MONONGALIA GENERAL HOSPITAL 1200 J.D.

ANDERSON DRIVE MORGANTOWN, WV 26505 EMERGENCY DEPARTMENT NURSING INTERVENTION SHEET

Nursing Interventions Triage Includes Initial VS and WTs (on peds) 1. Adult 2. Peds 3. Pulse Oximetry 4. Pulse oximeter continuous 5. Cardiac Monitors 6. Visual Acuity 1. Reassess pt 2. Retake vital signs 3. Discharge Instruction- a. Simple b. Discharge Instruction- Complex Pts Nursing Interventions 1. Sub Q/IM/event 2. Rectal- X _____ 1. Eye/ear installation each 2. IV push/piggyback 3. IV Cont. infusion- no med x ______ hrs 4. IV cont. inf. W meds x ______ hrs Venipuncture: (Specimen Collection) 1. Adult x ________ 2. Peds X _________ 3. AG Sugar x _____ 4. Dip Urine Pts 50 50 50 50 50 75 50 75 40 40 Restraints/30 minutes Pts who require 1:1 or who are confused/combative, pyschotic/15 min X ______ Peds<6 (no adult) Abuse exam, peds/adult Asst with: 1. Peds exam 2. Gyn Exam (no specimen) 3. Gyn Exam (specimen) 4. Suture setup 5. Suture assist 6. Rape Examination 7. Lumbar Puncture 8. Chest tube insertion 9. Needle decompression 10. 11. 12. 13. 1. 2. 3. 4. Thoracentesis Paracentesis Nasal Packing Rectal Exam 100 100 100 150 100 75 100 35 65 250 90 200 80 80 80 60 75 50 100 200 40 200 150 100 300 200 250 150 300 350 150 300 Nursing Interventions NG Tube Insertion NG Lavage/15 min x _____ Pts 100 100

25 30 30 40 30 40 45 35 30 45

Oxygen Admin per hr x___ 1. Nasal Cannula 2. Simple Mask 3. Non re-breathing venti- mask

40 30 35

Wound Care: 1. Irrigation <15 min 2. Irrigation >15 min <30 min 3. Irrigation >30 min 1. 2. 3. 4. Dressing-simple Dressing- wet/dry Dressing- complex Suture Removal

30 70 100 30 45 75 35 50 60 100 40 50 40 45 100 125 45 150

1. ED Staff to lab x _______ 2. Arrange Outpt. Testing 3. D/C pt via W/c to POV 4. Assist pt to ED via W/C 5. ED staff with pt for tests per 15 min x ______ 6. Pt transfer with ED staff to another hosp Admission Pt transport by ED Staff 1. To Xray 2. To Floor Other tests Arrange: Transfers (nsrg home,home) Taxi/Bus Transfer to another hosp Perform: 1. Ear irrigation 2. Eye irrigations 3. Fill foley cath 4. Enema X _____ 5. Foley Cath- Insert adult 6. Cath Peds 7. Peds apply U-Bag 8. Irrigate Cath 9. Oral suctioning x _____ 10. Tracheal suctioning x _____

50 55 45 45 45 300 45 65 50 75 65 100 80 70 60 100 80 50 45 40 50 50

Fetal Heart tones Newborn Care Prepare pt for OR Bed linen change X ______

1. Splint application- wrist 2. Splint application- ankle 3. Splint application- knee 4. Dislocations 1. 1. Crutch (adjust/teach) Sling, ACE wrap, etc. (apply/teach)

1. Cardiac Arrest <15 min 2. Cardiac arrest each addl. 15 min x ______ 3. Ventilator pt x ______ hrs 1. Cardioversion/event 2. Intubation 3. External Pacer 4. Defib/time Conscious Sedation Thrombolytic Administration Critically Ill pt observation x ____ hr Committal of patient for drug/alcohol rehab

Medications: 1. Oral- per trip x ______ IV Start- each attempt 1. Adult X ____ 2. Peds x _____ 3. DC IV Site Administer blood x ______ unit

99281( 0-50) 99282 (51-100) 99283 (101-150) 99285 (201-300) 99291 (301-400) Prepared by:

99284 (151-200) Date: