INFECTION CONTROL GUIDELINES FOR BASIC WOUND CARE
Wash hands before and after all patient care

Use sterile technique for dressing changes of open wounds
Use aseptic techniques for dressing changes of closed wounds

Use ½ strength H2O2 and NS to clean suture lines, abrasions, and closed

lacerations unless ordered otherwise by physician

Dressings saturated with drainage fluid should be changed as needed if cleared by physician

Chest tube dressings should be changed every day unless ordered by physician. Chest tube sites should be assessed, cleansed using ½ strength H2O2 and sterile

saline and redressed with Vaseline gauze, drain sponge, and foam tape
Document and notify physician of changes in drainage characteristics i.e.;

amount, color, odor, viscosity

Document and notify physician of any purulent drainage, signs of inflammation, or changes in integrity of suture lines or wound margins

If wound cultures are required, obtain 2 aerobic and 1 anaerobic specimens for gram stain and culture

TRAUMA GUIDELINE

TRAUMA SERVICE Bowel Care Guideline St. Joseph’s Hospital &

Medical Center PAGE 1 of 1

February 2001 April 2010

ORIGINAL DATE REVISED

PURPOSE: To raise awareness of complications in ICU patients with alteration in elimination.

GUIDELINES: 1. Patients at risk:

a. Spinal cord injuries (refer to SCI protocol) b. Comatose or altered LOC

c. Pelvic fractures d. GI post-op patients e. Non-ambulatory patients f. Patients on narcotics g. Elderly patients 2. Assessment: (Daily)

a. Assess patient’s normal pattern of elimination b. Usual bowel care maintenance

c. Daily activities (exercise patterns, etc)

d. Assess for presence of bowel sounds to determine return of bowel function e. Ask the patient if they are passing flatus rectally, also indicative of return of

bowel function

f. Evaluate patient for abdominal distention, nausea or vomiting, which may be indicative of obstruction

g. Monitor stool for frequency, amount, and consistency

h. Administer stool softener or laxative as ordered; to promote comfort with elimination

i. Encourage diet with adequate fiber and fluid content for natural laxative effect j. Encourage and assist with ambulation to promote peristalsis

k. Test all stools for occult blood 3. Management:

Discuss assessment findings with physician and anticipate orders for: a. Stool softeners

b. Laxatives c. Suppositories d. Enema

4. Expected Outcome: (Minimum)

TRAUMA GUIDELINE

TRAUMA SERVICE Management of the SCI Patient St. Joseph’s Hospital & Or Patient in C-Spine Precautions Medical Center

Page 1 of 6

December 2008 April 2010

ORIGINAL DATE REVISED DATE

PURPOSE: To standardize the process of removing patients from emergency transport boards and maintaining spinal immobilization.

GUIDELINES:

Patients with cervical or thoracolumbar fractures should be removed from spine boards as soon as possible after arrival in the Trauma Room or Emergency Department.

 After diagnostic studies have been performed and it is thought that the patient will not require further tests and/or transports

 After diagnostic studies have been performed and the patient is waiting to be admitted.

All cervical and thoracolumbar fractures are considered unstable until cleared..  Unstable fractures do not have to be cleared before a spine board is removed.

A physician's order is not needed prior to removing the patient from a spine board except in the case of thoracolumbar fractures.

 Patients with thoracolumbar fractures may be removed from a spine board by nursing personnel with a physician's order or with a neurosurgical physician present.

Nursing personnel educated in the procedures for removing a patient from a spine board may do so.

 The logroll method is used to remove patients from spine boards.

 Cervical collars, if in place, should not be removed prior to removing the patient from the spine board.

 A minimum of four personnel, including at least one R.N. or M.D. is recommended for removal of a patient from a spine board.

Patients with stable fractures may be transferred from a gurney to a bed or procedure table by nursing personnel.

 A minimum of five personnel, including at least one R.N. or M.D. is recommended when transferring a patient using a total body lift.

 Whenever possible a patient slide board should be used to transfer the supine patient.

Patients in Gardner-Wells Tongs Traction may be removed from a spine board only when a physician is controlling the tongs/weights and holding traction.

PROCEDURE:

Assess the patient's neurological sensory/motor levels.

Assess where and to what intensity of pain the patient is experiencing. Explain the procedure to the patient.

 Instruct the patient to report any sensory/motor or pain level changes. Removal from the Spine Board:

 One person is assigned to hold the patient's head from behind.

 Place one hand over each ear with fingers positioned beneath the occiput so that the head is cradled.

 DO NOT APPLY TRACTION ON THE HEAD/NECK WHILE CRADLING THE HEAD.

 Two personnel position themselves on the same side of the patient, one at the shoulders and one at the hips and legs.

 Another person positions themselves on the opposite side of the patient.

 The person cradling the head is the team leader. On the count of three the leader indicates when they are ready to log roll the patient in unison, using one slow, smooth movement and maintaining the spine in complete midline alignment.  The patient is log rolled slowly towards the personnel positioned at the shoulder

and hip of the patient.

 This person should check for and remove any dirt, foreign objects, etc under the board. A clean sheet may be placed at this time.

 On the count of three the leader indicates that the patient is to be log rolled to their back.

Mobilizing the Poly Trauma Patient:

 Patients with injuries in addition to the Spinal Cord injury or vertebral injuries may need clearance for mobilization (i.e.; orthopedics)

 Initial mobilization should be coordinated between Neurosurgery and orthopedic services following the patient.

 Any restrictions must be clearly identified and described in the mobilization orders by the physician.

Transferring the patient:

 One person is positioned at the patient's head and cradles the head as described above. This nurse is the team leader.

 At least one person is positioned at each of the patient's shoulders and hips.  On the team leader's three count, the team, in unison lifts and transfers the patient.

A sheet placed under the patient using the logrolling method described above may be used to lift the patient.

Cervical Collars:

 Patients admitted to the floor or ICU who are still in their cervical collars must be left in their collar until cleared by the physician.

 If there is documentation that the CT Scan(s) of the spine are negative for fractures or subluxations the patient may be mobilized to a chair and have the head of the bed up 30 degrees with the cervical collar on.

 Patients with cervical collars that are left on the patient more than 48 hours require neck/skin care daily.

 The patient's cervical collar must be removed with the patient positioned flat in bed.

 An R.N. must provide cervical spine alignment by using two hands to cradle the head while a second R.N. removes the collar, checks for signs of

excoriation or breakdown, cleans and thoroughly dries the neck, changes the pads on the collar and replaces the collar securely in place.

TLSO:

 Physicians ordering the use of a TLSO for the management of the patient with a TLS spine fracture must document these specifies in the patient’s chart:

 Unless otherwise ordered a patient who has been surgically stabilized may don their TLSO brace in a sitting or standing position.

 Unless otherwise ordered a patient who has been surgically stabilized may have bathroom privileges without their brace on.

 The TLSO brace should be on at all times when the patient is up greater than 30 degrees for long periods of time.

 Unless otherwise ordered a patient who has been surgically stabilized may sit and shower without their brace on.

 The TLSO brace may be off when the patient is in bed.

 When ordering PT/OT specific instructions for any restrictions should be clearly written in the chart.

 When discharging home the physician should write specifics instructions for the use of the TLSO brace and what activity and lifting restrictions the patient must adhere to.

Specifics for Care of the SCI Patient:

 Once there is documentation of a SCI the ICU/Floor nursing staff should institute the Acute SCI Guideline. This guideline outlines the important needs of a SCI patient by systems and includes psych/social, spiritual, and educational needs as well as dispositional needs.

 Pulmonary – Goal is to prevent pneumonia. Pulmonary toilet is very important and should include elevating the HOB as soon as allowed, aspiration precautions, routine SVN’s, suctioning, manually coughing when appropriate (SCI at the level of T-6 or higher), early mobilization (after stabilization), weaning from ventilator when ready (per Trauma Weaning Protocol), daily SVP’s, and use of incentive spirometer. Once stabilized, orders should be obtained from the physician to mobilize to the chair (this should be done regardless if the patient is intubated or not). The patient should also be proned once a week (once stabilized) to assess the skin under the Halo.

 Cardiovascular – Goal is maintaining hemodynamic stability and prevent DVT/PE’s. During resuscitation phase of injury the patient should be fluid resuscitated until euvolemic status has been achieved. VS and fluids should be managed carefully. Strict I&O’s every shift and urine output should be

documented every hour when in the ICU phase. The patient may require the use of vasopressors if neurogenic shock is present. PAS should be applied within the first 24 hours of admission. Medications for DVT/PE prophylaxis should be instituted by the physician when there is no further danger of hemorrhage found. In SCI at the level of T10 or above obtain order for an abdominal binder and thigh-high TED hose prior to mobilizing out of bed to chair to prevent orthostatic hypotension.

 Nutrition – Goal is to meet the nutritional needs of the SCI patient within 72 hours of admission. Nutritional assessment should be performed upon admit and a nutritional consult obtained early if appropriate. If intubated provide either enteral

or parenteral nutrition as appropriate. Keep HOB elevated. Follow guidelines for placement of feeding tube. Once extubated the nurse should perform a dysphagia screening assessment on the patient. A consult for swallow evaluation by Speech Therapy should be obtained if appropriate. Assistance with feeding should be anticipated and provided in a timely manner.

 Communication – Goal is to identify the communication needs of the SCI patient and anticipate the need for other modes of communication, thereby providing the patient with feelings of security and control over his/her environment. Identify the appropriate call system for the patient such as the Soft Touch Call Button. Prism glasses should be obtained for the patient if appropriate. This should include a cognitive evaluation by Speech Therapy if appropriate.

 Pain – Goal is for the patient to remain pain free. Nursing staff should assess for pain, spasms and hyperesthesias every 2 to 4 hours and treat appropriately. Pain management should not only include medication management but assessment for the need to reposition.

 Mobility – Goal is to prevent complications such as pneumonia, decubitus ulcers, and skin breakdown but also to prevent contractures. Patient and family members should be available for training by PT/OT staff when appropriate. Nursing staff should haveguidance in the management of splints, mobilizing, gait training, transfer training, and use of DME (Durable Medical Equipment). A schedule for placing and removing hand splints (on 2 hours/off 2 hours) should be posted in the room for staff to adhere to. The physician should order Prafo boots for patients who have sustained injuries resulting in flaccid lower extremities. A schedule for Prafo boots application and removal should be posted in the room for staff to adhere to (on 2 hours/off 2 hours). Patient mobility to a chair and periods of activity should be increased daily to a goal of 2 to 3 hours of activity a day. This includes OOB to Cadillac chair for ALL meals. Elevation of BUE and BLE extremities to prevent dependent edema should be performed. PT/OT and a Neuro Rehab consult should be obtained early. The physician should write specific activity orders for PT/OT to prevent delay in treatment.

 Skin/Hygiene – Goal is to prevent decubitus ulcers. Assess the patient’s skin every 2 hours. Turn the patient every 2 hours. Teach the patient/family to weight shift every 15 minutes. Obtain a waffle mattress or Accumax bed with pump as soon as the patient has been stabilized and order a waffle chair pad once the patient is able to transfer into a chair. If in a Halo Brace pin care should be

initiated immediately and should be performed every shift. The Halo brace patient should be proned once a week for skin assessment on the back.

 Bowel and Bladder – Goal is to initiate a program early to prevent complications. Foley Catheter on admission with every 1 hour urine output monitoring while in the resuscitative phase. Strict I&O. Discontinue the Foley catheter and begin intermittent catheterizations or leave the Foley catheter in place when transferred to neuron rehab. Self cath training will begin there. Foley care should be provided every shift. Monitor for an ileus in early stages of injury. Stool softeners, Senokot, and Dulcolax suppositories should be ordered daily by the physician. Monitor for a UTI.

 Sleep – Goal is to provide periods of uninterrupted sleep. Assess the patient’s sleep patterns. Discuss sleep/rest needs with the patient and patient’s family. Medicate prn for sleep and post a sleep schedule in the patient’s room

 Psych/Social/Spiritual Needs – Goal is to identify and address any psych/social needs the patient or family may have and establish trust with the patient/family. This should include proactive listening, communication and reinforcement of the plan of care, facilitation of communication between the disciplines, establishing realistic expectations with the patient/family, help the patient/family identify the main caregivers, and most importantly involve the patient/family in the plan of care. Case Management/Social Services should see the patient within 24 hours of admit and begin disposition planning and provide counseling and resources for any needs. The on call Chaplain should be notified of the spiritual needs or requests of the patient/family. They should identify resources and provide a supportive environment for the patient/family. This should include coping strategies.

 Patient/Family Education – Goal is to educate the patient/family members by discharge on the care and needs of the SCI patient. Education should begin from day one and be provided by all healthcare staff who come into contact with the patient/family members. Provide community resources for SCI support groups, etc. The patient and family members must be educated on which physician to follow-up with and what they are seeing the patient for. (Example: Neurosurgery will see the patient for follow-up for the back stabilization but orthopedics will see the patient in follow-up for the femur fracture.) They should also be educated in restrictions concerning orthopedic injuries such as non-weight bearing on a certain extremity that has been fractured.

NEUROSURGERY GUIDELINE

NEUROSURGERY SERVICE Halo Brace Application & St. Joseph’s Hospital &

Management Medical Center

PAGE 1 of 3

July 1984 April 2010

ORIGINAL DATE REVISED

PURPOSE: To provide guidelines for assisting with the application of a halo brace. GUIDELINES:

1. The halo brace is applied by the neurosurgery physician with nursing assistance and with the assistance of an orthotist

2. A consent form should be signed prior to the brace application

3. The application of this brace is done in the patient’s room. Intensive care patients may require brace application in the ICU.

4. Scheduling of the orthopedic technician, orthotist, and physician are done by the physician’s office

5. The patient does not need to be NPO. However, each patient should be assessed by the nurse as to when nasogastric or oral intake should cease prior to the procedure. Usually 1-2 hours prior to the procedure is adequate.

6. The patient’s neurological status should be monitored frequently during this procedure 7. EQUIPMENT: a. 2 EA Sterile Towels b. 1 EA Sterile Bowl c. 8 EA Sterile 4x4’s d. 2 EA Size 7 ½ gloves e. 1 EA Size 8 & 9 gloves

f. Providone-iodine solution g. 2 EA Safety Razors

h. 1 EA Rubber band – To secure long hair i. Bath towels (several)

j. 1 EA 20cc Syringe k. 1EA 18 gauge needle

l. 1 EA 22 gauge needle, 1 – ½”

m. Xylocaine 1 & 2%, with & without Epinephrine n. Adhesive tape – 1”