E



E



1640


Ear Care


Definition: Prevention or minimization of threats to ear or hearing


Activities:



• Monitor auditory function


• Monitor anatomical structures for signs and symptoms of infection (e.g., inflamed tissue and drainage)


• Instruct patient on the ear’s anatomical structures and their function


• Monitor for patient-reported signs and symptoms of dysfunction (e.g., pain, tenderness, itching, change in hearing, tinnitus, and vertigo)


• Monitor episodes of chronic otitis media (i.e., ensure appropriate preventative measures and treatments are employed)


• Instruct parent how to observe for signs and symptoms of auditory dysfunction or infection in child


• Administer hearing test, as appropriate


• Instruct patient on importance of annual hearing testing


• Instruct women of childbearing age on importance of prenatal care (e.g., avoidance of ototoxic medications, adequate dietary intake, and strict control of alcoholism)


• Inform parent about vaccinations which eliminate the possibility of sensorineural hearing loss (e.g., vaccination against rubella, measles, and mumps)


• Cleanse external ear using washcloth-covered finger


• Instruct patient how to cleanse ears


• Monitor for an excessive accumulation of cerumen


• Instruct patient not to use foreign objects smaller than patient’s fingertip (e.g., cotton-tipped applicators, bobby pins, toothpicks, and other sharp objects) for cerumen removal


• Remove excessive cerumen with twisted end of washcloth while pulling down the auricle


• Consider ear irrigation for the removal of excessive cerumen if watchful waiting, manual removal, and ceruminolytic agents are ineffective


• Instruct parent to ensure child does not place foreign objects into ear


• Administer eardrops, as needed


• Instruct patient on proper eardrop administration


• Instruct patient how to monitor for persistent exposure to loud noise


• Instruct patient on importance of hearing protection during persistent exposure to loud noise


• Instruct parent to avoid bottle-feeding or allowing infant to bottle-feed while in supine position


• Instruct patient with pierced ears how to avoid infection at the insertion site


• Encourage use of earplugs for swimming, if patient is susceptible to ear infections


• Instruct patient on appropriate use of and care for assistive devices or treatments (e.g., hearing aids, medication regimen, and ear tubes)


• Instruct patient on signs and symptoms warranting reporting to health care provider


• Refer patient to ear care specialist, as needed


1st edition 1992; revised 2013



1030


Eating Disorders Management


Definition: Prevention and treatment of severe diet restriction and overexercising or binging and purging of food and fluids


Activities:



• Collaborate with other members of health care team to develop a treatment plan; involve patient and/or significant others, as appropriate


• Confer with team and patient to set a target weight if patient is not within a recommended weight range for age and body frame


• Establish the amount of daily weight gain that is desired


• Confer with dietician to determine daily caloric intake necessary to attain and/or maintain target weight


• Teach and reinforce concepts of good nutrition with patient (and significant others as appropriate)


• Encourage patient to discuss food preferences with dietician


• Develop a supportive relationship with patient


• Monitor physiological parameters (vital signs, electrolytes), as needed


• Weigh on a routine basis (e.g., at same time of day and after voiding)


• Monitor intake and output of fluids, as appropriate


• Monitor daily caloric food intake


• Encourage patient self-monitoring of daily food intake and weight gain/maintenance, as appropriate


• Establish expectations for appropriate eating behaviors, intake of food/fluid, and amount of physical activity


• Use behavioral contracting with patient to elicit desired weight gain or maintenance behaviors


• Restrict food availability to scheduled, pre-served meals and snacks


• Observe patient during and after meals/snacks to ensure that adequate intake is achieved and maintained


• Accompany patient to bathroom during designated observation times following meals/snacks


• Limit time spent in bathroom during periods when not under observation


• Monitor patient for behaviors related to eating, weight loss, and weight gain


• Use behavior modification techniques to promote behaviors that contribute to weight gain and to limit weight loss behaviors, as appropriate


• Provide reinforcement for weight gain and behaviors that promote weight gain


• Provide remedial consequences in response to weight loss, weight loss behaviors, or lack of weight gain


• Provide support (e.g., relaxation therapy, desensitization exercises, opportunities to talk about feelings) as patient integrates new eating behaviors, changing body image, and lifestyle changes


• Encourage patient use of daily logs to record feelings, as well as circumstances surrounding urge to purge, vomit, overexercise


• Limit physical activity as needed to promote weight gain


• Provide a supervised exercise program, when appropriate


• Allow opportunity to make limited choices about eating and exercise as weight gain progresses in desirable manner


• Assist patient (and significant others as appropriate) to examine and resolve personal issues that may contribute to the eating disorder


• Assist patient to develop a self-esteem that is compatible with a healthy body weight


• Confer with health care team on routine basis about patient’s progress


• Initiate maintenance phase of treatment when patient has achieved target weight and has consistently shown desired eating behaviors for designated period of time


• Monitor patient weight on routine basis


• Determine acceptable range of weight variation in relation to target range


• Place responsibility for choices about eating and physical activity with patient, as appropriate


• Provide support and guidance, as needed


• Assist patient to evaluate the appropriateness/consequences of choices about eating and physical activity


• Reinstitute weight gain protocol if patient is unable to remain in target weight range


• Institute a treatment program and follow-up care (medical, counseling) for home management


1st edition 1992; revised 2000




2570


Electroconvulsive Therapy (ECT) Management


Definition: Assisting with the safe and efficient provision of electroconvulsive (ECT) therapy in the treatment of psychiatric illness


Activities:



• Encourage patient (and significant others, as appropriate) to express feelings regarding the prospect of ECT treatment


• Instruct patient and/or significant others about the treatment


• Provide emotional support to patient and/or significant others, as needed


• Ensure that the patient (or the legal designee if the patient is unable to give informed consent) has adequate understanding of ECT when the physician seeks informed consent to administer ECT treatments


• Confirm there is a written order and signed consent for ECT treatment


• Record patient’s height and weight in the medical record


• Discontinue or taper medications contraindicated for ECT as per physician order


• Review medication instructions with the outpatient who will be receiving ECT


• Inform the physician of any laboratory abnormalities for the patient


• Ensure that the patient receiving ECT has complied with the NPO requirement and medication instructions as ordered by the physician


• Assist patient to dress in loose fitting clothing (i.e., preferably hospital pajamas) that can be opened in front to allow placement of monitoring equipment


• Perform routine preoperative preparation (e.g., removal of dentures, jewelry, glasses, contact lenses; obtain vital signs; have patient void)


• Ensure that patient’s hair is clean, dry, and devoid of hair ornaments in preparation for electrode placement


• Obtain a fasting blood glucose reading preprocedure and postprocedure for those patients who have insulin-dependent diabetes


• Ensure that patient is wearing an identification band


• Administer medications prior to and throughout the treatment as ordered by the physician


• Document the specifics of pretreatment preparation


• Verbally communicate unusual vital signs, physical complaints/symptoms, or unusual occurrences to the ECT nurse or ECT psychiatrist prior to the treatment


• Assist the treatment team in placing leads for various monitors (e.g., EEG, ECG) and monitoring equipment (e.g., pulse oximeter, blood pressure cuff, peripheral nerve stimulator) on to the patient


• Place a bite block in patient’s mouth, and support chin allowing for airway patency during delivery of the electrical stimulus


• Document the time elapsed, as well as the type and amount of movement, during the seizure


• Document treatment-related data (e.g., medications given, patient response)


• Position the unconscious patient on his/her side on the stretcher with side rails raised


• Perform routine postoperative assessments (e.g., monitor vital signs, mental status, pulse oximeter, ECG)


• Administer oxygen, as ordered


• Suction oropharyngeal secretions, as needed


• Administer intravenous fluids, as ordered


• Provide supportive care and behavior management for postictal disorientation and agitation


• Notify the anesthesia provider or ECT psychiatrist if patient is destabilizing or failing to recover as expected


• Document care provided and patient response


• Observe patient in recovery area until fully awake, oriented to time/place, and can independently perform self-care activities


• Assist patient, when adequately alert, oriented, and physically stable to return to the inpatient nursing unit or another recovery area


• Provide the nursing staff that receive the post-ECT patient with a report on the treatment and patient’s response to the treatment


• Determine level of observation needed by patient upon return to the unit or recovery area


• Provide that level of observation on the inpatient nursing unit or recovery area


• Place patient on fall precautions, as needed


• Observe the patient the first time that he/she attempts to ambulate independently to ensure that full muscle control has returned since receiving a muscle relaxant during the ECT treatment


• Ensure that the patient’s gag reflex has returned prior to offering oral medications, food, or fluids


• Monitor patient for potential side effects of ECT (e.g., muscle soreness, headache, nausea, confusion, disorientation)


• Administer medications (e.g., analgesics, antiemetics) as ordered for the treatment of side effects


• Treat disorientation by restricting environmental stimulation and frequently reorienting patient


• Encourage patient to verbalize feelings about the experience of ECT


• Remind the amnesic patient that he/she had an ECT treatment


• Provide emotional support to the patient, as needed


• Reinforce teaching on ECT with patient and significant others, as appropriate


• Update significant others on patient’s status, as appropriate


• Discharge the outpatient recipient of ECT to a responsible adult when patient had adequately recovered from the treatment per agency protocol


• Collaborate with treatment team to evaluate the effectiveness of the ECT (e.g., mood, cognitive status) and modify patient’s treatment plan, as needed


4th edition 2004




2000


Electrolyte Management


Definition: Promotion of electrolyte balance and prevention of complications resulting from abnormal or undesired serum electrolyte levels


Activities:



• Monitor for abnormal serum electrolytes, as available


• Monitor for manifestations of electrolyte imbalance


• Maintain patent IV access


• Administer fluids, as prescribed, if appropriate


• Maintain accurate intake and output record


• Maintain intravenous solution containing electrolyte(s) at constant flow rate, as appropriate


• Administer supplemental electrolytes (e.g., oral, NG, and IV) as prescribed, if appropriate


• Consult physician on administration of electrolyte-sparing medications (e.g., spiranolactone), as appropriate


• Administer electrolyte-binding or electrolyte-excreting resins (e.g., sodium polystyrene sulfonate [Kayexalate]) as prescribed, if appropriate


• Obtain ordered specimens for laboratory analysis of electrolyte levels (e.g., ABG, urine, and serum levels), as appropriate


• Monitor for loss of electrolyte-rich fluids (e.g., nasogastric suction, ileostomy drainage, diarrhea, wound drainage, and diaphoresis)


• Institute measures to control excessive electrolyte loss (e.g., by resting the gut, changing type of diuretic, or administering antipyretics), as appropriate


• Irrigate nasogastric tubes with normal saline


• Minimize the amount of ice chips or oral intake consumed by patients with gastric tubes connected to suction


• Provide diet appropriate for patient’s electrolyte imbalance (e.g., potassium-rich, low-sodium, and low-carbohydrate foods)


• Instruct the patient and/or family on specific dietary modifications, as appropriate


• Provide a safe environment for the patient with neurological and/or neuromuscular manifestations of electrolyte imbalance


• Promote orientation


• Teach patient and family about the type, cause, and treatments for electrolyte imbalance, as appropriate


• Consult physician if signs and symptoms of fluid and/or electrolyte imbalance persist or worsen


• Monitor patient’s response to prescribed electrolyte therapy


• Monitor for side effects of prescribed supplemental electrolytes (e.g., GI irritation)


• Monitor closely the serum potassium levels of patients taking digitalis and diuretics


• Place on cardiac monitor, as appropriate


• Treat cardiac arrhythmias according to policy


• Prepare patient for dialysis (e.g., assist with catheter placement for dialysis), as appropriate


1st edition 1992; revised 2008




2001


Electrolyte Management: Hypercalcemia


Definition: Promotion of calcium balance and prevention of complications resulting from serum calcium levels higher than desired


Activities:



• Monitor trends in serum levels of calcium (e.g., ionized calcium) in at risk populations (e.g., patients with malignancies, hyperparathyroidism, prolonged immobilization in severe or multiple fractures or spinal cord injuries)


• Estimate the concentration of the ionized fraction of calcium when total calcium levels only are reported (e.g., use serum albumin and appropriate formulas)


• Monitor patients receiving medication therapies that contribute to continued calcium elevation (e.g., thiazide diuretics, milk-alkali syndrome in peptic ulcer patients, Vitamin A and D intoxication, lithium)


• Monitor intake and output


• Monitor renal function (e.g., BUN and Cr levels)


• Monitor for digitalis toxicity (e.g., report serum levels above therapeutic range, monitor heart rate and rhythm before administering dose, and monitor for side effects)


• Observe for clinical manifestations of hypercalcemia (e.g., excessive urination, excessive thirst, muscle weakness, poor coordination, anorexia, intractable nausea [late sign], abdominal cramps, obstipation [late sign], confusion)


• Monitor for psychosocial manifestations of hypercalcemia (e.g., confusion, impaired memory, slurred speech, lethargy, acute psychotic behavior, coma, depression, and personality changes)


• Monitor for cardiovascular manifestations of hypercalcemia (e.g., dysrhythmias, prolonged PR interval, shortening of QT interval and ST segments, cone-shaped T wave, sinus bradycardia, heart blocks, hypertension, and cardiac arrest)


• Monitor for GI manifestations of hypercalcemia (e.g., anorexia, nausea, vomiting, constipation, peptic ulcer symptoms, abdominal pain, abdominal distension, paralytic ileus)


• Monitor for neuromuscular manifestations of hypercalcemia (e.g., weakness, malaise, paresthesias, myalgia, headache, hypotonia, decreased deep tendon reflexes, and poor coordination)


• Monitor for bone pain


• Monitor for electrolyte imbalances associated with hypercalcemia (e.g., hypophosphatemia or hyperphosphatemia, hyperchloremic acidosis, and hypokalemia from diuresis), as appropriate


• Provide therapies to promote renal excretion of calcium and limit further buildup of excess calcium (e.g., IV fluid hydration with normal saline or half-normal saline and diuretics, mobilizing the patient, restricting dietary calcium intake), as appropriate


• Administer prescribed medications to reduce serum ionized calcium levels (e.g., calcitonin, indomethacin, pilcamycin, phosphate, sodium bicarbonate, and glucocorticoids), as appropriate


• Monitor for systemic allergic reactions to calcitonin


• Monitor for fluid overload resulting from hydration therapy (e.g., daily weight, urine output, jugular vein distention, lung sounds, and right atrial pressure), as appropriate


• Avoid administration of vitamin D (e.g., calcifediol or ergocalciferol), which facilitates GI absorption of calcium, as appropriate


• Discourage intake of calcium (e.g., dairy products, seafood, nuts, broccoli, spinach, and supplements), as appropriate


• Avoid medications that prevent renal calcium excretion (e.g., lithium carbonate and thiazide diuretics), as appropriate


• Monitor for indications of kidney stone formation (e.g., intermittent pain, nausea, vomiting, and hematuria) resulting from calcium accumulation, as appropriate


• Encourage diet rich in fruits (e.g., cranberries, prunes, or plums) to increase urine acidity and reduce the risk of calcium stone formation, as appropriate


• Monitor for causes of increasing calcium levels (e.g., indications of severe dehydration and renal failure), as appropriate


• Encourage mobilization to prevent bone resorption


• Instruct patient and/or family in medications to avoid in hypercalcemia (e.g., certain antacids)


• Instruct the patient and/or family on measures instituted to treat the hypercalcemia


• Monitor for rebound hypocalcemia resulting from aggressive treatment of hypercalcemia


• Monitor for recurring hypercalcemia 1 to 3 days after cessation of therapeutic measures


1st edition 1992; revised 2008




2002


Electrolyte Management: Hyperkalemia


Definition: Promotion of potassium balance and prevention of complications resulting from serum potassium levels higher than desired


Activities:



• Obtain specimens for laboratory analysis of potassium levels and associated electrolyte imbalances (e.g., ABG, urine, and serum levels), as appropriate


• Avoid false reports of hyperkalemia resulting from improper collection methodology (e.g., prolonged use of tourniquets during venous access, unusual exercise of extremity prior to venous access, delay in delivery of sample to laboratory)


• Verify all highly abnormal elevations of potassium


• Monitor cause(s) of increasing serum potassium levels (e.g., renal failure, excessive intake, and acidosis), as appropriate


• Monitor neurological manifestations of hyperkalemia (e.g., muscle weakness, reduced sensation, hyporeflexia, and paresthesias)


• Monitor cardiac manifestations of hyperkalemia (e.g., decreased cardiac output, heart blocks, peaked T waves, fibrillation, or asystole)


• Monitor gastrointestinal manifestations of hyperkalemia (e.g., nausea, intestinal colic)


• Monitor for hyperkalemia associated with a blood reaction, if appropriate


• Monitor lab values for changes in oxygenation or acid-base balance, as appropriate


• Monitor for symptoms of inadequate tissue oxygenation (e.g., pallor, cyanosis, and sluggish capillary refill)


• Administer electrolyte-binding and electrolyte-excreting resins (e.g., sodium polystyrene sulfonate [Kayexalate]) as prescribed, if appropriate


• Administer prescribed medications to shift potassium into the cell (e.g., 50% dextrose and insulin, sodium bicarbonate, calcium chloride, and calcium gluconate), as appropriate


• Insert rectal catheter for administration of cation-exchanging or binding resins (e.g., sodium polystyrene sulfonate [Kayexalate] per rectum), as appropriate


• Maintain potassium restrictions


• Maintain IV access


• Administer prescribed diuretics, as appropriate


• Avoid potassium-sparing diuretics (e.g., spironolactone [Aldactone] and triamterene [Dyrenium]), as appropriate


• Monitor for therapeutic effect of diuretic (e.g., increased urine output, decreased CVP/PCWP, and decreased adventitious breath sounds)


• Monitor renal function (e.g., BUN and Cr levels), if appropriate


• Monitor fluid status (e.g., intake and output, weight, adventitious breath sounds, shortness of breath), as appropriate


• Insert urinary catheter, if appropriate


• Prepare patient for dialysis (e.g., assist with catheter placement for dialysis), as appropriate


• Monitor patient’s hemodynamic response to dialysis, as appropriate


• Monitor infused and returned volume of peritoneal dialysate, as appropriate


• Encourage adherence to dietary regimens (e.g., avoiding high-potassium foods, meeting dietary needs with salt substitutes and low-potassium foods), as appropriate


• Monitor for digitalis toxicity (e.g., report serum levels above therapeutic range, monitor heart rate and rhythm before administering dose, and monitor for side effects), as appropriate


• Monitor for unintentional potassium intake (e.g., penicillin G potassium or dietary), as appropriate


• Monitor potassium levels after therapeutic interventions (e.g., diuresis, dialysis, electrolyte-binding and electrolyte-excreting resins)


• Monitor for rebound hypokalemia (e.g., excessive diuresis, excessive use of cation-exchanging resins, and postdialysis)


• Monitor for cardiac instability and/or arrest and be prepared to institute ACLS, as appropriate


• Instruct patient about the rationale for use of diuretic therapy


• Instruct patient and/or family on measures instituted to treat the hyperkalemia


1st edition 1992; revised 2008



2003


Electrolyte Management: Hypermagnesemia


Definition: Promotion of magnesium balance and prevention of complications resulting from serum magnesium levels higher than desired


Activities:



• Obtain specimens for laboratory analysis of magnesium level, as appropriate


• Monitor trends in magnesium levels, as available


• Monitor for electrolyte imbalances associated with hypermagnesemia (e.g., elevated BUN and Cr levels), as appropriate


• Assess dietary and pharmaceutical intake of magnesium


• Monitor for causes of increased magnesium levels (e.g., magnesium infusions, parenteral nutrition, magnesium rich dialysate solutions, antacids, laxatives, frequent magnesium sulfate enemas, lithium therapy, and renal insufficiency or failure)


• Monitor for causes of impaired magnesium excretion (e.g., renal insufficiency, advanced age)


• Monitor urinary output in patients on magnesium therapy


• Monitor for cardiovascular manifestations of hypermagnesemia (e.g., hypotension, flushing, bradycardia, heart blocks, widened QRS, prolonged QT, and peaked T waves)


• Monitor for CNS manifestations of hypermagnesemia (e.g., drowsiness, lethargy, confusion, and coma)


• Monitor for neuromuscular manifestations of hypermagnesemia (e.g., weak-to-absent deep tendon reflexes, muscle paralysis, and respiratory depression)


• Administer prescribed calcium chloride or calcium gluconate IV to antagonize neuromuscular effects of hypermagnesemia, as appropriate


• Increase fluid intake to promote dilution of serum magnesium levels and urine output, as indicated


• Maintain bed rest and limit activities, as appropriate


• Position patient to facilitate ventilation, as indicated


• Prepare patient for dialysis (e.g., assist with catheter placement for dialysis), as indicated


• Instruct patient and/or family on measures instituted to treat the hypermagnesemia


1st edition 1992; revised 2008




2004


Electrolyte Management: Hypernatremia


Definition: Promotion of sodium balance and prevention of complications resulting from serum sodium levels higher than desired


Activities:



• Monitor trends in serum levels of sodium in at-risk populations (e.g., unconscious patients, very old or very young patients, cognitively impaired patients, patients receiving hypertonic intravenous infusions)


• Monitor sodium levels closely in the patient experiencing conditions with escalating effects on sodium levels (e.g., diabetes insipidus, ADH deficiency, heatstroke, near drowning in sea water, dialysis)


• Monitor for neurological or musculoskeletal manifestations of hyponatremia (e.g., restlessness, irritability, weakness, disorientation, delusions, hallucinations, increased muscle tone or rigidity, tremors and hyperreflexia, seizures, coma [late signs])


• Monitor for cardiovascular manifestations of hyponatremia (e.g., orthostatic hypotension, flushed skin, peripheral and pulmonary edema, mild elevations in body temperature, tachycardia, flat neck veins)


• Monitor for GI manifestations of hyponatremia (e.g., dry swollen tongue and sticky mucous membranes)


• Obtain appropriate lab specimens for analysis of altered sodium levels (e.g., serum and urine sodium, serum and urine chloride, urine osmolality, and urine specific gravity)


• Monitor for electrolyte imbalances associated with hypernatremia (e.g., hyperchloremia and hyperglycemia), as appropriate


• Monitor for indications of dehydration (e.g., decreased sweating, decreased urine, decreased skin turgor, and dry mucous membranes)


• Monitor for insensible fluid loss (e.g., diaphoresis and respiratory infection)


• Monitor intake and output


• Weigh daily and monitor trends


• Maintain patent IV access


• Offer fluids at regular intervals for debilitated patients


• Administer adequate water intake for patients receiving enteral feeding therapy


• Collaborate for alternate routes of intake when oral intake is inadequate


• Administer isotonic (0.9%) saline, hypotonic (0.45% or 0.3%) saline, hypotonic (5%) dextrose, or diuretics based on fluid status and urine osmolality


• Administer prescribed antidiuretic agents (e.g., desmopressin [DDAVP] or vasopressin [Pitressin]) in the presence of diabetes insipidus


• Avoid administration/intake of high-sodium medications (e.g., sodium polystyrene sulfonate [Kayexalate], sodium bicarbonate, hypertonic saline)


• Maintain sodium restrictions, including monitoring medications with high-sodium content


• Administer prescribed diuretics in conjunction with hypertonic fluids for hypernatremia associated with hypervolemia


• Monitor for side effects resulting from rapid or over-corrections of hypernatremia (e.g., cerebral edema and seizures)


• Monitor renal function (e.g., BUN and Cr levels), if appropriate


• Monitor hemodynamic status, including CVP, MAP, PAP, and PCWP, if available


• Provide frequent oral hygiene


• Provide comfort measures to decrease thirst


• Promote skin integrity (e.g., monitor areas at risk for breakdown, promote frequent weight shifts, prevent shearing, and promote adequate nutrition), as appropriate


• Instruct patient on appropriate use of salt substitutes, as appropriate


• Instruct the patient/family about foods and over-the-counter medications that are high in sodium (e.g., canned foods and selected antacids)


• Institute seizure precautions, if indicated, in severe cases of hypernatremia


• Instruct the patient and/or family on measures instituted to treat the hypernatremia


• Instruct the family or significant other on signs and symptoms of hypovolemia (if hypernatremia is related to abnormal fluid intake or output)

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