHECKLIST MONTHLY VISITS For Male Patients And Female Patients Who Cannot Get Pregnant Patient name Monthly Visits Confirmation Information I have counseled this patient on the following Drag should nar be shared with anyone Blood should not be donated while taking isotretinoin Panent program adherence 1 1 have confirmed with the PLEDGE system that have counseled the patient Ehave prescribed maximum 30 day supply of isotretinoin Confirmation Information J I have counseled rhis patient on the following Drug rhould nos be shared with anyone Blood should not be donated while taking isotretinoin Patient program adberence QI have confirmed with the iPLEDGE system that 1 have counseled the patient U E have prescribed maximum 30 day supply of isotretinoin Contirmation Information T 1 have counseled this patient om the following Drug should nor be shared with anyone Blood should noz be donazed while taking isotretinoin Panem program adherence 1 have confirmed with the iPLEDGE system tha I have counseled che panest 7 1 have prescribed maxinsum 30 day supply of isotretinoin Last Month Of Therapy Date Confirmation Information I have counseled this patient on
57. bsequently do not need to be re tested The results of the PPD must be documented on a PPD form that is signed or stamped by a U S physician or other authorized official A Mantoux PPD test administered in a foreign country that yielded a negative result will not be accepted even with a validated PPD form or other documented test results These student will be re tested by QTF G at the Health Center A student with a Mantoux PPD test administered in a foreign country that yielded a positive result and without certificate of completion of INH therapy will be required to have QTF G test or a chest x ray and offered medications Only exception for TB screening is if certification of completion of pharmaceutical INH therapy for the appropriate period of time Section IV Classifying Tuberculin Reaction The area of swelling around the site of the PPD injection is the reaction to tuberculin The PPD test is read by taking a measurement in millimeters of the induration hardness under skin not the redness of the skin perpendicular to the long axis of the forearm 1 Areading of five or more millimeters is positive for the following groups Persons who have close contact with an individual with infectious tuberculosis Persons with HIV infection Persons who have chest x rays with fibrotic lesions likely to represent old healed tuberculosis Persons who inject drugs if HIV status is unkown 2 Areading of ten or more millimeters is posi
58. call 2 Attendance and performance of on call staff members will be reviewed at the end of each semester and names will be continued or removed from the staff list 3 On call staff members for University Health Services Student Health Center will have preferential consideration over those who only work for special events when full or part time positions become available in the Student Health Center ON CALL HEALTH CENTER STAFF REQUIREMENTS ANNUAL REVIEW Reviewed O Bo SSS un Reviewed __ Reviewed Reviewed Reviewed Reviewed Reviewed Reviewed aunt Liar UNIVERSITY OI NOTRE DAME V Y HEALTH SERVICES SUBJECT OXYGEN DELIVERY AND CYLINDER CHANGE AUTHORIZATION Assistant Director Clinical Services DATE March 2011 PURPOSE To assure proper oxygen therapy as ordered To maintain safe handling of oxygen cylinders Oxygen Delivery 1 2 3 4 9 6 Slowly turn green cap or wrench handle counter clockwise one full turn Check pressure gauge to determine amount of pressure in cylinder Replace cylinder if REFILL is indicated Attach the plastic tubing of the delivery device mask or cannula to oxygen port near the flowmeter Adjust flowmeter to desired flow rate Verify delivery of oxygen by listening and feeling for Oz flow through the delivery device Place delivery device on patient adjust for proper fit and comfort After Use Bleed the System 1 2 3
59. cutane Accutane dosage Allergies Weight kg Temp FEMALES FDLMP Methods of Birth contral primary sec Review of Systems Check all problems that apply to the past month of treatment e Headaches e Genital Urinay 9 Hairloss e Achingjoints back Dryliritatedeyes _ e Dry skin please indicate areas Dry bloody nose e Drylcrackedlips e Moodswings nausea diarrhea bloody stool cramps __ Labs Date drawn _ 7 CBC hCG Glucose Total Cholesterol _____ Triglycerides Hepatic Panel RN Signature amt Liar SUBJECT AUTHORIZATION PURPOSE DATE UNIVERSITY OI NOTRE DAME UNIVERSITY HEALTH SERVICES INTRAVENOUS THERAPY Assistant Director Clinical Services To provide access for the delivery of IV fluids and medications To maintain or restore fluid and electrolyte balance To provide intravenous access when frequent lab draws are necessary March 2011 PROCEDURE AND OR GUIDELINES A VENIPUNCTURE 1 Equipment 8 Gloves unsterile minimum PPE b Waterproof drape C Tourniquest or BP cuff d Povidone iodine prep e Alcohol prep pads f IV device of choice g Plastic tape h Tegaderm dressing small IV fluids and tubing premed or Reseal cap and 1 syringe sterile saline j IV pole or pump k Gauze sponges l Sharps container 2 Selection of Veins and IV Site Preparation Exhibit a Wash hands wear gloves b Provide
60. d be kept in a locked position when the hand control is given to the patient T Cleaning Infection Control a Turn unit off disconnect from power source b Spray approved disinfectant onto the surfaces plastic leg support plastic covers and metal parts Use a new padding system for each patient d The Adjust a Cinch straps are reusable and only need to be replaced when soiled These may be washed in soap and water 8 Maintenance Breakdown Notify Clinical Services Administrator 9 Charges Daily use charge Padding EQUIPMENT SUPPLIES KINETIC Performa Universal Quilted Pad System Adjust a Cinch Straps AUTHORIZED PERSONS Physician prescribes settings for set up duration and frequency of each session per written orders RN programs and implements settings instructs patient in use RN and PCA monitors use measures patient response and follows infection control measures KINETEC Performa Continuous Passive Motion CPM Exerciser ADDITIONAL CONSIDERATIONS Manufacturer s guidelines for use will be followed unless otherwise defined Remember you are programming the machine s angle NOT THE PATIENT S KNEE ASSOCIATED POLICIES or PROCEDURES or FORMS CPM Physician Orders CPM Flow Sheet Kinetec Performa Manual located in the IOU Nurses Station and the Clinical Nurses Station ANNUAL REVIEW Revewed Reviewed Reviewed Jo Reviewed Reviewed Reviewed J o g
61. d equipment must be decontaminated if feasible using approved methods prior to servicing or shipment When not feasible the equipment must be clearly labeled asa biohazard to alert employees as well as transportation and service people of the need to use Universal Precautions e Eating drinking smoking applying cosmetics and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure f Food or drink storage is prohibited in work areas i e refrigerators freezers shelves cabinets countertops where blood or OPIM are used or stored Refrigerators used for storage of blood or specimens may not be used for storage of food or drink D Personal Protective Equipment PPE PPE refers to specialized clothing or equipment used by workers to provide barrier protection of the skin or mucous membranes from direct exposure to blood or OPIM The use of appropriate PPE is required as supplementary protection in all situations where occupational exposure remains after use of both engineering and work practice controls The Health Center requires the use of appropriate PPE for all employees for whom SUBJECT BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN occupational exposure is reasonably anticipated when engaged in tasks involving contact with blood body fluids or any potentially infectious material Appropriate PPE shall be readily accessible to all employees for whom it is required sha
62. d nitrogen is obtained on Mondays or early Tuesday morning Using Personal Protective Equipment PPE goggles and leather insulated gloves fill the large isotherm liquid nitrogen container with 2 liters of liquid nitrogen Amount of liquid nitrogen obtained must be signed for in the Radiation Laboratory on the appropriate form RN will fill Nitrospray device 2 3 full using PPE face shield and leather insulated gloves when needed To dispense the liquid nitrogen via the Nitrospray device e Choose appropriate tip Squeeze trigger to dispense to site To dispense the liquid nitrogen via cup e Pour a small amount of the nitrogen into a 6 8 oz Styrofoam cup from the Nitrospray device or from the large isotherm container NOTE When pouring the nitrogen into the cup the following PPE is required to be worn e Face shield or goggles LIQUID NITROGEN e Leather or insulated glove on hand holding the cup The nitrogen will dissipate from the cup in several minutes If any product remains in the cup after use allow it to dissipate completely before disposing of the cup Nitrogen must never be discarded into a sink or on asphalt grass or shrubs All equipment can then be placed in cupboard of Procedure Room A Material Safety Data Sheet is on file See Quick Tips for Nitrospray Instrument EXHIBIT I ANNUAL REVIEW Reviewe dl o Reviewed D Reviewe Reviewed Reviewe Rev
63. de 1 Local reactions Ice bag to injection site Benadryl or hydrocortisone topical cream to injection site prn Extended observation time and recording of vital signs Possible dose adjustment for next injection Notification of UHS Physician and Allergist prn 2 Systemic reactions MEDICAL EMERGENCY Position patient in supine position with head lower than rest of body if possible Placement of tourniquet above the site of the injection Remove every 10 minutes for 1 2 minutes Epinephrine 0 3cc SQ Notify UHS Physician or Physician Assistant Extended observation time and recording of vital signs Document reference to systemic reaction event in medical record on clinic data sheet Inform Allergist per telephone All instructions must be followed by written verification before next dose is given Reactions requiring medical intervention should also be documented on the organizational Adverse Event paperwork and given to the Assistant Director of Clinical Services or Department Director E Forms and Documentation 1 General Instructions A sticker is placed on the front of the student s medical record indicating that there is additional allergy immunotherapy documentation in the Allergy Room file All instructions received from the Allergist will be dated and initialed in the lower right hand corner upon receipt and become a permanent part of the patient s medical record Information is reviewed for complete and clear i
64. e becomes difficult to operate an obstruction may have occurred Do not continue suctioning until the source of the obstruction is determined Either remove the plastic plug at the canister top or remove the canister from the pump to release vacuum and help clear a blockage at the catheter tip When the tip is clear reattach the plug and the canister If the catheter becomes obstructed it may be cleared by repeatedly squeezing the pump handle to move the obstruction through the catheter and into the canister When the obstruction is cleared continue suctioning of the patient 100 mi Disposable Canister 4 Catheter te j S f 55 mi Disposable Canister A Catheter Set FORMS or REFERENCES American Red Cross reference material MANUAL SUCTIONING Note Always follow standard precautions when providing care If needed assemble the device according to manufacturer s instructions POSITION THE VICTIM Roll the body as a unit onto one side Open the mouth REMOVE DEBRIS FROM THE MOUTH u With a gloved fi nger sweep out any visible large debris MEASURE AND CHECK THE SUCTION TIP Measure from the victim s earlobe to the corner of the mouth Note the distance to prevent inserting the suction tip too deeply u Check that the suction is working by placing your fi nger over the end of the suction tip as you squeeze the handle of the device SUCTION THE MOUTH u Insert the suction tip into the back of the mouth u
65. e informed that the result will be released only to the exposed employee and the healthcare professional evaluating the employee after exposure Likewise the employee and healthcare professional evaluating the employee after exposure shall be informed of confidentiality requirements Any positive HIV test result must be reported to the Indiana State Board of Health 16 1 9 5 2 SOURCE INDIVIDUAL Requested tests include HIV antibody Hepatitis B surface antigen Hepatitis C antibody NOTE If the source individual is known to be infected testing does not need to be repeated to SUBJECT BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN determine the known infectivity EXPOSED EMPLOYEE Requested tests include HIV antibody Hepatitis B antibody Hepatitis C antibody C Post Exposure Prophylaxis and Follow Up The referral physician shall counsel the exposed employee regarding the potential risk of HIV infection from the exposure in question the advantages and disadvantages of post exposure prophylaxis possible medication side effects possible symptoms of early HIV infection and the need to observe precautions to prevent potential secondary HIV transmission Hepatitis B immunoglobulin HBIG and the Hepatitis B vaccine series will also be offered when indicated A written evaluation of the exposure incident shall be provided to the employer within 15 days of the completion of evaluation Exhibit VIII Evaluation of any reported post
66. ed po Reviewed Reviewed ant Liar UNIVERSITY OI NOTRE DAME t IVERSITY HEALTH SERVICES SUBJECT INTERNATIONAL TRAVEL CONSULTATION PROCEDURE AND PATIENT EDUCATION PROTOCOL AUTHORIZATION Assistant Director Clinical Services DATE June 2014 PURPOSE To provide educational resources for students traveling to international travel destinations for University purposes To recommend and administer immunizations to patients seeking protection from vaccine preventable diseases To provide appropriate documentation to individuals receiving vaccinations To research the patient s personal medical history and offer appropriate prescriptions for prevention or treatment of various diseases associated with the country traveling to PROCEDURE AND OR GUIDELINES The CDC travel site is used for all travel vaccine recommendations given in the travel clinic Travax Shoreland and Stay Healthy When You Travel Sanofi Pastueur websites are also used for patient information and education purposes Immunization dosages intervals routes of administration etc are based upon manufacturers recommendations The travel clinic record will be completed by a travel nurse consultant and co signed by the travel physician Patients with special medical needs or who require alteration in vaccines dosages intervals etc must be referred to a physician For All Immunizations RN will e Explain procedure s to patient Revi
67. ed the 30 day supply osiedla Pregnancy Test Results Pregnancy Test Type Serum Urine Serum Lab Test Results lJ Positive Negative Preseriber Diagnosi J Pregnant J Not Pregnant Blood should noe be donated while taking isoeretinoin Patient program adherence J1 have confirmed with the PLEDGE system that I have counseled the pari 41 have prescribed maximum 30 day supply of isotretinoin Lab Test Kesula 4 Positive J Negative Prescriber Diagnosis J Pregnant J Not Pregnant Blood should not be donated while taking isotretinom Patient adherence J 1 have confirmed with the PLEDGE tystem that 1 have counseled the patient J I have prescribed maximum 30 day supply of isotretinom Specimen Collection Date ZE Serum Urine hCG z A Posniye J Negative Prescriber Diagaosis J Pregnant J Nos Pregnant Blood should not be donated whale taking Patient program His oai WA EUFOGE erm om hee counseled the patie Specimen Collection Dase Bene Ya Serum J Urine ee ORTI Rois 2 Positive J Negative Prescriber Diagnosis J Pregnant J Not Pregnant 30 day Follow up Fina ordered serum or urine pregnancy test through Preynancy Test Results Specimen Collection Date Pregnancy Test Type Serum 2 Serum hCG mlU mi Lab Test Results Positive J Negative Pre
68. eeds to be interrupted for a cough spasm have the patient turn off the machine until the coughing subsides Encourage the patient to cough at the end of the treatment to remove secretions H Assess patient pre and post treatment a b C d e Note color Check pulse and respiratory rate i Aresting pulse over 120 bpm is cause for concern Notify physician or if possible delay treatment until pulse rate slows Auscultate breath sounds Observe for retractions labored respirations or use of accessory muscles After treatment retain patient for further observation if incicated Evaluate patient response to treatment after 5 7 minutes of treatment initiation a b C Check pulse Observe patient chest for adequate expansion Observe patient breathing rate and pattern i If too rapid instruct patient to slow breathing ii If breathing without sustained inspiration reinstruct iii Remind patient to relax shoulders J Monitor patient for any adverse response Color change Diaphoresis Nausea Abnormal sensations i e numbness or tingling Pulse change of 20 bpm Dizziness These symptoms may be due to hyperventilation Observe closely K If you suspect adverse patient reaction Stop therapy immediately Check vital signs Monitor SaO prn Do notleave patient unless stable or another staff is with pt Notify physician for further orders
69. el 46 du loving Requirement to use 2 farms of birth control every time she has intercourse Drug should not be shared with anyone Confirmation Information 32 forms of used aeos TE t m CZ M Um Serum anh ordered through of ui test a JI have counseled this patient on the following Requirement to use 2 forms of berth comro every she has intercourse Drug should not be shared with anyone Confirmation 22 accepeable forms of comraception used simultaneously for 30 days prior to pregnancy test Coenracepoon form 1 Contraception form 2 Serum or test ordered throagh QI have Wi piden die following Requirement to use 2 forms of birth contral every time she has intercourse Drug should not be shared with anyone After The Last Dose Confirmation Information D Serum or urine test ordered through 2 CLIA certified si 1 have counseled this patient on the following Requirement to use 2 forms of birth control every time she bas intercourse for at least 30 days Any remaining drug should noc be shared with anyone Blood should not be donated for at least 30 days Pregnancy Tost Results Specimen Collection Dare Ine JSenm Urine mlU ml Fek kde 2 Positive 2 Negative Prescriber Diagnosis J Pregnant J Not Pregnant IDe Blood should not be donated while taking isotretinoin Panien program adherence Si tiem dat Thay counsel
70. elette to moisten the skin area to enhance the adhesive tack prior to applying the sensor If methods a and b do not work shaving may be necessary EKG Electrocardiogram 4 EKG Training a Allow at least 30 seconds after lead placement before performing a tracing to allow the system to stabilize and patient to relax Automatic operation 12 lead EKG and Lead II Rhythm strip a Turn machine ON prior to lead placement b Afterlead placement push AUTO c Then push YES Manual operation Rhythm strip only Lead II a Turn machine ON prior to lead placement b Afterlead placement push MANUAL one sheet of paper equals 10 seconds tracing c Push STOP when desired strip is obtained Note Machine will indicate loose lead if one or more leads are loose or off Check all sensors and lead wires and repeat steps for automatic or manual operation d Remove and discard sensors after procedure is completed e Turn machine off 5 Paper Refill Use Burdick thermally responsive paper Remove Z fold paper from the package Open paper compartment on machine touch pad facing you Place paper into compartment The queueing holes are to the right of the unit Lift top sheet and feed it into the slot in front of the roller Close the compartment cover Press ON button Press LOAD PAPER button oon 6 Troubleshooting a Referto Operator s Manual which is kept with the machine b Report proble
71. encounter form G Immunizations for international travel a Referto Travel Nurse consultant at UHS Reviewed Reviewea Reewed Reviewed Reviewed Reviewed Revewed f Reviewed UNIVERSITY OI NOTRE DAME UNIVERSITY HEALTH SERVICES SUBJECT IMMUNIZATIONS VACCINE ADVERSE EVENT REPORTING SYSTEM VAERS AUTHORIZATION Assistant Director Clinical Services DATE March 2011 POLICY University Health Center staff will report all reports of adverse events following the administration of any US licensed vaccine in all age groups including but not limited to the events mandated for reporting by the National Childhood Vaccine Injury Act of 1986 NCVIA PURPOSE To establish an accurate database of adverse events associated with vaccines To provide feedback which helps direct initiatives in the development of vaccines and improving the safety and effectiveness of current vaccines SPECIAL INFORMATION The National Childhood Vaccine Injury Act NCVIA requires health care providers to report adverse events possible side effects that occur following vaccination so the Food and Drug Administration FDA and Centers for Disease Control and Prevention CDC established the Vaccine Adverse Events Reporting System VAERS in 1990 VAERS is a national passive vaccines licensed in the United States VAETS data are monitored to Dectect new unusual or rare vacci
72. ers and give injections Sub q It should already be noted on the Allergy Injection Schedule regarding special instructions including which arm dry needles etc Use cotton ball to wipe site after injection applying pressure for 10 20 seconds DO NOT RUB INJECTION SITE d Use Benadryl cream ice and or band aids per patient comfort and preference e Have student go to waiting area for 30 wait f Document on Allergy Injection schedule and allergist sheet g Document on encounter form noting number of injections h After 30 check injection site and document any reaction on brown sheet and allergist sheet i Confirm next appointment with patient and in Medicat j Any reactions requiring significant medical intervention should be noted on the patient chart as well as filing an Adverse Event organizational report University of Notre Dame ALLERGY INJECTION SCHEDULE Health Center Name NDID DOB EXTRACTS A Alternate Arms Yes No B Benadryl Cream Yes No C Ice Yes No Additional Information Frequency Pt Year Arm Code upper R Right middle Exp Date L Left z lower Dose amp Time of Date Time Extract Dilution Site Check Remarks 3 UNIVERSITY IEALTH SERVICES RECEIPT OF EXTRACTS Place extracts in a plastic bag Label the bag with the patient s name and DOB and place it in alphabetical order
73. ew previous immunization records and provide vaccine recommendations e Provide patient with written Vaccine Information Statement VIS sheets for each vaccine needed e Address questions and concerns patient may have about vaccinations travel etc Complete Travel Clinic Record to rule out any contraindications prior to administration of any vaccines If there are any contraindications to any vaccine do not administer the vaccine and recommend patient contact primary care provider or consult with UHS physician e Administer vaccines Complete travel clinic sheet sign and stamp travel physician signature if all responses are negative and no follow up care needed If not send to appropriate physician for review and signature Review Health Questionnaire brought to appointment by student and complete necessary documentation Form is sent back to appropriate department by interoffice mail Any concerns regarding physical health refer to UHS physician Complete and provide patient with International Travel Certificate of Vaccination for Yellow Fever Vaccine e Instruct patient to wait 20 minutes after vaccine administration For All Prescription Medications RN will e Review medication allergy history and current medication list For any concern regarding possible medication allergy contraindication or potentially negative interaction consult with or refer back to travel physician e Travel prescriptions for medication wil
74. exposure illnesses shall be made available through UHS Follow up medical evaluations and lab testing shall be coordinated by a UHS physician In addition to medical follow up the Dept of Risk Management amp Safety or Clinical Services Administrator at UHS will conduct an evaluation of the exposure incident to determine whether changes in policies or practices are needed to prevent recurrences of similar incidents NOTE The RN completing the Exposure Incident Report must inform the Clinical Services Administrator in writing about the exposure incident Information should include patient name and social security number and date and time of the exposure incident ANNUAL REVIEW Review __ Signature Date Signature Date aac EUN DN bc Reviewed m m mI aunt Liar UNIVERSITY OI NOTRE DAME V HEALTH SERVICES SUBJECT CLEANING OF EXAM AND PROCEDURE ROOMS AUTHORIZATION Assistant Director Clinical Services DATE March 2011 PURPOSE To minimize risk of contamination between patients who use exam and or procedure rooms EQUIPMENT SUPPLIES 1 Approved disinfectant cleaner 2 Paper towels 3 Gloves PROCEDURE AND OR GUIDELINES RN or PCA performs task at completion of patient exam procedure room use 1 2 eo ANNUAL REVIEW Reviewed Reviewed Reviewed Signature Reviewed EE p EA Don gloves
75. gation AUTHORIZATION Assistant Director Clinical Services DATE March 2011 PURPOSE For lavage of the cornea and conjunctiva to remove foreign substance from eyes EQUIPMENT SUPPLIES Lactated Ringers or NS IV solution 1000cc IV tubing Towels Ophthalmic topical anesthetic Tetracaine with physician order Morgan Therapeutic Lens May use when indicated per Medical Directives PROCEDURE AND OR GUIDELINES 1 Explain purpose and procedure to the patient 2 Have the patient lie in supine position with head tilted towards the affected side Place towels around head to absorb flow of IV fluid 3 Check patient allergies Instill topical anesthetic Tetracaine to affected eye 4 Irrigate by one of these methods with 1000cc fluid a Prime IV tubing and begin to irrigate the affected eye s with the IV solution at a rapid free flow rate Direct flow of IV solution at the inner canthus to then wash laterally not directly over anterior surface of the eye 5 If the Morgan Lens is indicated follow instructions for use a Attach IV tubing and prime tubing b Instruct the patient to look down insert lens under the eyelid Have the patient look up retract lover lid drop lens in place c Release the lower lid over lens and start flow slowly and adjust flow as necessary Tape tubing to the patient s forehead to prevent accidental lens removal Absorb outflow Eye Irrigation 6 Removal a Continue flow have patient look up
76. h liquid nitrogen based cryosurgical systems for the contents to completely evap orate even without use Systems using cryogens other than liquid nitrogen may have the ability to retain their agents for longer periods or even indefinitely The tradeoff is treatment efficacy versus convenience Many clinicians have come to rely upon liquid nitrogen the most efficacious cryogen available in the treatment of their patients Nitrospray Plus cryosurgery devices are constructed with a double chamber stainless steel vacuum container to safely hold liquid nitrogen The outflow track located on the tap eap has a luer Ipck connector for easy insertion or changing of the various probes cones spray tips or other attachments selected according to intended use These cost effective units provide either 16 oz or 10 oz capacity Both sizes permit treatment a number of patients throughout the course of a day Depending upon your level of use it may be necessary to fill your Nitrospray Plus unit several times per day Nitrospray Plus is suitable for the treatment of cryoresponsive lesions and may be used in conjunction with thermocouples INSTRUCTIONS Before using on a patient the user should become familiar with the operation of Nitrospray Plus by closely following the steps below Appties to units with serial numbers RP 11061 LP 10852 or higher Please contact Premier Customer Service for assistance un units Protective eye and body
77. he allergy clinic The Allergy Nurse will work with you to order and obtain new extract Expired serum will be discarded Unless you are receiving injections at UHS in the summer all unclaimed serum will be discarded after July 1 9 Non compliance with instructions given will result in the discontinuation of your allergy injection s at University Health Services have read the above information and acknowledge its contents Printed Name Patient Signature Date UNIVERSITY HEALTH SERVICES TO PHYSICIAN Prescribing Allergy Immunotherapy to Notre Dame Student FROM Mary Ellen McCaslin RN BSN Assistant Director Clinical Services RE Allergy Injections University Health Services at the University of Notre Dame provides the service of administering allergy injections to those students who are presently being treated by an Allergist We will NOT be responsible for skin testing the initial dose for new patients or those resuming therapy after an extended delay in treatment The administration of extracts is based on the guidelines that you send to us The continuation of therapy requires specific instructions The following criteria are necessary Date and dose of last injection Vials that are labeled coded with patient name contents of vial dilution and expiration date Single dose vials are to be numbered or dated Guidelines that clearly state the recommended doses interval of injections route and site of administration
78. he vein Signs and Symptoms Area along vein red tender and warm vein hard and cordlike when palpated decreased flow rate and irritation with infusion Interventions Remove IV device apply warm soaks notify doctor restart IV infusion in a different arm and document observations and actions 4 Hematoma a Causes Result from uncontrolled bleeding at a venipuncture site and not enough pressure at site when removing IV catheter b Signs and Symptoms Hard painful lump at site C Interventions Apply direct pressure with a sterile dressing and elevate affected arm check site frequently for any impairment and apply ice immediately to prevent enlargement 5 Mechanical Failure Sluggish IV flow a Causes Catheter may be lying against the side of the vein cutting off fluid flow there may be a clot at the end of the catheter infiltration and kinking of the tubing or catheter b Signs and Symptons Possible swelling redness etc at site of infusion C Interventions Assess for signs of local infiltration remove tape and check for kinking of catheter tubing pull back catheter because it may be lying against the wall of the vein move the patient s arm to a new position lower solution container below the level of the patient s heart and observe blood flowback and may need to restart infusion at another site K CALCULATIONS OF FLOW RATE 1 When calculating the flow rate of IV solutio
79. hesive paper transpore 1 ea Airway kit set of asst sizes 1 Tongue blades 2 Suction set amp refill unit 1 Gloves Sterile sizes 6 6 1 2 7 7 8 aa Plastic gown 1 Sutures 3 0 Silk FS 1 8 4 0 Ethilon P 3 1 ea Face Shield 1 Vaseline gauze 2x2 3x9 5x9 3ea Gloves Unsterile S M L 3ea Laceration tray 1 Scissors 1 DRAWER 3 IV START LAB SUPPLY AMT EXP DATE Sterile Field pads 3 SYRINGES BD Brand 3ml 22gX 1 42 4 ea 23g X 1 25g X 5 8 4 ea DRAWER 6 SUPPLY AMT EXP DATE 5cc 10cc catheter tip 2 ea Blood pressure cuff 1 Alcohol pads Betadine prep pads 10 Stethoscope 1 Tegaderm 2 Locks and sealing links 1 NEEDLES 18g X 1 22g X 1 12 25g X 1 2ea Flashlight 1 NS for injection 10cc vial 2ml x 2 4 Ambu spur infant 8 child 1 Floor only IV CATHETERS Insyte 22g 1 20g 1 4 16g 2 ea IV Start Kits 2 OUTSIDE ON HOOK IV Reseal 2 Ambu Bag Adult 1 BLOOD DRAW SUPPLIES O2 Tank 1 Lab Draw Kit Sharps Container 1 Vacutainers needles 21g 4ea CPR Backboard Specimen Tubes Red top 2 Clipboard Purple top 2 AED ist Floor Triage Only Gold top 2 Biohazard labeled lab bag 2 REFRIGERATED Ativan 2 mg ml 1 University of Notre Dame University Health Services EMERGENCY CART LOG MONTH YEAR IOU TRIAGE TIME RN SIGNATURE LOCK gt lt o jo JD A U IN je 55 5 55 N 55 w 5 B
80. his can only be achieved by tightening the assembly in accordance with the following steps After filling or refilling wait until the liquid cryogen is no longer bubbling aggressive ly approximately 30 seconds to 1 minute depending on the initial container temper ature Firmly grasp the top cap by holding the black plastic area only Hold the vacuum con tainer firmly on a flat surface in a verticat position and place the top cap ever the con tainer top Make sure that the outflow track of the cap is pointed away from you and others at all times Do not use the outflow track as a fulcrum to avoid bending or breaking Slowly turn the vacuum container counter clockwise while holding the top cap stationary until you reach a firm stop There is no need to over tighten the cap 3 USING THE NITROSPRAY At na time while the unit contains the liquid cryogen should it be inverted or severe ly tilted regardless of the amount of liquid remaining in the container Inverting the unit will result in spontaneous discharge of trysgen through the pressure safety valve This will put the operator and patient at potential risk of unwanted exposure to the eryagen Install the desired spray ar accessory tip in the luer lock end of the outflow track Slowly depress the trigger and the Nitraspray Plus will begin to dispense a spray During its use the vacuum container will become cold to the touch This is normal and is due to the thermal transfer that
81. holder and clean with mild detergent and soft cloth rinsing immediately b Clean inside of chamber copper tubes and reservoir with Chamber Brite c Spread the contents of a packet in a straight even line along the bottom of the chamber from back to front d Select program with scissor symbol on the top row of the control panel e At the end of the exhaust cycle water will self drain Fill the reservoir with distilled water Repeat the sterilization cycle as in d above 1 During this second cycle clean the air jet located in the water reservoir by manipulating the air trap wire in and out 10 times INSTRUMENT PROCESSING AND STERILIZATION h At the end of the exhaust cycle the water must be manually drained i Tur off and allow to cool j Remove the tray holder rinse and wipe the interior of the chamber with a damp cloth k Fill the reservoir with distilled water Press the manual water fill button next to START on control panel and allow a small amount of water 2 4 ounces to fill chamber and flush out the fill tube m Put 2 drops of oil on the two door pins and door tightening bolts n Wipe outside and electrode with soft cloth o Drain water from reservoir and refill with fresh distilled water 4 Semi Annually Check air filter in June and December of each year Replace as needed ANNUAL REVIEW d Reviewed __ Signature Reviewed Reviewed Review
82. ible contamination with blood or body fluids After completion of work After removing gloves and between glove changes Before leaving the work area Before and after eating drinking smoking applying cosmetics or lip balm changing contact lenses After using bathroom facilities Before all activities which involve hand contact with mucous membranes eyes or breaks in the skin When handwashing facilities are not available employees shall be provided antiseptic towelettes or hand cleanser and clean paper towels When these alternatives are used employees shall wash their hands with soap and running water as soon as possible 2 Handling Contaminated Sharps Any object which is contaminated with blood or OPIM and is capable of penetrating the skin is considered a contaminated sharp Breakable equipment or supplies are potential sharps if they can create surfaces capable of penetrating the skin Examples of sharps include needles scalpels broken glass and exposed ends of dental wires Needle sticks are an efficient means of transmitting bloodborne diseases Because of their high potential for transmitting bloodborne pathogens to employees contaminated sharps should be handled as follows SUBJECT BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN Contaminated needles and other contaminated sharps or potential sharps shall not be recapped removed or bent unless no alternative is feasible or unless required by a specific med
83. ical procedure i e inoculation of blood culture bottle In situations where recapping or needle removal is required it shall be accomplished only by means of mechanical device or a one handed technique All contaminated sharps shall be transferred to rigid puncture resistant labeled leak proof containers immediately or as soon as possible after use They may not be stored or handled prior to decontamination in such a way as to require employees to reach their hands into the container to retrieve the item 3 Other Work Practice Controls All procedures involving direct handling or OPIM should be accomplished in a manner which minimizes splashing spraying spattering or aerosol production of OPIM Mouth pipetting suction of blood OPIM and all other material is prohibited Specimens of blood or OPIM must be placed in labeled containers which prevent leakage and are of sufficient strength to prevent expulsion during collection handling processing storage transport or shipping The following container requirements must be met a The containers must be closed prior to storage transport or shipping b Biohazard labeling or color coding is required on each container which leaves the University c The specimen must be placed in a second container which meets the same provisions as above if the outside of the primary container becomes contaminated or if the specimen could puncture the primary container d Contaminate
84. iewed Reviewe Reviewed PRODUCT INFORMATION Congratulations on your purchase of Nitrospray Plus a trigger activated liquid nitrogen cryosurgical instrument Because Nitrospray Plus utilizes a self regulating pressure safety valve it is classified as a closed system device Nitraspray Plus is able te dispense a nitrogen spray or mist by safely build ing a controlled pressure inside the container to dispense the contents when the trigger is depressed The true convenience of Nitrospray Plus is realized by the user being able to produce a cansistent nitrogen spray and easily direct it to a treatment site Nitrogen exists in its normal state as a gas It is converted into a liquid by pressur ization As tiquid nitrogen warms it converts into a gas This is the reason why the user is instructed to fill the container 1 2 to 2 3 fuli The temperature difference between the liquid nitrogen and the dry container sidewalls actually warms the liquid inta a gas Even though the container of the Mitrospray system is vacuum insulated the outflow track and top cap conducts heat into the liquid causing it to slowly change to a gas if the gas were unable to vent over time the pressure inside the container could reach a point where rupture is possible and cauld result in bodily harm When the pressure inside Mitrospray Plus reaches a preset value 7 psih the pressure safety valve opens thus releasing pressure It is a norma occurrence wit
85. in the boxes in the refrigerator Obtain Allergist s instructions from the student Date and initial the papers in lower right hand corner Note patient name phone number year in school and preferred appointment time amp day on Allergy Patient Listing Exhibit II Initiate Allergy Injection Schedule and Immunotherapy Checklist Exhibits VI and IV by checking off each listed item The patient does not need to wait while this is being done Initiation of these forms will expedite their first visit If information is missing from the Allergist s instructions item checked on the checklist start the form letter to the doctor to request the missing information With yellow highlighter mark the areas of importance on the Allergist instructions Place all forms and instructions in a plastic folder and place tab with patient s name on folder Schedule first appointment in Medicat under Travel Allergy screen Remember appointments are Monday through Friday mornings during Fall semester and Monday through Friday afternoons during Spring semester Appointment availability is indicated in Medicat Note e If patient is not sure of their schedule make sure to note their phone number on Allergy Patient Listing Give them an allergy card with Allergy Nurse contact info and remind them that it is their responsibility to contact the Allergy Nurse to set up their appointment If you have any questions please contact Mary Ellen McC
86. ing the eye using a new test kit i Note if a second sampling is required eye fluid may be reduced and inadequate for testing If both eyes are affected and second sample needed use other eye If only one eye is affected the sample may be repeated immediately if adequate secretions are available or it may be repeated several hours later 12 Refer to package insert for color photographs and illustrations on proper use of test kit 13 Document results of test in medical record notify physician as indicated 14 Document charge for test on encounter form FORMS or REFERENCES Conjunctivitis label for assessment Encounter form ANNUAL REVIEW Signature Date Signature Date Reviewed Reviewed Reviewed Reviewed Reviewed Reviewes Reviewed Bewiewwa Reviewed Reviewed j DATE ALLERGIES TIME PROCEDURE Explanation of Procedure given Consent signed for Procedure Release of Information consent form signed Specimen sent to Pathology SITE Other medication used Local Marcaine 1 Xylocaine 1 w epinephrine 2 Xylocaine 2 w epinephrine Topical Liquid Nitrogen AgNo Sticks MEDICATIONS USED I hereby give my permission for the above listed Procedure to be performed on me by the physician M D I have identified the operative area wound as the location f
87. ings Select EXTENSION limit by pressing the top left extension key then or arrow Select FLEXION limit by pressing the top right flexion key then or arrow Select the SPEED button then or arrow Select FORCE button then or arrow Simultaneously press keys PAUSE EXT and PAUSE FLEX to lock the hand control settings Turn the patient lock out switch on switch to picture without x on the base of the exerciser C Place the thigh slide on the same side as the leg to be mobilized To change legs withdraw the hip bar from thigh support bar and slide the hip bar to the correct side of the exerciser Tighten all 3 knobs KINETEC Performa Continuous Passive Motion CPM Exerciser d Place protective padding over CPM e Set CPM Q 30 of flexion 3 Prepare patient refer to user manual a Instruct patient in purpose and use of apparatus b Measure in cm or inches the length of the patient s femur Adjust the thigh support to this measurement Push the foot plate up to the patient to a position of comfort and tighten the knob d Make sure all knobs are tight e Instruct patient in Start Stop Reverse function of the hand control 4 Notify the attending or on call physician as appropriate if the patient experiences increasing pain swelling etc 5 Document therapy on Flow Sheet 6 Safety Measures 8 The hand control should always be given to the patient b The switch on the base of the unit shoul
88. inistrator will be responsible to develop an Exposure Control Plan as it relates to the Health Center and to review and update the plan at least annually and whenever necessary to a reflect technology that eliminate or reduce exposure to bloodborne pathogens b document annually the consideration and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure PURPOSE To eliminate or minimize occupational exposure to the Hepatitis B virus HBV Human Immunodeficiency virus HIV and other bloodborne pathogens SUBJECT BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN EXPOSURE CONTROL PLAN Reference the University of Notre Dame s plan Exhibit I TRAINING Training will be provided as outlined in the Exposure Control Plan An educational verification form will be completed upon annual training Exhibit TERMINOLOGY 1 Bloodborne Pathogens BBP Pathogenic microorganisms that are present in human blood and can cause disease in humans These pathogens include but are not limited to Hepatitis B virus HBV and Human Immunodeficiency virus HIV 2 Contaminated The presence or the reasonably anticipated presence of blood or other potentially infectious materials 3 Decontamination The use of physical or chemical means to remove inactivate or destroy bloodborne pathogens on a surface or item to a point where they are no longer capable
89. is will be documented a refusal form will be completed and she he will be taught the signs and symptoms of tuberculosis and encouraged to seek medical care if these symptoms develop A risk assessment Exhibit Il will be done at the beginning of each academic year while attending school here If the chest x ray is abnormal and suggestive of active TB the student will be required to follow up with the SJCHD and have further testing done including sputum smears for TB germs and TB culture A student may NOT attend class Any student diagnosed with active tuberculosis disease will be required to follow the recommendations of the SJCHD and the Medical Director of the Health Center regarding attendance in class Failure to comply with these standards will result in a report to Student Affairs e f other abnormal findings on the chest x ray films are to be repeated in 6 months at the discretion of the Medical Director of the Health Center ANNUAL REVIEW Signature Date Revewed Signature Date Reviewed Reviewed Reviewed Reviewed j Reviewed Reviewed Reviewed Reviewed Reviewed Reviewed UNIVERSITY OI NOTRE DAME UNIVERSITY HEALTH SERVICES amt Liar SUBJECT VACUTAINER URINE CULTURE KIT Authorization Assistant Director Clinical Services DATE March 2011 PURPOSE To stabilize a sampling of urine for culture
90. it E Normal test results may be given to patient by leaving a voice message if patient has given permission to UHS to do so Designated phone number provided by patient and documented on face sheet will be used for this notification FORMS or REFERENCES ICM letter ANNUAL REVIEW Reviewed Reviewed Reviewed Bwewea Reviewed Reviewed Reviewed UNIVERSITY OI NOTRE DAME aunt Liar March 2011 Reviewed Approved By Director University Health Services Assistant Director Clinical Services Medical Director SUBJECT ON CALL HEALTH CENTER STAFF REQUIREMENTS PURPOSE To provide appropriate competent healthcare to meet the staffing needs of University Health Services PROCEDURE AND OR GUIDELINES Those persons hired as on call staff members for University Health Services UHS Student Health Center will maintain their position status by working at least 16 hours each Fall and Spring semester Those who cannot fulfill this requirement will be removed from the on call list Those persons hired as on call staff members for special events only such as Pre participation sports physicals and flu shot clinics and coverage for special events With no other role at the Health Center will have active status only for special events 1 Staffing levels will be determined by the Assistant Director Clinical Services with input from other managers as appropriate or the UHS Administrator on
91. itation within the unit The spray is emitted from a distance of 1 to 2cm from the treatment site and perpendicular to it AL the end of your treatment day the unit should be wiped free of any condensation and stored dry CAUTIONS Do not invert ar drop a Nitrospray Plus unit containing liquid nitro gen De not simultaneously obstruct outflow track and depress trigger as this wil interfere with proper venting and could allow excessive pressure to build within the instrument Use protective eye and hody wear when handling liquid nitrogen Do not till more than 2 3 full Always remove and replace the top slowly in order to compensate for pressure build up Allow natural agitation or bubbling to subside before securing the top cap to the vacuum container A warm unit will most likely have significant agita tion To prevent the unitended spray of it is important to verify the proper tuer tack connection of accessories to outflow track of Nitrospray Plus Spray tips should be inspected prior to each use for cracks breakage and any other damage Store and handle liquid nitrogen only in ventilated areas aunt Liar SUBJECT AUTHORIZATION DATE PURPOSE GUIDELINES PROCEDURE UNIVERSITY OI NOTRE DAME V Y HEALTH SERVICES MEDICAL DIRECTIVES Assistant Director Clinical Services March 2011 To ensure safe consistent quality patient care while maintaining medical legal standards University Heal
92. l be provided using the guidelines and recommendations for the country specific destination All exceptions or concerns regarding medication dosage contraindications or related questions will be routed to the travel physician ANNUAL REVIEW Reviewed Reviewed o Reviewed o Reviewed o Reviewed Reviewed o Reviewed Revewed d Reviewed o Reviewed o Reviewed Reviewed UNIVERSITY OI NOTRE DAME aunt Liar SUBJECT INTRADERMAL INJECTION SIMULATOR AUTHORIZATION Assistant Director Clinical Services PURPOSE To provide realistic means of demonstrating and practicing intradermal injections DATE March 2011 EQUIPMENT SUPPLIES List Equipment or Supplies involved here PROCEDURE AND OR GUIDELINES A General Instructions for Use 1 Insert a 27 gauge needle 77 long at a 10 15 degree angle to the skin 2 Inject fluid 0 1cc distilled water into 1 of the 8 spots on the arm The injected fluid should produce a small bleb just under the skin which causes a visible welt on the outer skin surface 3 Remove fluid from welt by reinserting a needle without the syringe attached B Care of the Simulator Should leakage occur inject the supplied sealant fluid into the blistered dot Allow to set overnight before withdrawing excess fluid and using the site again Clean with a mild solution of Ivory liquid detergent and water Do not use abrasive or
93. ll be available in appropriate sizes and shall be disposed of at no cost to the employee Immediately after removal all PPE must be discarded into a biohazard container Training and certification for PPE shall be conducted as specified in the University s PPE Policy 1 Gloves Gloves must be worn by all employees when performing tasks involving contact with blood body fluids OPIM or when handling or touching contaminated items or surfaces The types of gloves selected i e latex nitrile or utility should be impervious to liquids and strong enough to withstand the rigors of the task to be performed Use of latex or vinyl gloves is intended to cover defects in the skin on the hands and is not intended to provide protection from wounds caused by sharps The following guidelines are recommended by the Center for Disease Control Morbidity and Mortality Weekly Report Vol 24 6 24 88 a Sterile gloves should be used for procedures involving contact with normally sterile areas of the body b Examination gloves should be used for procedures involving contact with mucous membranes unless otherwise indicated and for other patient care or diagnostic procedures that do not require the use of sterile gloves c Surgical and examination gloves may not be reused Washing gloves with soap or detergents may cause enhanced penetration of liquids through undetected holes in the glove Disinfecting agents may cause deterioration d Use gener
94. ll be considered potentially infectious materials COMPLIANCE IS MANDATORY Failure to follow Universal Precautions will result in corrective action B Engineering Controls Engineering controls includes all control measures that isolate or remove a hazard from the workplace encompassing not only sharps with engineered injury protections and needleless systems but also other medical devices designed to reduce the risk of percutaneous exposure to bloodborne pathogens This may include but is not limited to SUBJECT BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN a Handwashing facilities b Sharps containers c Specimen containers d Regulated waste containers e Safer medical devices such as sharps with engineered sharps injury protections and needleless systems Engineering controls shall be examined and maintained or replaced on a regular schedule to ensure their effectiveness Appropriate engineering controls should be used in preference to other control methods in order to limit occupational exposure C Work Practice Controls Work practice controls reduce the likelihood of exposure by altering the manner in which a task is performed This may include but is not limited to 1 Handwashing Hands and any other exposed skin surfaces should be washed with soap and running water and mucous membranes should be flushed with water as soon as possible after contact with blood or OPIM Handwashing should occur Whenever there is vis
95. llergy symptoms Staff initials Signature Student Health Center Notre Dame Indiana 46556 DATE TO Dr UNIVERSITY HEALTH SERVICES Telephone 574 631 7497 Facsimile 574 631 6047 FAX RE Dear Doctor DOB Please verify the recent phone order regarding the above patient and his her dosage change or adjustment Physician Signature Please correct and sign then fax back to me at 574 631 6047 If you have any questions I can be reached at 574 631 7497 or directly at 574 631 3738 Thank you Allergy Nurse UNIVERSITY HEALTH SERVICES Name DOB ND ID 4 Date ALLERGY IMMUNOTHERAPY CHECKLIST Complete checklist before administering allergy injections This checklist is completed yearly and whenever new vials of extract are received 1 Number of vials 1 2 3 4 5 6 Other 2 Vials are labeled with PATIENT NAME Yes No 3 Vials are labeled coded as to CONTENT and Yes No correspond with written instructions 4 Vials are labeled coded as to DILUTION Yes No 5 EXPIRATION DATES are indicated Yes No 6 SIGLE DOSE vials are numbered or dated N A Yes No 7 ROUTE and SITE of administration are indicated Yes No 8 RECOMMENDED DOSES are indicated Yes No 9 INTERVAL of injections are indicated Yes No 10 Instructions for MISSED LATE injections are present Yes No 11 Instructions for REACTIONS are present Yes No 12 Instructions for NEW VIALS are presen
96. loyees are instructed to report all exposure incidents to their supervisor Initial evaluation and treatment of the injury will be performed at UHS Upon authorization of a UHS physician the referral physician shall be contacted immediately Medical evaluation and counseling for the exposed employee shall occur within 24 hours of exposure Immediate first aid treatment 1 Minor injuries cuts needlesticks Allow to bleed and clean wound with soap amp water Apply antibacterial ointment and bandage as needed 2 Mucous membrane exposure eye mouth etc Flush with large amounts of water or saline 3 Non intact skin exposure open wounds dermatitis etc Wash thoroughly with soap amp water An Exposure Incident Report Exhibit V should be completed by an RN at UHS The exposed employee should bring a copy of this report to the appointment with the referral doctor The content of all reports must be kept confidential including the information about the source individual SUBJECT BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN The referral physician shall complete and forward to the UHS physician an Exposure to Bloodborne Pathogen Report This document shall be placed in the employee s medical record The employee shall be informed of the results of the evaluation and told of any medical conditions resulting from exposure to blood which require further evaluation or treatment B Collection and Testing of Blood Consent must be
97. m Reviewed o O Reviewed _ Revewed Revewed Reviewed Revewed University of Notre Dame Health Center Name PHYSICIAN S ORDERS NDID FUL UQUDS CLEAR LIQUIDS o AS TOLERATED OTHER 2 PAIN FEVER __ NONE ACETAMINOPHEN 650MG OR 1000MG EVERY 3 4 HOURS PRN FOR PAIN OR FOR TEMPERATURE OF 100F OR HIGHER P O OR SUPPOSITORY URINE FECES ROUTINE _ C amp S COMPREHENSIVE METABOLIC PANEL OTHER 4 ACTIVITY UP AD LA University ef Notre Dame Name ND 10 Room CIRCLE LOCATION LEFT KNEE SHOULDER RIGHT KNEE SHOULDER University Health Services CPM THERAPY FLOW SHEET FREQUENCY LENGTH OF TIME FOR TX UNIVERSITY OI NOTRE DAME ant Liar SUBJECT LIQUID NITROGEN AUTHORIZATION Assistant Director Clinical Services DATE June 2014 PURPOSE Liquid nitrogen is available for physician use in the treatment of certain dermatologic conditions and wart removal PROCEDURE AND OR GUIDELINES The physician will apply the liquid nitrogen to the affected area using one of two methods Acotton tipped applicator e Nitrospray cryosurgery instrument with a reusable tip Appointments for procedures requiring the use of liquid nitrogen will be scheduled on Tuesdays through Fridays Liquid nitrogen will be obtained from the Radiation Laboratory on campus by the Assistant Director Clinical Services or other designated staff member Liqui
98. may also be filed online by accessing CDC website VAERS related quick links E Call 1 800 822 7967 24 hour recording for questions regarding the reporting requirements completion of VAERS report form or if additional forms are needed Annual Review Signature Reviewed z ET 1 p 1 Signature Bevewed Reviewed Reviewed Reviewed Reviewe d Reviewed UNIVERSITY OI NOTRE DAME aunt Liar SUBJECT INJECTABLE TRAINING ARM AUTHORIZATION Assistant Director Clinical Services PURPOSE To simulate the human condition to teach and practice venipuncture and injection Techniques for IV catheter insertions and intramuscular injections DATE March 2011 PROCEDURE AND OR GUIDELINES A General Instructions for Use Refer to Instruction Manual B Care of Simulator Treat with care to avoid damage Remove pinch clamps and IV sets from arm Use tap water to flush venous system Wash outside of arm with a mild solution of Ivory liquid detergent and water Remove excess water from the arm by raising the hand lowering the shoulder and draining it into a sink Always remove the metal pinch clamps from shoulder tubing and drain excess Water from the veins before storing 7 Do not place simulator on any kind of printed paper or plastic as this will permanently stain the arm 5 65 NN C
99. mechanical means i e tongs dust pan and broom These items should then be disposed of with contaminated sharps 13 Contaminated reusable sharps shall not be stored or processed in such a way that employees are required to reach by hand into containers where these sharps have been placed Reusable sharps shall be cleaned and processed before reuse in a way that ensures safe handling a Wear gloves b Place contaminated sharps in a rigid leak proof container with lid and take to the utility room for cleaning c Clean and package heat stable sharps Use care when handling so as not to injure self d Follow directions for autoclaving for all heat stable instruments If the package integrity of sterilized instruments has been compromised the instrument must be re sterilized NOTE GLOVES ARE MANDATORY DURING ANY HANDLING OF NON STERILIZED INSTRUMENTS 14 Contaminated disposable sharps shall be discarded immediately after use Never manually open empty or clean contaminated sharps containers Securely close and discard container as regulated waste when 3 A full 15 All regulated waste should be removed routinely per established procedure 16 The only designated refrigerator freezer for storage of blood body fluids is in the lab It shall be labeled with a biohazard symbol 17 Laboratory work areas shall be cleaned decontaminated by lab personnel per South Bend Medical Foundation protocols 18 Laundry shall be bagged at its locatio
100. ms to Assistant Director Clinical Services EKG Electrocardiogram EQUIPMENT SUPPLIES EKG machine paper Sensors electrodes Chest and extremity leads Disposable razor Alcohol wipes AUTHORIZED PERSONS RN ANNUAL REVIEW Reviewed Reviewed Reviewed Reviewed O Reviewed 0 0 Reviewed Signature Reviewed Reviewed Reviewed Reviewed RZEK Resting ECG Lead Placement amp Coding Chart AHA LEAD CODING AND MEASUREMENTS STANDARD LIMB LEADS STANDARD LIMB LEADS AHA COLOR CODE PLACEMENT OF THE LIMB SENSORS AHA V Fourth intercostal space at right margin of stemum V Fourth intercostal space at left margin of sternum Filth intarcostal space at junction of left midctavicular fine V4 Midway between position V and position V At horizontal level of position Va at lett anterior axillary fina At horizontal tevel of position V 81 185 midaxikary line Fourth Intercosta space at right margin of stemum Fourth intercostal space at teft margin of sternum C Filth intercostal space at Junction left midclavicular line C way between position C and position C At horizontal levet of position C at left axillary ine At horizontal level of position C at lett midaxiliary line Eclipse Operating Instructions 5 3 UNIVERSITY OI NOTRE DAME aunt Liar SUBJECT Eye Irri
101. n form 1 Contraception form 2 Second serum or urine pregnancy test ordered through a CLIA certified laboratory OI have counseled this patient on the following Requirement to use 2 forms of birth control every time she has intercourse Drug should not be shared with anyone Blood should not be donated while taking isotretino n Patient program requirements DI have confirmed with the PLEDGE system that I have counseled the patient OT have prescribed maximum 30 day supply of isotretinoin Pregnancy Test Results Pregnancy Test Type Serum Urine Serum hCG _ 1 mIU ml Lab Test Results O Positive 2 Negative Prescriber Diagnosis I Pregnant 2 Not Pregnant USE REVERSE SIDE FOR MONTHLY VISITS EXHIBIT T EN iPLEDGE zam test te Ferte PRESCRIBING CHECKLIST MONTHLY VISITS For Female Patients Of Childbearing Potential Patient name gt Monthly Visits acceptable forms of 32 contraception used similaneously for 30 days prior to pregnancy test Contraception form 1 Contraception form 2 lJ Serum i ordered or urine pregency through Ihave counseled this patient on the following Requirement to use 2 forms of birth control every time she has intercourse Drug should not be shared wich anyone Confirmation Information 531 forms of used pears mri ray ps rane ex Q Serum or urine test ordered through a cercfied laboratory Thies piesa dis pos
102. n liquid FORMS or REFERENCES ANNUAL REVIEW ae A Reviewed BH p Ss Date Signature Reviewed Reviewed Reviewed Reviewed Reviewed FEE MI Reviewed UNIVERSITY OI NOTRE DAME aunt Liar SUBJECT Suction Portable Hand Held Res Q Vac AUTHORIZATION Assistant Director Clinical Services DATE March 201 1 PURPOSE To provide for the suction of fluids from the oropharyngeal and nasopharyngeal cavities EQUIPMENT SUPPLIES Res Q Vac Kit containing reusable vacuum pump handle collection canister and Yankauer suction tube PROCEDURE AND OR GUIDELINES 1 Remove contents form package 2 Test the vacuum handle before using to ensure that the unit produces a vacuum Place a finger over the vacuum port and squeeze the handle As the handle is squeezed a vacuum should be felt and the handle becomes difficult to squeeze Do not use the device if a vacuum is not felt 3 Tighten canister cap If required attach catheter to canister cap by gently twisting catheter luer fitting onto the cap luer fitting until secure Snap the 55 ml canister into the pump handle by aligning the vacuum fitting on the canister cap or the 300 ml adapter with the vacuum port the 300 ml canister requires the adapter 4 Introduce the catheter into the patient s airway and suction the airway GENTLY INTRODUCE THE CATHETER TO AVOID TRAUMA TO THE PATIENT If the pump handl
103. n meals They are delivered Monday and Friday Sandwiches good for 48 hours and milk has expiration date listed Ordering Meals Stock A Meals will be ordered according to physician order and designated menu selection B A Health Services representative will fax completed menus to the Dining Hall at 1 4529 and call extension 1 5775 at the following times to alert dietary staff of faxed menus and to verify receipt of the order 1 Monday Friday Breakfast call at 6 30am for a 8 00am delivery Lunch call at 10 00am for a 11 30am delivery DIETARY SERVICE AT UNIVERSITY HEALTH CENTER Dinner call at 4 30pm for a 5 00pm delivery 2 Saturday and Sunday Continental Breakfast call at 6 30am for a 8 00am delivery Brunch call at 10 00am for a 11 30am delivery Dinner call at 3 30pm for a 5 00pm delivery C If any other meals are needed due to late admission etc the following is the schedule of meal hours at North Dining Hall Call extension 1 5775 and speak to the Manager on duty 1 Monday Friday Breakfast 7 00am 9 15am Lunch 10 30am 2 00pm Dinner 4 30pm 7 00pm Grab n Go 7 00am 7 00pm 2 Saturday and Sunday Continental Breakfast 8 00am 10 30am Brunch 10 30am 11 30am Dinner 4 30pm 7 00pm D Student menu selections are obtained from the ND food service website at http fsntserv foodserv nd edu dh menus ndh menu today cfm Orders must be faxed to 1 4529 prior to or at the designated times of orde
104. n of use and stored in a designated area with no public access Contaminated laundry shall be handled as little as possible and with a minimum of agitation 19 Laundry shall be placed in plastic leakproof containers No color code or labeling is necessary as all employees of St Michael s Laundry are trained in Universal Precautions and treat all laundry ascontaminated LABELS AND SIGNS Warning labels shall be applied to containers of regulated waste refrigerators and freezers containing blood or OPIM Labeling also applies to other outer containers used to store transport or ship blood or OPIM Labels are also required for equipment to be serviced or transported that have parts that are unable to be decontaminated These labels must identify which portions of the equipment remain contaminated These labels must meet the following criteria SUBJECT BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN 1 Include the Biohazard symbol 2 Have a fluorescent orange or orange red colored background with lettering or symbols in a contrasting color 3 Be affixed as close as possible to the container by string wire adhesive or other method that prevents loss or unintentional removal Exceptions to the warning label 1 Individual containers of blood or OPIM that are placed in a labeled container during storage transport shipment or disposal 2 Red bags or red containers may be substituted for labels CONTAINING AND HANDLING REGULATED WASTE
105. n screening is required for the following groups of students All new students who are foreign born or are non U S citizens who have been U S permanent residents for less than 4 years and are enrolled for on campus course work will be screened for Tuberculosis by the following 1 Country of origin Those who are from low risk countries will be screened out e hose from high risk countries will be screened in e Those US citizens living in high risk countries should be screened in 2 Those from high risk countries will be required to Provide proof of a negative Mantoux skin test performed in the United States within the last 12 months Undergo TB testing through Health Services within the first month of the first semester of attendance at the university e Show certification of completed INH therapy if previous positive TB skin test Mantoux tuberculin skin testing is highly recommended for the following persons e All international postdoctoral fellows and visiting scholars e Any Notre Dame student who has participated in international travel to a high risk area for more than one month as part of an official university program Testing is recommended 3 months after the student s return e Any student not included in groups listed above who has traveled for one month to a country outside the U S which is identified as high risk Exceptions a delay for tuberculosis testing will be permitted for e lf tuberculin skin test o
106. n testing the initial dose for new serum or immunotherapy to students who are resuming therapy after an extended delay in treatment Incomplete dosing information from the Allergist may result in a delay in treatment Any immediate treatment for reactions will be directed by a University Health Services Physician or Physician Assistant PURPOSE To maintain the management of patients requiring allergy injections To assist in providing optimum results from allergy immunotherapy SPECIAL INSTRUCTIONS A Incoming students who request the continuation of allergy immunotherapy are identified by the information on the Medical History amp Physical Report Information is mailed to the student prior to their arrival on campus informing them of the procedure to have therapy continued at University Health Services This information is available on UHS website http uhs nd edu services allergy injections ALLERGY INJECTIONS B Current students receiving injections are given instructions for serum pick up prior to the end of each academic year PROCEDURE A Administration of Injections 1 Injections are administered by an RN following the guidelines sent by the patient s physician ONLY when a UHS physician or physician assistant is in the clinic 2 Used supplies are discarded according to Infection Control Universal Precautions guidelines 3 Suggestions to decrease the risk of a local reaction include Wipe the needle with an alcohol
107. n the test strip after meter reading is ascertain that the test spot was covered completely 2 Control Solutions Use only ONE TOUCH Ultra control solutions shake well Record a discard date on the control solutions once opened Discard the solutions 3 months after opening A control solution test will be performed every month per Owner s booklet procedure and documented on the One Touch Ultra Log Exhibit I 3 Replace the battery when the battery symbol appears on the meter display 4 A system check will be performed Once a month and When new vial or test strips is opened Any time a problem is suspected with the meter or test strips Any time to improve technique After dropping the meter Any control result that falls outside of acceptable control range the owner s booklet will be referenced and the problem will be corrected before proceeding with the patient testing a Infection control measures will be followed for the cleaning and disinfection of the monitor b Alog will be maintained to record this action Exhibit I A Quality Control Log will be maintained by the Assistant Director Clinical Blood Glucose Testing ONE TOUCH Ultra System Services for a period of 3 years EQUIPMENT SUPPLIES TOUCH Ultra Blood Glucose Meter ONE TOUCH Ultra Test Strips ONE TOUCH Ultra Control Solution ONE TOUCH Ultra Owner s Booklet Lancet device Alcohol pad Cotton ball Disposable gloves
108. ne adverse events Monitor increases in known adverse events e Identify potential patient risk factors for particular types of adverse events e Identify vaccine lots with increased numbers or types of reported adverse events e Assess the safety of newly licensed vaccines The Vaccine Injury Table defines the events that are legally reportable EXHIBIT The table lists specific injuries or conditions and the time frame in which they occur after the vaccine administration PROCEDURE A Encourage patients to inform UHC professional staff of adverse events following immunization B The NCVIA requires the following events to be reported 1 Any event set forth in the Vaccine Injury Table that occurs within the time period specified or within seven 7 days a Access table on CDC website VAERS related quick links 2 Any event listed in the manufacturer s package insert as a contraindication to subsequent doses of the vaccine In addition VAERS accepts all reports of any suspected clinically significant adverse event occurring after the administration of any vaccine Reporting of an event does not necessarily imply that a vaccine s caused the event A report is made by completing and mailing a VAERS report form EXHIBIT Il The report form is a single page pre addressed postage paid form for pertinent information including a narrative description of the adverse event The forms are located in Clinic desk drawer D Reports
109. not available by letter Student Health Services will forward the name of any student who has not met the testing requirements to the Office of International Studies and to the Office of Student Affairs International Student Services will attempt to make a personal contact with any non compliant student Section Ill Screening for Tuberculosis Disease and Infection Class attendance is contingent upon the student providing documentation of negative results of a valid PPD test To be accepted as valid the tuberculin skin test must meet the following requirements The testing process used must be the Mantoux purified protein derivative PPD test This test must be administered by an intradermal injection of the purified protein derivative PPD tuberculin containing 5 tuberculin units injected into the underside of the forearm After the PPD test is placed it must be read at least 48 hours and no more than 72 hours after being administered If the test is not read within this 48 72 hour time frame a negative test must be repeated A positive test will be accepted even if greater than 72 hours after administration A student having a prior history of a positive Mantoux PPD test without certification of completion of INH therapy will be required to have a Quantiferon Gold serum blood test Students who have had PPD tests done and read as negative at another health care facility in the United States and have not traveled outside the U S su
110. ns the number of drops required to deliver 1 ml varies with type of administration set used Check directions on set 2 Calculate infusion rate utilizing the following formula Drop minute total volume infused x drops ml total time for infusion in minutes Example Infuse 150ml of DSW 1 hour set indicates 10 drops ml 150 x 10 25 drops minute 60 minutes 3 As a quick guide refer to the chart below Drops Minute To Infuse 500 ml 24hr 1 000 Company Name Drops ml 21 ml hr ml 20hr 50 ml hr Baxter Interlink 17 gtts min 21 gtts min 28 gtts min INTRAVENOUS THERAPY ANNUAL REVIEW Reviewed Bewiewwa Reviewed Reviewed _ Reviewed Reviewes o Reviewed _ Reviewed Bewiewwa Reviewed Revewea University of Notre Dame University Health Services Name ND ID IV THERAPY Site Codes Activity Codes Catheter type Change schedule R Right UA Upper arm S Start D Discontinue A Insyte Site Q72 hours L Left FA Forearm R Restart C Rate Change B Intima Bag Q24 hour H Hand A C Antecubital B Bag Change Date Time Bag Activity Catheter Solution INT ES size type Initials Signature Initials Signature Initials Signature Amt Infused SAS 12 5 2011 University of Notre Dame University Health Services NDID IV THERAPY Primary Tubing Secondary Tubing Site checks are done at a minimum of every 2 hours Documentation is req
111. ns are given by appointment only and can be scheduled by calling 574 631 3738 2 To assure you optimum results of your therapy you are responsible for obtaining the information we require and to follow the schedule provided by your Allergist 3 It is important to inform the nurse if you have any current health problem or if you had any reaction to your previous injections 4 Avoid strenuous exercise 1 hour before and after your injection s 5 You will NOT receive an injection if you a Had a fever of 100 degrees or more in the past 24 hours b Are acutely ill Have severe asthma or hay fever symptoms d Had an immunization excluding influenza vaccine in the past 24 hours e Have any swelling remaining from the previous injection f Are taking any beta blocker medications 6 You are expected to wait in University Health Services UHS for 30 minutes following the injection s and report any reactions that occur a LOCAL may consist of redness itching and or swelling at site of injection b SYSTEMIC OR GENERALIZED report any distress IMMEDIATELY Symptoms may include but not limited to hives tightness in chest coughing wheezing excessive sneezing itching extreme redness in face and or eyes nausea dizziness headache or fainting If you have any questions please check with the nurse T A copy of your injection schedule will be provided upon request 8 Your extract is stored alphabetically in the refrigerator in t
112. nstruction If not clear fax request for clarification of orders to Allergist Exhibit III Significant information is identified using a yellow highlighter All discontinued instructions are identified by the placement of a diagonal line across the paper using a pink highlighter All Allergy forms for the current year are maintained in a locked file in the Allergy Room At the end of each academic year or summer session all Allergy documentation is tabbed into the medical record in front of the H amp P and after the Clinic Data Sheets Verbal orders for dose adjustments due to previous reactions or length of interval between injections shall be faxed to the ordering doctor for signature within 24 hours Exhibit Ill 2 Patient Information Sheet Exhibit lc Patient must sign this form before therapy is administered No injections will be given if the patient refuses to sign the form 3 Consents to Release or Acquire Medical Information Consent to Release or Acquire Medical Information is not required for office to office communications according to HIPPA guidelines 4 Allergy Immunotherapy Checklist Exhibit IV Complete annually and whenever new vials of extract are received It is the patient s responsibility to obtain written clarification for any items checked In some instances this may delay car Upon clarification the corresponding YES box will be checked dated and initialed by RN 5 Allergy Injecti
113. on Clear Z z productive Temp 2 5mg 3ccNS O Clear productive p 11 Rales __ __ __ 11 Productive 11 Other 11 Rales _ _ __ os H Productive R O Rhonhi 0 RI dBuRenhi __ __ O2sat C2sat PeakFlow _ U Wheezes __ __ __ PeakFlow luwheezes__ __ __ eakFiow Diminished__ ___ II Dimnished KEY LOCATION Anterior Posterior Right Left Upper Lower Bilateral RESPIRATORY FLOW SHEET 2 10 09 P8 P pb UNIVERSITY OI NOTRE DAME aunt Liar SUBJECT Notification of Laboratory Test Results AUTHORIZATION Assistant Director Clinical Services DATE September 2012 PURPOSE To assure that test results are communicated to patients in a timely and efficient manner to establish a timeframe and process for attempted notifications that are not responded to by the patient PROCEDURE AND OR GUIDELINES A Upon direction of physician RN will call patient to notify of test results and provide instructions B RN will make three attempts to notify patient over a two week course medical record with test result is kept in file cabinet drawer in first floor clinic area C After three unsuccessful attempts over a two week period of time medical record with test result will be taken to front office work room to be filed D Letter will be sent by RN via Medicat ICM to notify patient of unsuccessful attempts to call Exhib
114. on Protocol Exhibit V Criteria on checklist must be met before and after administering allergy injection s 6 Off Campus Injection If the student is going off campus to receive allergy injection s copy their current Allergy Injection Schedule to take with them and return when completed T Allergy Injection Schedule Exhibit VI All allergy injections administered at UHS are documented on this form All extracts should be recorded on one form Note the content of each extract using A B C etc Note the dilution concentration of each extract Note the site of injection using the arm code next to each extract when multiple extracts are to be given and specific sites of injections are identified Note important information in the additional information section i e alternate arms change needles after withdrawal of serum previous systemic reaction frequency etc When giving the injection Note date and time of injection s Note extract using letter code i e A B C etc Note dilution concentration i e 1 10 000 1 100 5000 AU Note does given and site of injection using the arm code After a 30 minute observation period Note the time of site check and record any reactions under remarks F Receipt of Extracts Exhibit VII Place extracts in a plastic bag Label the bag with the patient s name and DOB Store in alphabetical boxes in the Allergy Clinic refrigerator Obtain Allergist s instructions
115. or the procedure LEFT RIGHT The proposed Procedure and the expected outcome risks and reasonable alternative of the proposed pro cedure have been explained to me I have had the opportunity to obtain answers to all questions I have regarding the Procedure Patient Signature Date and Time Witness Physician or RN POST PROCEDURE INSTRUCTIONS Follow up appt WOUND CARE Hand out R I C E Other Instructions MD or Ns signature PROCEDURE Explanation of Procedure given Consent signed for Procedure Release of Information consent form signed optiona Specimen sent to Pathology SITE Other medication used DATE TIME ALLERGIES Local Marcaine 1 Xylocaine 1 w epinephrine 2 Xylocaine 2 w epinephrine Topical Liquid Nitrogen AgNo Sticks I hereby give my permission for the above listed Procedure to be performed on me by the physician M D I have identified the operative area wound as the location for the procedure as LEFT RIGHT 2 The proposed Procedure and the expected outcome risks and reasonable alternative of the proposed pro cedure have been explained to me I have had the opportunity to obtain answers to all questions I have regarding the Procedure Patient Signature Date and Time Witness Physician or RN POST PROCEDURE INSTRUCTIONS Follow up appt WOUND CARE Hand out R LC E Other Instructions MD or Ns signature PRO
116. ot flush Remove reseal and restart prn or contact physician to discontinue as appropriate Document on IV Therapy Flow Sheet IV INFUSION PUMPS 1 Model Baxter Flo Gard 6201 Volumetric Infusion Pump Reference Operator s Manual Inpatient Unit Clean Utility Room 2 Store unused pumps OFF covered and plugged into a standard outlet COMPLICATIONS 1 Infiltration a Causes Displaced catheter enlarged puncture wound b C Signs and Symptoms Swelling tenderness above IV site decreased skin temperature around site fluid continues to infuse even when vein is occluded backflow of blood absent and flow rate slow or stopped Interventions Apply warm moist heat elevate arm restart the infusion at another site and document observations and actions Infection a Causes underlying phlebitis contaminated equipment prolonged placement of an IV device catheter tubing or solution and faulty aseptic techniques Signs and Symptoms Redness warmth tenderness and swelling at site Possible exudate of purulent material Interventions Discontinue the infusion obtain culture of drainage at the insertion site and tip of catheter cleanse site and apply bacteriostatic ointment wash hands and replace gloves restart infusion if indicated and document observations and actions Notify physician Phlebitis a b Causes Movement of catheter within vein and medications that irritate t
117. ou are responsible for obtaining the following from your physician Date and dose of last injection Vials that are labeled coded with your name contents of vial dilution and expiration date Single dose vials are to be numbered or dated Guidelines that clearly state the recommended doses interval of injections route and site of administration Instructions for missed late injections new vials and reactions 6 The physician s signature who is authorizing the therapy gt e IT IS YOUR RESPONSIBILITY TO BE CERTAIN THAT ALL THE INFORMATION REQUESTED IS WITH YOUR EXTRACTS WHEN YOU ARRIVE ON CAMPUS INCOMPLETE INFORMATION MAY RESULT IN A DELAY IN TREATMENT You may bring in the extracts and instructions at your convenience and schedule your first appointment Saint Liam Hall is open 24 hours a day Please note however that allergy injections are given by appointment only and a physician must be in the building For your first injection please make a 1 hour appointment It is MANDATORY for you to remain in our clinic for 30 minutes after each injection Non compliance will result in termination of services at our clinic If you or your physician has any questions regarding our policy and procedure for allergy injections at University Health Services please feel free to contact the allergy nurse at 574 631 3738 UNIVERSITY HEALTH SERVICES INFORMATION FOR PATIENTS RECEIVING ALLERGY INJECTIONS 1 Allergy injectio
118. pproved by Office of Student Affairs Director University Health Services Director of Risk Management SUBJECT CONSENT FOR PROCEDURE POLICY Written signed consent will be obtained from the patient prior to any operative procedure being performed PURPOSE inform patient of procedure to be performed the risks alternatives and the expected outcome To provide the patient with the opportunity to ask questions and receive information as needed GUIDELINES A Following decision to proceed with procedure and explanation given to patient by physician RN places Procedure label onto Clinic Data Record RN completes label information with guidance from physician as needed B Information to be completed includes Date and time Allergies Site Name of physician Operative area including left or right if indicated Type of anesthetic being used Any other medication used Patient signature with date and time of signature and signature of witness Post procedure instructions 10 Physician or RN to sign at bottom of label overlapping signature to page beneath 11 Follow up appointment information CONSENT FOR PROCEDURE Annual Review Reviewed Review Reviewed Reviewed Reviewed Reviewed Reviewed Reviewed Reviewed Reviewed Reviewed Reviewed UNIVERSITY OI NOTRE DAME
119. pproved solution and steel wool Rinse with water Disinfect inside of unit with approved solution Rinse with water Refill heating unit with DISTILLED WATER Plug unit in and turn unit to the on position Replace packs into unit to heat ANNUAL REVIEW Signature p Reviewed SS U i Signature Reviewed O Reviewed Reviewed Reviewed Reviewed p Bevewed Reviewed Reviewed BZ Reviewed Sample log reduced size HYDROCOLLATOR TEMP LOG Mot M meae 1 2 3 4 5 6 7 s 12 13 14 ts 16 17 18 19 20 21 22 23 24 25 26 27 2s 5 o 31 pem 8 8 TL TL LG LI LLL LL Lg gj UNIVERSITY OF NOTRE DAME UNIVERSITY HEALTH SERVICES Saint Liam Hall tel 574 631 7497 Notre Dame Indiana 574 631 6047 46556 USA web http uhs nd edu SUBJ ECT IMMUNIZATION ADMNISTRATION AUTHORIZATION Assistant Director Clinical Services DATE July 2013 To update immunity for enrollment or athletic eligibility or to protect from illness or injury To provide vaccination information describing the potential benefits and risks as required by law EQUIPMENI SUPPLIES Disposable needles and syringes gloves alcohol wipes VIS sheets PROCEDURE AND OR GUIDELINES A RNto perform B Follow immunization manufacturer prescribing information C Asrequired unde
120. pressure is in cylinder and if there are leaks in the system Reviewed Reviewed UNIVERSITY OI NOTRE DAME UNIVERSITY HEALTH SERVICES zem Liam March 2011 Issued Approved by Office of Student Affairs Director University Health Services Medical Director SUBJECT Pain Management POLICY University Health Services utilizes the numeric scale of one through ten to assess patients level of stated pain PURPOSE determine the level of pain a patient is having as described by that patient To monitor effectiveness of analgesic medication GUIDELINES A The RN or physician will ask the patient to rate the amount of pain they are having using a scale of one through ten one described as very minimal discomfort and ten described as the most severe pain B Following administration of analgesic medication and within a reasonable period of time the patient will be monitored for effectiveness of the medication by being asked to rate their pain using the numeric scale C Medical Directives will be followed in the assessment and management of acute pain Annual Review Reviewed Reviewed o Reviewed Reviewed o Reviewed Reviewed Reviewed Reviewed o Reviewed o Reviewed Reviewed Reviewed _ aunt Liar UNIVERSITY OI NOTRE DAME V Y HEALTH SERVICES SUBJECT PULSE OXIMETER AUTHORIZATION Assistant Director Clinical Services
121. r all heat stable nondisposable instruments requiring sterilization before each use Records documenting equipment description maintenance monthly biological testing length of timing plus temperature for the sterilization cycle will be maintained PURPOSE To provide guidelines for the cleaning packaging and steam sterilization of items requiring sterilization To assure sterility of items To assure proper functioning of the sterilizer PROCEDURE A CLEANING AND LUBRICATION Instruments must be thoroughly cleaned prior to sterilization Soaking contaminated Instruments will prevent drying of blood and OPIM and will facilitate cleaning 1 Each morning Mon Fri weekends prn night shift PCA or designee will prepare a fresh solution of the enzymatic presoak following the manufacturer s instructions and place in soaking pans Discard the used solution each evening Wear gloves and a face shield 2 Transport instruments immediately after use in a closed rigid plastic container to the utility room With the instruments in a wide open position carefully place them into the enzymatic solution Gloves must be worn as minimum PPE INSTRUMENT PROCESSING AND STERILIZATION 3 The RN will pre label the new package using a permanent marker with a Name of instrument i e curved or straight scissors hemostat forceps with or without teeth b Date of sterilization c Clinic location 4 Soakinstruments for a minimum of five 5 minutes
122. r live vaccine MMR varicella BCG yellow fever administered lt one month ago the student is to wait 30 days for QTF G test Section Il NOTIFICATION OF STUDENTS All new international students foreign born non U S citizens who are not U S permanent Residents enrolled for on campus course work will be notified of the requirement for tuberculosis testing upon arrival at the University of Notre Dame by International Student Services The following consequences of non compliance with this testing requirement will also be communicated by the International Studies Office e Hold on their account by Registrar s office Tuberculosis testing will be offered by Student Health Services The Registrar s office will provide a current demographic file of international students for download to Student Health Services prior to each testing clinic date Students will be required to have testing completed by September 30th of the Fall semester February 15 for the Spring semester and July 15th for the Summer session Student Health Services will communicate names of students not yet tested to the Office of International Studies in an attempt to verify presence on campus and to seek updated information concerning email addresses telephone numbers and current residence Student Health Services will attempt to notify any student who has not met the testing requirement by email by personal telephone call and if email and telephone numbers are
123. r the National Childhood Vaccine Injury Act 42 U S C 300aa 26 all health care providers in the United States who administer any vaccine containing diphtheria tetanus pertussis measles mumps rubella polio Hepatitis B Haemophilus influenza type b Hib or varicella shall prior to administration of each does of the vaccine provide a copy of the relevant vaccine information materials that have been produced by the Centers for Disease Control and Prevention CDC a Tothe parent of legal representative of any child to whom the provider intends to administer such a vaccine and b Toany adult to whom the provider intends to administer such vaccine D Administration of vaccines a Wash hands b Gloves are optional c Tominimize risk of contamination disposable needles and syringes will be used The size of each will depend on amount and route of delivery d Needles and syringes will be discarded in labeled puncture proof containers e Different vaccines will not be mixed in same syringe IMVUNIZATION ADMINISTRATION E Storage handling and reconstitution of vaccines a Follow recommendations included in the product packaging to assure F Documentation a On clinic data record to include i Date and time ii of vaccine including dose route site manufacturer vaccine number with expiration date signature of RN iii Vaccine label for documentation recommended b Charge for each vaccine given is documented on
124. raduates will again be tested if they have traveled outside the U S to a high risk area since their initial admission as an undergraduate and were previously negative All new international students must prove that they are free of active infectious tuberculosis either through a negative skin test or a negative Quantiferon Gold QTF G lab test done in the U S The only TB skin test accepted is a Mantoux purified protein derivative PPD test that is read within 48 to 72 hours Documented negative TB tests or X Rays performed outside the U S are not acceptable Failure to comply with the testing requirement will result in a hold being placed on the student s account and they will be unable to register for future classes until the requirement is met Students with a positive TB skin test result or QTF G results are positive must have a chest X ray Students with an indeterminate chest x ray may remain registered for classes with the physician s approval Chest x rays and x ray reports from outside the United States will not be accepted except for clinical comparison at the discretion of the physician 5 Students with a positive chest x ray Will be referred to the St Joseph County Health Department SJCHD for possible additional testing and treatment Will maintain compliance with a treatment regimen as determined by the SJCHD or be reported to the Health Center by that agency Section Population Testing Parameters Tuberculi
125. red employee SUBJECT BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN The contaminated sharps injury record will be maintained for at least the duration of employment plus thirty 30 years HEPATITIS B VACCINATION The Hepatitis B vaccine shall be made available to all Notre Dame employees who are identified by Risk Management and Safety as having potential occupational exposure to bloodborne pathogens Reference the University s Exposure Control Plan Vaccinations shall be available after receiving training regarding the risk of exposure to bloodborne pathogens and within 10 days of initial assignment to job with occupational exposure Complete consent form Exhibit Ill Vaccination is not indicated for employees who have already had the HBV series who have had antibody testing documenting immunity to HBV or who have medical contraindications to the vaccine An employee who initially declines vaccination shall be required to sign a declination form Exhibit IV Employees who decline the vaccination initially may elect to accept it at a later date if still employed in a position with potential occupational exposure to blood OPIM POST EXPOSURE EVALUATION amp FOLLOW UP A Medical Examination After Exposure Employees exposed to bloodborne pathogens as a result of their employment duties are entitled to all necessary counseling testing and treatment related to the incident These services will be provided at no cost to the employee Emp
126. ring E Orders for Grab n Go meals or other food items needed prior to the next routine inventory order are to be placed on a separate menu selection sheet with the name UHS F Food services will check inventory at the Health Center twice per week during the Academic year on Tuesdays and Fridays 1 The RN on duty in Inpatient Observation Unit is responsible for daily review of inventory and placing order with Food Services in basement on Tuesday and Wednesday 2 Inhouse food service items will be restocked according to inventory levels and patient needs q day or q shift prn 3 The PCA role is responsible for assembling patient care kits from the Food Services inventory sore throat kits GI kits G Food services will check inventory at the Health Center once per week during the summer 1 Health Services nursing staff will maintain inventory and order prn H Concerns related to Dietary Service will be routed through the Assistant Director Clinical Services to the appropriate person s Revewed Po Reviewed Revewed So kod ERN p p ANNUAL REVIEW ey Reviewed EO A Ea Lo UNIVERSITY OI NOTRE DAME UNIVERSITY HEALTH SERVICES amt Liar SUBJECT EAR IRRIGATION AUTHORIZATION Assistant Director Clinical Services DATE March 2011 PURPOSE Safely remove impacted cerumen from ear canal EQUIPMENT SUPPLIES Refer to Medical Directives before initiating procedure
127. s or staff Therefore extraordinary attempts to disinfect or sterilize these surfaces are rarely indicated SUBJECT BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN However the Health Center will be maintained in a clean and sanitary condition To reduce the risk of transmission of infections the clinic and inpatient areas will be cleaned on a regular basis 1 Appropriate PPE shall be worn during all cleaning of blood or OPIM during decontamination procedures and when handling contaminated laundry or infectious waste 2 Exam tables countertops Mayo stands other work surfaces or equipment that may have been contaminated with blood or OPIM shall be cleaned then decontaminated with an appropriate disinfectant After completion of procedures Immediately when overtly contaminated After any spill of blood or OPIM At the end of a work shift when surfaces have become contaminated since the last cleaning 3 Procedure for handling blood and OPIM spills a Put on disposable gloves b Use paper towel or a sanitary absorbent to absorb the spill c Place used towels or absorbent in a leak proof red plastic bag d Decontaminate the area by flooding the area with an approved disinfectant e Remove gloves f Wash hands thoroughly with soap and water NOTE If vacuum cleaner was used on carpeted areas to pick up the absorbent material vacuum bag must be discarded after use Solutions which are acceptable disinfectants include but are not
128. scriber Diagnosis UJ Pregnant 2 Not Pregnant e mor 19066 8 www ipledgeprogram com 1 866 495 0654 ACCUTANE SHEET Name Date Age Weeks on Accutane Accutane dosage Allergies Weight kg Temp FEMALES FDLMP Methods of Birth control primary sec Review of Systems Check all problems that apply to the past month of treatment e Headaches e Genita Urinary 9 Hairloss e Achingjoints back Drylimitatedeyes _ e Dry skin please indicate areas e Drylboodynose e Drylcrackedlips e Moodswings nausea diarrhea bloody stod cramps __ Labs Date drawn o CBC hCG Glucose Total Cholesterol Triglycerides ___ 1 1HepaticPanel RN Signature ACCUTANE SHEET Name Date Age Weeks on Accutane Accutane dosage Allergies Weight kg Temp FEMALES FDLMP Methods of Birth contra primary sec Review of Systems Check all problems that apply to the past month of treatment e Headaches e Genita Urinary e Hairloss __ e Achingjoints back e Dryl mitatedeyes e Dry skin please indicate areas e Drylboodynose e Drylcrackedlips e Moodswing 9 nausea diarrhea bloody stool cramps __ Labs Date drawn _ 7 CBC hCG Glucose Total Cholesterol Triglycerides 1 Hepatic Panel RN Signature ACCUTANE SHEET Name Date Age Weeks on Ac
129. set of asst sizes 1 NaCl 0 9 2ml 4 Tracheal Tube 7 0 8 5 lea Tourniquet 1 Laryngeal Mask w 60cc syringe sae Bandaids 1 Blood pressure cuff 1 Reseal Valve 2 Stethoscope 1 BLOOD DRAW SUPPLIES Locks and sealing links 1 Auto drop tube holder amp disks set 1 Flashlight 1 Vacutainer needles 21g 4 Nu trach Emergency kit Vacutainers Red top 2 OUTSIDE ON HOOK Purple top 2 Ambu Bag Adult Gold top 2 Biohazard labeled lab bag Revised 08 21 08 Triage Emergency Cart DRAWER 4 IV BAGS TUBING EXP DATE DRAWER 1 MEDICATION AMT EXP DATE 1000CC 5 Dextrose D5W 1 Benadryl 50mg ml 1ml single dose syringe 1 1000cc 0 9 Sodium Chloride NaCl 1 Calcium Gluconate Gel Ist Floor Triage Only A T MS amp 0 45 NaCl 1 50 Dextrose 25gm 0 5g ml 50ml 1 IV Start Kit 2 Epinephrine 1 10 000 1mg 0 1mg ml 10ml 1 Tegaderm Ultrasite valve Epinephrine1 1000 1mg ml 1ml 2 2 ml NS Betadine prep pad Glucagon Emergency kit 1 IV Tubing primary set 2 Glutose 15 Oral Gel 15gm of Glucose 2 Narcan 0 4 0 4mg ml 1 ml Naloxone HCL 1 DRAWER 5 SUPPLY Nitrostat 0 4mg 1 150gr Multiple tablet bottle 1 4X4 Topper Dressing sponges 4 4X4 Gauze Sponges pkg of 10 2 DRAWER 2 SUPPLY AMT EXP DATE Kerlix 5 3 2 188 O2 mask Adult Pediatric Nasal cannula 1ea Surgipad 2 Bitestick 1 Tape 1 ad
130. shes spray splatter or droplets of blood or OPIM may be generated and eye nose or mouth contamination can be reasonably anticipated 3 Gowns Protective body clothing shall be provided to cover and protect work clothing and exposed skin from contamination with blood body fluids Use of protective clothing may be required during patient treatment or when handling contaminated materials Protective gowns are disposable and made of impervious material They should be long sleeved and kept fastened at all times to maximize protection of exposed skin and work clothes 4 Cardiopulmonary Resuscitation Masks When performing mouth to mouth resuscitation a mouth shield with a one way valve or an ambu bag shall be provided and made readily available whenever the need for CPR may be reasonably expected to occur All PPE shall be removed before leaving the work area Contaminated PPE may not be worn in public areas Public areas include but are not limited to employee break rooms lounges eating areas storage areas and restrooms PPE shall be changed immediately or as soon as possible after becoming visibly contaminated with blood body fluids PPE should be discarded in biohazard containers bags PPE may not be taken home to be washed or discarded HOUSEKEEPING Although microorganisms are a normal contaminant of walls floors and other surfaces these environmental surfaces are rarely associated with the transmission of infections to patient
131. shipping Containers must be closed prior to being stored or transported LAUNDRY All employees who have contact with contaminated laundry must wear protective gloves and other appropriate PPE All contaminated laundry shall be handled as little as possible with minimum SUBJECT BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN agitation during handling All contaminated laundry shall be bagged or put into containers at the location where it is used Bags are not labeled since all laundry from the Health Center is considered to be contaminated A laundry cover on the cart identifies this potential biohazard Laundry is cleaned and disinfected on campus and all laundry employees are trained in Universal Precautions Laundry is placed and transported in bags which prevent liquids from soaking through or leaking to the exterior Linens not identified as contaminated with blood OPIM in the clinic areas may be placed directly in containers at point of use The contents of these containers will be consolidated into the laundry bags by gloved and gowned staff RECORDKEEPING University Health Center will establish and maintain for each employee of the University an accurate record of occupational exposure according to OSHA s rule governing access to employee exposure and medical records Title 29 Code of Federal Regulations Part 1910 20 and under the Bloodborne Pathogen standard Medical records shall include a Name and social security number of the
132. sues are available in waiting and reception locations Annual Review Reviewe Reviewe Reviewed Reviewed Reviewed Reviewed o Reviewed Reviewed Reviewe Reviewe d d d d d UNIVERSITY NOTRE DAME UNIVERSITY HEALTH SERVICES March 2011 Issued Approved by Office of Student Affairs Director University Health Services Medical Director Assistant Director Clinical Services SUBJECT ISOTRETINOIN ACCUTANE THERAPY POLICY Isotretinoin Prescriptions will be initiated according to the PLEDGE recommendations PURPOSE In order to comply with prescribing requirements for this medication students who are prescribed Isotretinoin by a University Health Services UHS physician will have their required information kept up to date on the iPLEDGEprogram com website by physicians or their designee and the pharmacist PROCEDURE A Students make an appointment with a University Health Services physician 1 Gender Specific iPLEDGE educational kit is given and explained proper forms are completed a Isotretinoin forms kept at Triage A bottom drawer in red folders b Nurse initiates forms prior to student seeing physician c Kits kept in Dr Moskwinski s office and are ordered by physician as needed d TheiPLEDGE forms are assembled and fastened to the inside back cover of the student s medical report with vertical clip in the following
133. t Yes No 13 PHYSICIAN SIGNATURE authorizing therapy is present Yes No If there are any items checked it is the patient s responsibility to obtain written clarification In some instances this may delay care Upon clarification the corresponding YES box will be checked and dated by the RN RN completing this checklist Name ALLERGY INJECTION PROTOCOL Sign on to Medicat Click on Appointments Select Trav Allergy C Check each chart for a b Injection schedule and interval of injections Crosscheck this with last dose given to assure proper dosage If interval is too long follow the allergist s schedule for decreasing amount If unclear or interval falls longer than orders include place a call to the allergist s office and ask to speak to the nurse Identify yourself as ND Allergy Nurse Check reaction orders for each individual patient Check serum in the refrigerator a Forexpiration date b Check volume of serum Note if new serum needs to be ordered When student arrives a Recheck orders b Assess health status of student Document findings on Pre Therapy Questionnaire Exhibit IX Do not give if Temp gt 100 appears acutely ill asthma or hay fever symptoms had tetanus or other immunization in past 24 hours excluding influenza vaccine ifany swelling remains from last injection taking any beta blocker medications c Draw up proper dosage recheck with ord
134. t shift 6 The interior of the cart will be cleaned yearly at the end of the academic year or as needed FORMS or REFERENCES Emergency Medical Report Exhibit I Emergency Cart Inventory IOU Exhibit II Emergency Cart Inventory Triage Exhibit III Emergency Cart Log Exhibit IV MEDICAL EMERGENCY RESPONSE EMERGENCY CARTS ANNUAL REVIEW Reviewed Reviewed Reviewed o Reviewed Reviewed Reviewed Reviewed _ Reviewed Reviewed Reviewed Reviewed Reviewed UNIVERSITY OF NOTRE DAME MEDICAL EMERGENCY REPORT UNIVERSITY HEALTH CENTER STATUS 7 student 7 Faculty Staff visitor Puvsiciav s in ATTENDANCE BY PERSON TIME NOTIFIED NA msn NOTIFICATION IRESPIRATORY LlcARDiAC CPR TYPE OF ARREST CD STOPPED IV STARTED TAE SITE 4 BY moe jg om Dlambu Onc wow amy TRANSFERRED TO Bv Tie EXHIBIT II 10 95 EXP INPT OBS Emergency Cart DRAWER 3 SUPPLY AMT DATE DRAWER 1 MEDICATION AMT DAE 4X4 Topper Dressing sponges 4 Ammonia Ampules 5 4X4 Gauze Sponges pkg of 10 2 Atropine Sulfate 1mg 0 1mg ml 10ml 1 Kerlix 5 3
135. takes place when liquid cryegen transforms inta gas Depending on the outside temperature and the length of time unit is used con tainer temperature can drop to 50 60 4 REMOVING THE CAP Allow the top cap to warm before attempting io remove it from the container A top cag that is cold to the touch may be difficull to remove Place the vacuum container on a flat surface in a vertical position with the outflow track pointed away fram you and others at all times Depress the trigger to relieve the internal pressure and twist the container clackwise IMPORTANT NOTES Each Nitrospray unit has a factory matched vacuum container and top cap This has been done to achieve optimal performance Therefore it is NOT recommended to interchange the vacuum containers and caps Doing so may cause poor performance and damage the unit Each cap has a matching serial number inside INSUFFICIENT SPRAY This can be caused by the following Freezing in the spray tip or the outflow track If heavy frost coats the tip and track allow the parts to warm and then use A small tip orifice i e 20 gauge needle pro duces a slow spray output that is more prone to freezing than a larger orifice Particulate matter in the outflow track This can be caused when using a cryogen that is not sufficiently clean and a build up occurs in the container Inspect the container 1 must be cleaned of particulate matter periodically If the cryogen contains particu late
136. tear fluid 5 Begin the test by gently placing the sampling pad of the sample collector into the sample transfer window of the test cassette body 6 Press firmly where indicated until the test feels secure A double click means that test is properly assembled 7 Open the buffer vial and remove the protective cap from the test Do not allow any portion of the cassette besides the absorbent tip to touch the buffer vial Immerse the absorbent tip into the buffer vial for 15 seconds 9 Remove the absorbent tip from the buffer vial Replace the protective cap and place the test cassette horizontally on a flat surface for 10 minutes Do not interpret test prior to completing 10 minutes of development time 10 Once the background of the result window is white again it may be pink during testing time and 10 minutes has elapsed the test may be accurately read If there is a streaky pink background e eo after 10 minutes allow an additional 5 minutes of running time 11 Results are indicated through two lines which appear in the result window the result line and the control line The control line appears as a red line the control line zone It indicates the correct application and performance of the test and must appear for the test to be valid a Negative result only the control line appears A negative result should be reported as a presumptive negative for the presence of adenovirus antigens b Positive result the result line appe
137. th Services UHS Medical Directives will be reviewed and approved annually by the UHS physicians before the start of each academic year 116 the responsibility of the Assistant Director Clinical Services to inform the UHS RN s of any changes in the Medical Directives annually and whenever changes are made thereafter A Medical Directives manual will be available at the clinic workstations and at the nurses station on the inpatient unit In addition the Medical Directives manual will be given to all newly hired Registered Nurses upon orientation at UHS Any nonconformity to this policy procedure may result in disciplinary action leading up to and including termination of employment The UHS RN will have a current and accurate knowledge base of the medical Directives before providing care to a patient Each RN will be responsible to periodically review the Medical Directives manual in order to maintain a current knowledge base Any questions concerning treatment procedures that are not answered in the manual should be referred to a UHS physician or the Administrative staff as niappropriate Any suggested additions deletions or clarifications to the Medical Directives should be place in a written memo to the Assistant Director Clinical Services MEDICAL DIRECTIVES ANNUAL REVIEW Reviewed Reviewed Revewed f Reviewed Reviewed Revewd
138. the following Drug should eot be shared with anyone even any drog remaining after therapy Blood should not be donated while raking isotretinoin and for ac least 30 days alter the last dose Patient program adherence J I have confirmed with she PLEDGE system that I have counseled the patient J 1 have prescribed maximum 30 day supply of isotretinoin Date Confirmation Information I have counseled this patient oa the following Drug should not be shared with anyone Blood should not be donated while taking isotretinoin Patient program adherence O have confirmed with the PLEDGE ayscem that 1 have counseled the patient Gl have peeseribed maximum 30 day supply of isocretinoin Date Confirmation Information 4 1 have counseled this patient on the following Drug should nor be shared wish anyone Blood should noe be donated while taking isotretinoin Patient program adherence O 1 have confirmed with the PLEDGE system thar I have counseled the patient O have prescribed maximum 30 day supply of isotretinoin Date C T have counseled this patient on the following Drug should nox be shared with anyone Blood should not be donated while taking isotrenmain Patient program adherence 1 1 bave confirmed with the PLEDGE system that have counseled the patient O 1 kawe prescribed maximum 30 day supply of isotretinoin www ipledgeprogram com 1 866 495 0654 iPLEDGE PRESCRIBING C
139. tive for the following groups Foreign born persons from areas with reportedly high occurrence rates of TB American born students who have traveled abroad to a high risk country for more than one month Intravenous drug users Persons with known medical risk factors Children younger than four years of age 3 Areading of fifteen or more millimeters is positive for all American born students who have no known risk factors Section V Follow up of PPD Test If the QTF G test result is negative no further testing or treatment is required The student is informed of the signs and symptoms of tuberculosis and encouraged to seek medical care if these symptoms develop If the QTF G result is positive the student is required to have a chest x ray any films or x ray reports from a foreign country will not be accepted If the chest x ray is negative for active TB disease the student will be managed according to CDC guidelines with possible preventive treatment If the student decides to follow the recommended medication therapy the SJCHD will provide the medication through University Health Services Pharmacy on a monthly basis The student will be screened for side effects monthly If at least 6 months of medications are completed within 9 months or 9 months of medication within 12 months a certificate of completion Exhibit will be issued to the student for verification If the student decides NOT to follow this recommendation th
140. to campus If student is returning for summer school indicate this on Allergy Injection Schedule ExhibitVI Place their name on the summer list H Unclaimed or Expired Extracts Annual Review Reviewed Reviewed 0 Reviewed Reiewet Reviewed Reviewed _ When extracts go unclaimed after the academic year the patient is notified via their ND email address and disposed of it expired Expired serum is discarded according to organizational guidelines Reviewed Reviewed Reviewed Reviewed Reviewed UNIVERSITY HEALTH SERVICES TO Notre Dame Students on Allergy Immunotherapy FROM Mary Ellen McCaslin RN BSN Assistant Director Clinical Services RE Allergy Injections University Health Services at the University of Notre Dame located in Saint Liam Hall is pleased to administer allergy injections to our students who are under an immunotherapy regimen prescribed by their private physicians Our records indicate that you are either a new or returning student receiving allergy injections To assure a standard of quality care we ask for your cooperation The continuation of this therapy at University Health Services requires specific instructions from your physician It is imperative for us to have this information before we will provide care for you Please give your physician the enclosed letter and verification forms Y
141. to the billing department to make arrangements for payment Options include placing it on the student account as a Health Services charge or paying by cash or check to University Health Services H In the event of a positive HIV antibody test it is the responsibility of the physician to complete the reporting form required by the Indiana State Department of Health Exhibit I Special Considerations A Anonymous Testing 1 In Indiana the State Board of Health must grant permission for an agency to perform anonymous testing This Health Center does not perform anonymous testing In South Bend the St Joseph County Health Department performs anonymous testing 2 In anonymous testing no records are kept which could identify the person tested 3 In Indiana results of anonymous testing are reported to the State Board of Health B Confidential Testing 1 In confidential testing records identifying the patient are kept confidential 2 The names of persons who test positive for HIV are reported to the State Board of Health by the South Bend Medical Foundation 3 This Health Center offers confidential testing which may be requested on an anonymous testing form available atthe front desk or on the standard lab requisition form in use HUMAN IMMUNODEFICIENCY VIRUS HIV TESTING C Confidentiality Confidentiality will be maintained in the process of ordering drawing billing storing and later the release of these test results Failure
142. uired once per shift when status meets expected outcome All exceptions restarts or discontinuation of therapy require additional entry EXPECTED OUTCOME Site is without redness swelling pain hardness drainage or palpable venous cord KEY Y Meets expected outcome IV INT removed catheter intact See nurse s notes Initials Signature Initials Signature Initials Signature SAS 12 5 2011 UNIVERSITY OI NOTRE DAME aunt Liar SUBJECT KINETEC Performa Continuous Passive Motion CPM Exerciser AUTHORIZATION Assistant Director Clinical Services DATE March 2012 PURPOSE Decrease pain swelling joint stiffness adhesions and contractions during rehabilitation following knee surgery PROCEDURE 1 Physician writes orders for use of CPM See Exhibit 1 PANURSINGWURSING FORMS Inpatient Chart forms CPM PhysicianOrders 8 Extension limit 3 to 125 NOTE Full extension 3 There is a 5 limit between extension and flexion b Flexion limit 130 to 2 C Speed 1 to 7 d Force movement inversion load 0 6 mini to maxi e Times duration and frequency f Foot plate position in position of comfort for patient 2 Prepare CPM Machine refer to user manual a Plug in turn power on on is the minus sign turn patient lock out switch off off is without b Enter prescribed settings into handset Simultaneously press keys PAUSE EXT and PAUSE FLEX to unlock the hand control sett
143. ultures will be retained for at least 2 years Ifa culture grows the enospore all packages with that date of testing and all subsequent packages will be removed from patient care areas and will need to be resterilized The nurse will submit a written documentation of the failure to the Assistant Director Clinical Services The autoclave manufacturer will be notified and requested to immediately check for proper use and function and the spore test repeated MAINTENANCE AND CLEANING DAILY Clean door gasket with alcohol and a soft cloth 2 WEEKLY Clean the water sensor located in the rear of the inside of 3 Monthly the chamber with a damp cloth or sponge It is especially important to wipe the sides and the tip to remove any dirt or debris Clean the safety valve located in the water reservoir It is necessary to allow the steam pressure to escape to prevent it from becoming blocked a Operate the sterilization cycle b Allow a pressure of 30 psi to build up in the chamber check printout c Turm the unit off Use the padded gloves provided and keep clear of steam discharge to avoid burns d Remove the cover from the water reservoir e Pullthe ring of the safety valve using a tool open for 10 seconds then release f Turn the unit back on and press the STOP key to abort and vent the cycle g Wait until pressure decreases to zero then open the door h Document on Autoclave Maintenance Record a Remove trays and
144. wear are recommended when handling liquid cryogens 1 FILLING Place the vacuum container on a flat surface in a vertical position Remove the black plastic top cap by turning it in a counterclockwise direction Check that the o ring is present and properly seated inside the cap Slowly begin filling the container with liquid nitrogen by pouring or by using a low pressure withdrawal device from a dewar storage tank It is recommended that the unit be filled approximately 2 3 o1 its capacity This will yield an average of 3 6 hours of intermittent use depending on the number of treatments applied and the duration of each individual treatment Fill container based on your daily treatment needs A full unit will be lighter and the plastic top wilt be slightly warmer Refilling when the container still contains liquid nitrogen allowed However it should be done with extreme caution as the fluid inside is under pressure Place the vacuum container on a flat surface in a vertical position with the outflow track pointed away from you and others at all times Depress the trigger to relieve the internal pressure and twist the container clock wise Remove cap and refili as described above Do not leave the filled container uncapped for more than 1 minute as this may cause ice crystals ta accumulate in the cryogen 2 CAP TIGHTENING For proper operation it 15 essential to create a pressure tight seal between the top and the vacuum container T
145. wing defined steps in owner s booklet a b Insert a test strip to turn on meter The display check will appear then the code number which should match that of the test strip vial If the code numbers do not match or appears press the C button until the correct code number appears It will flash for 3 seconds then appear solid for 3 seconds Watch for the blood drop symbol to appear Lance patient finger Apply blood sample Obtain test result in 5 seconds Remove strip only after result is displayed Universal Precautions Wash hands before and after procedures for testing and cleaning Wear disposable gloves for testing and cleaning Always use a new sterile lancet Lancets are for single use only Discard lancet and test strip into sharps container immediately after use Blood Glucose Testing ONE TOUCH Ultra System 5 Clean the meter after each patient Remove test strip holder and discard C Quality Control Measures 1 TestStrips a b C d m Use only ONE TOUCH Ultra test strips Store at room temperature Check expiration date of unopened vials Record a discard date on the vial once opened Discard the test strips 4 months after opening Replace vial cap immediately after removal of test strip Do not touch the test spot on the test strip Code number on the meter display must match the code number on the vial of ONE TOUCH strips in use Check the amount of blood o
146. y in the administration of Intravenous therapy PROCEDURE and or GUIDELINES A Using aseptic technique the seals should be broken and the vial attached to the bags immediately before use if possible If non activated bags are to be stored a 30 day expiration date should be attached B Toassure a tight fit twist the vial on the bag until a click is felt C To activate the bag pull down on the cap covering the additive to release medication powder shaking the bag and squeezing solution into the vial until the solution is fully dissolved D Attach appropriate IV set and use immediately E If activated mixed bags cannot be used immediately affix expiration dates according to manufacturers directions and refrigerate Discard after expiration ADD VANTAGE INTRAVENOUS MEDICATION Annual Review d Reviewed Dae Signature Reiewed Reviewed J Redewed NENNEN Ea p a peu Reviewed Reviewed 0 UNIVERSITY OF NOTRE DAME UNIVERSITY HEALTH SERVICES July 2013 Issued Approved by Director University Health Services Medical Director Assistant Director Clinical Services SUBJECT ALLERGY INJECTIONS POLICY It is the policy of University Health Services UHS to provide allergy immunotherapy to currently enrolled students at the University of Notre Dame based on the guidelines set by their Allergist University Health Services will not be responsible for ski
147. ysician s order allergy history Use asceptic technique in adding diluent to additive adding medication to IV solution or using the ADD Vantage system e Gently agitate the solution to mix the medication upon dilution or when adding medication to IV solution T Label IV solution T Patient s name Room number Date amp time Name of additive and does Rate of administration Nurse s initials ADMINISTRATION OF INTRAVENOUS MEDICATIONS 1 Professional RN staff may administer IV medications in the following ways as ordered by a physician a IV push If administering med through a reseal flush site with 1cc NS to check Patency administer medication flush with 1cc NS IVPB secondary infusion Set up with 50 100cc of NS or D5W to primary tubing and piggyback antibiotic with secondary tubing Check patency of site prior to infusion of med Post infusion of med flush tubing with NS or DSW Directly into the IV bag 2 Document on IV Therapy Flowsheet G ADD VANTAGE SYSTEM See Procedure H IV RESEAL or INT This intravenous access is for intermittent or periodic infusions of medications or fluids It may also be used for some blood samples for lab analysis Maintain patency by flushing site with 1 NS every 8 12 hours If patient is outpatient with visits gt q12 hours flush with 2cc Heparin 1 100u NOTE If there is redness J at site or if resistance is met do n

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