Contents:

•Patient Assessments…………………………………...….. 2

•Pain Assessment……………………................................. 2

•Violence Risk Assessment (Broset)…………………...…. 3

•Medication Administration……………………………...….. 4

•Home Medication Process…………………………...……. 5

•Hazardous Medications……………………………………. 6

•IV Therapy………………………………………………..…. 6

•Detox Protocols………………………………………...…... 10

•Code Situations—RN Specific Information…………….…. 11

•Anaphylaxis………………………………………………….. 14

•Tourniquet……………………………………………………. 15

•Certification and Continuing Education Credits…………... 16

Vanderbilt Psychiatric Hospital

RN SKILLS FOR SUCCESS

Policy Statement:

All policies that are referenced

throughout this Clinical

Orientation Manual are subject

to change at any time. The

policies that are included in this

manual are abbreviated and not

in their entirety, therefore, this

manual cannot be the sole

independent source when

referring to a policy.

Complete policies can be found

online.

Go to vumc.org

Click Resources Directory

Then search for policy.

Each patient admitted to Vanderbilt Psychiatric Hospital (VPH) is assessed by the RN at the

time of admission. This assessment includes:

• Physical Assessment / Head-to-Toe

• Suicide Risk / Ideation

• Violence Risk

• Mental Status Exam

• Pain Assessment

• Nursing Admission History (due within 8 hours of admission)

• Medication Reconciliation

Assessments are repeated every shift.

Policy: VPH: Patient Assessments and Reassessments

PATIENT ASSESSMENT

PAIN ASSESSMENT Pain is assessed at admission and during every vital sign assessment. Pain is also re-

assessed after any pain-related intervention is performed.

The standard pain assessment tool is the 0-10 Numeric Pain Scale; an effective self-report

tool.

Patients under the age of 8 do not have a developmental grasp of number ratios and cannot

accurately report pain using a numerical scale. They should have pain assessments

conducted using the Wong-Baker FACES Pain Rating Scale. This scale should be

considered for adult and adolescent patients with a developmental delay.

Policy: Pain Management # CL 30-02.04

2

At VPH, the Broset Violence Checklist is the risk assessment tool utilized to help predict the

potential for violent behavior. The Broset is used to determine if medication is needed for

agitation / aggression management, and if so, what medication. Often medications are

ordered in accordance with the scoring to decrease therapeutic duplication and ensure the

patient has the best responses to the chosen medication.

The Broset assesses the 6 most common behaviors exhibited by patients who are likely to

become violent:

1. Confusion

2. Irritability

3. Boisterousness

4. Verbal Threats

5. Physical Threats

6. Attacking Objects

VIOLENCE RISK ASSESSMENT

BEHAVIOR DEFINITIONS

Interpretation of Scoring

Score = 0 The risk of violence is small.

Score = 1-2 The risk of violence is moderate.

Protective measures should be taken.

Score > 2 The risk of violence is high.

Preventative measures should be taken and

plans developed to manage potential violence.

Confusion Appears obviously confused and disoriented. May be unaware of time,

place, or person.

Irritability Easily annoyed or angered. Unable to tolerate the presence of others.

Boisterousness Behavior is overtly loud or noisy. Ex: slams doors, shouts when talking.

Verbal Threats A verbal outburst which is more than just a raised voice; and where there

is a definite intent to intimidate or threaten another person. Ex: verbal at-

tacks, name calling, verbally neutral comments voiced in a snarling ag-

gressive manner.

Physical Threats Where there is a definite intent to physically threaten another person. Ex:

taking an aggressive stance, grabbing a person’s clothing, raising an arm,

making a fist, modeling a head-butt directed at another.

Attacking Objects An attack directed at an object and not an individual. Ex: indiscriminate

throwing of an object, banging windows, kicking/banging/head-butting an

object, or breaking furniture.

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Ordered medications are administered and documented by appropriately trained and

authorized personnel in accordance with scope of practice, job descriptions, and applicable

state and federal regulations.

Ordered medications are reviewed by a pharmacist prior to

administration except in extreme circumstances (ex: delay would

harm the patient).

Medications are administered according to the five rights of

medication administration in order to minimize medication errors.

1. Right patient

2. Right Medication

3. Right Dose

4. Right Route

5. Right Time

Medications are administered using barcode-assisted medication

administration BCMA whenever possible.

MEDICATION ADMINISTRATION

Medication Policies:

Medication Administration # MM 10-10.10

Medication Reconciliation # MM 10-10.05

Look-Alike / Sound-Alike Medications

Hazardous Medication Handling # SA 20-10.04

High Alert Medications # MM 10-10.12

Patient Medications Brought from Home or Other Non-VUMC Sources # MM 10-10.08

Sole reliance on the 5 rights has not led to a significant reduction in medication error

rates. Critical thinking, inclusion of the patient, and careful adherence to policies and

clinical decision making tools are important factors in avoiding errors.

Reference: Nursing Rights of Medication Administration (2020)

Hubbl is the VUMC website that holds a wealth of information

regarding charting in eStar. You can access Hubbl at this

link or by searching for Hubbl on the resources tab of the

VUMC website.

Click on Tip Sheets to access step-by-step instructions for:

Medication administration

Using the MAR

Using BCMA

Accessing Lexicomp to look up medication information

And more 4

Upon admission, assess if the patient has medications with them and request they be sent

home with a responsible party. If not possible, home medications are stored as follows:

• Obtain a Patient Property Record Form: Medication, patient labels, and a patient

medication security bag.

• If any medications are narcotics, two RNs must be

present and sign the form.

• Inventory medications with name on container and

description (ex: pink oval tablet) and have patient

(or designee) sign. If patient unable to sign, two

RNs must sign.

• Keep 1 copy of record in sealed bag with

medications. Scan copy into the EMR.

• Store medications in designated area in unit.

• If a home medication is to be used

during the admission, there needs to be

a Provider order and an examination of

the medications by the Pharmacist.

• At discharge, review medications

with patient, return medications, and

complete Patient Property Record Form:

Medication. Have patient sign form. If

there are narcotics being returned to the

patient, two RNs must sign.

• Medications to be disposed instead

of returned to patient requires a Provider

order.

• Scan the completed form into the

EMR.

Policy: Patient Owned (Home) Medication

Storage and Handling: Inpatient Patient

Encounter—VPH

HOME MEDICATIONS

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Medications requiring PPE during handling are listed at the Omnicell (medication dispensing

machine). Please pay careful attention to medications with yellow alert labels. Follow the

hazardous medication policy for your safety.

To see the full hazardous medication list, click here.

Policy: Hazardous Medication Handling # SA 20-10-.04

Hazardous Waste: Handling and Disposal SOP

HAZARDOUS MEDICATIONS

IV THERAPY

Intravenous (IV) therapy at VPH is performed only via peripheral vascular access (PIV).

Peripherally inserted central catheters (PICC) may be placed by the VUMC PICC team.

PIVs may be started on adult patients by any nurse at VPH who is competent in the skill.

Responsibilities of all RNs:

PICC dressing changes and removals are supported by the RNs in ECT during business

hours. Outside of business hours, any RN can reinforce a PICC dressing until the ECT

team can evaluate it.

All medications and fluids are administered via the Guardrails system on the Alaris pump.

IV push medications are not administered by RNs at VPH.

Policy: Intravenous Therapy: Peripheral Vascular Access—Adult & Pediatrics # CL 30-07.01

Adult Intravenous (IV) Therapy Guidelines—VPH # AS-202700-05-045

PIV PICC

Insertion site assessment Insertion site assessment

IV maintenance & flushing IV maintenance & flushing

Medication administration Medication administration

Dressing maintenance & changes Dressing reinforcement

Removal

6

IV GUIDELINES

Touch—to ensure the site is soft, warm, dry, and pain-free

Look—to make sure there is no redness. Make sure the insertion site is visible and not covered

by tape or gauze

Compare—to see that both sides are the same size without swelling.

Assessment:

• At shift change, IVs should be assessed together by the oncoming and off-going RNs.

• Continuous infusions: Assess the site every 2 hours and document.

• Saline Locked IV: Assess the site once every shift at baseline. Also assess the site before

and after any medication or fluid administration.

Accessing the IV:

• Wash hands and apply gloves prior to manipulating the IV.

• Vigorously scrub the port with appropriate antiseptic at least 5 times around and 5 times

across the port (5x5 rule). Allow to fully dry.

• Check for patency of line.

• Administer medication or fluids per order using Guardrails on Alaris pump.

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Checking Line Patency:

• After scrubbing hub, attach 10mL syringe and attempt to aspirate blood. If no blood return, re-

position and try again. Proceed to next step whether or not blood return is achieved.

• Flush with preservative-free normal saline using start-stop pulsatile motion with enough vol-

ume to clear any visible blood from the line.

• If no resistance is met, connect medication or fluids and administer.

• If resistance is met, reposition the patient’s extremity and try again, gently. Do not force if re-

sistance is met.

• If resistance continues:

• PIV—assess insertion site and discuss with team if this PIV should be removed and re-

placed.

• PICC—tape the cap and label the lumen “DO NOT USE”. Notify the Provider to deter-

mine next steps.

Flushing PIV:

• Flush PIV after each medication or fluid infusion.

• Flush every 12 hours when not in use.

Flushing PICC:

• Flush PICC after each medication or fluid infusion.

• Flush every 12 hours when not in use.

Dressing Changes:

• PIVs and PICCs are dressed with transparent semi-

permeable membrane dressings.

• For PIVs the clear dressing may remain in place as long as it

is dry, clean, and intact.

• PIV dressings with gauze under the clear dressing must be

changed every 24 hours.

• For PICCs, the clear dressing is changed once every 7 days

as a sterile procedure by the ECT RNs or VUMC PICC Team.

PICC insertion and discontinuation

should be scheduled by calling

Radiology scheduling at:

3-2617 (advanced scheduling)

2-2394 (same day scheduling)

8

IV Bag & Tubing Maintenance & Changes:

• For intermittent infusions:

• Label the IV tubing and bag with the date and time.

• Antibiotics are administered via Piggyback, connecting secondary tubing to the prima-

ry IV fluid set.

• Discard the IV bag and tubing after each infusion. Do NOT save the fluids or tubing

for another infusion.

• For continuous infusions:

• Label the IV tubing and bag with the date and time.

• Change the IV bag when empty or every 96 hours. Change the IV tubing every 96

hours.

• Any tubing that is temporarily disconnected from the patient must have a end-cap applied.

Do not circle the end of the tubing into a tubing port.

Changing PIV sites:

• PIV should be removed with suspected infiltration. Notify the Provider for assessment and

next steps.

• PIV sites should be changed every 7 days for adult patients.

Alaris Pump:

• Always use Guardrails when administering fluids or medications.

• Clean the pump between each use using Super Sani-Cloth Wipes (purple-top wipes). Allow to

air dry.

• Place the pump in storage between each use.

9

VPH provides a range of services that include safe and monitored withdrawal from benzodiaze-

pines, opiates, and alcohol. These three substances carry a high risk profile during the withdrawal

process, so specific protocols are used to ensure safety and prevent seizures or other life-

threatening side effects.

CIWA—Clinical Institute Withdrawal Assessment for Alcohol:

• Provides a structured and safe withdrawal from alcohol and is designed to prevent seizures.

• Diazepam (Valium) is the primary medication. Ativan is also used depending on patient

needs.

CNSDP—Central Nervous System Depressant Protocol:

• Provides a structured and safe withdrawal from benzodiazepines and is designed to prevent

seizures.

• Phenobarbital is the primary medication.

COWS—Clinical Opiate Withdrawal Scale:

• Provides a structured and safe withdrawal from opiates.

• Clonidine is used initially and Buprenorphine may follow as needed for patient symptoms.

Modified COWS:

• Provides a structured and safe withdrawal from opiates for the pregnant patient.

• Buprenorphine is the primary medication.

DETOX PROTOCOLS

10

RNs at VPH are responsible for assessing their patients for both behavioral and medical status

and concerns. Behavioral Health Specialists may report a concern or alteration in vital signs to

you. As the RN, you must assess the patient to determine if they are stable or if they require an

intervention.

Your skills can determine if an alteration in patient status is due to anxiety, substance withdrawal,

acute medical change that needs a higher level of care, or other reason.

Assessment and trending of vital signs and patient symptoms is critical. If your patient exhibits

any early warning signs, call the Rapid Response Team and the patient’s primary team without

delay.

MEDICAL EMERGENCY

Triggers for Calling the Rapid Response Team

Staff Concerned / Worried “THE PATIENT DOES NOT LOOK / ACT RIGHT” The gut instinct that a

patient is beginning a medical downward spiral even if you can’t quite pin-

point a specific symptom.

Change in Respiratory Rate Adult patient’s Respiratory Rate is < 8 or > 30 breaths per minute. See next

chart for pediatric vital sign ranges.

Change in Oxygenation The pulse oximeter decreases below 90%. The patient’s skin or lips appear

dusky or blue.

Labored Breathing The patient appears to be working hard to breathe. May have nasal flaring,

using abdominal muscles, or retractions.

Change in Heart Rate Adult patient’s heart rate is < 40 or > 120 beats per minute. See next chart

for pediatric vital sign ranges.

Change in Blood Pressure Adult patient’s Systolic Blood Pressure is < 90 mmHg or > 200 mmHg

(consider baseline BP and possible withdrawal).

Hemorrhage The patient develops uncontrollable bleeding from any site.

Decreased Level of Consciousness

(LOC)

The patient becomes agitated or delirious (outside of expected symptoms

with diagnoses), obtunded, or unresponsive.

Seizure The patient has a seizure that is prolonged or with any complications.

Other Alterations in Consciousness Any other concerning CNS changes such as a 1 dilated pupil, onset of

slurred speech, onset of unilateral limb or facial weakness, etc.

Age Heart Rate Respiratory

Rate

Systolic BP Diastolic BP

Preschooler

(3-6) 60-140

Asleep 14-24

Awake 19-39 75-120 50-75

School-Age

(6-12) 50-140 13-30 80-130 50-80

Adolescent

(12-18) 50-120 14-22 80-135 50-80

Normal Pediatric

Vital Signs

11

Calling the Rapid Response Team

• Call 11111

• The dispatcher with Vanderbilt Communications will ask 3 initial questions.

Q—Where is your emergency?

A—Vanderbilt Psychiatric Hospital (then say specific area. Ex: Adult 3 or Cafeteria).

Q—Is this a patient or a visitor?

A—“Patient” or “Visitor”.

Q—Is the patient breathing EFFECTIVELY?

A—“Yes” (if patient is breathing comfortably). “No” (if breathing is absent, slow, or labored).

• Stay with the patient.

• Delegate two staff members to go to the lobby to escort the Rapid Response Team and EMS.

CODE BLUE

VPH is a BLS facility. All clinical employ-

ees are required to maintain the BLS

Healthcare Provider level of certification

through the American Heart Association.

BLS is required upon hire and must be

recertified every two years.

Free BLS classes are available through

the Vanderbilt Resuscitation Program.

For more information, click here.

ECT RNs are additionally required to ob-

tain and maintain ACLS.

12

Responsibilities During A Code

All of these tasks can be performed by any BLS trained staff member. Delegate these tasks as

needed to other nurses or non-licensed staff.

• Position head to maintain an open airway.

• Provide rescue breaths with a Bag Mask Device.

• Provide compressions at a rate of 100 beats per minute.

• Apply defibrillator pads to the patient’s chest.

All of these tasks can be performed by any staff member (whether they have been trained in BLS

or not).

• Bring the nearest crash cart.

• Go to the lobby and escort back the Rapid Response Team and EMS.

• Provide crowd control.

• Turn on the lights (important during nightshift) and move furniture out of the way.

Only the RN can:

• Document the code on an arrest record.

• Start a PIV.

• Administer code medications under the direction of a Provider.

Giving Report to the Rapid Response Team:

Start with the most important information first:

• What happened that caused the Team to be called (“Patient found unresponsive and not

breathing in room. Code was called.”)

• What has been done so far (“Performed CPR and attached defib pads. No IV placed.”)

Then you can move on to:

• Brief patient history, recent vital signs, recent lab values, if family has been notified.

13

VPH has an emergency anaphylaxis kit to treat patients during a reactive airway emergency. Fol-

low these steps to access the protocol and the medication:

• Assess the situation and get quick facts about what led up to the patient’s symptoms.

• Call (or delegate someone to call) a Code Blue (dial 827).

• Call (or delegate someone to call) a Rapid Response (dial 11111).

• For pediatric patients, instruct a staff member to locate the patient’s weight in the chart.

• Delegate a staff member to bring the crash cart.

• Delegate a staff member to escort the Rapid Response Team from the lobby.

• Obtain anaphylaxis kit from Omnicell medication machine.

• Select the Patient & search for Anaphylaxis in OVERRIDE.

• Anaphylaxis kit can also be obtained from the crash cart.

• Open the anaphylaxis kit and find the Protocol Sheet

• Pediatric

• If 15-29 kg, prepare 0.15 mg EPINEPHrine 1 mg/mL (1:1000) concentration.

• If ≥ 30 kg, prepare 0.3 mg EPINEPHrine 1 mg/mL (1:1000) concentration.

• Adult

• Prepare 0.3 mg EPINEPHrine 1 mg/mL (1:1000) concentration.

• Administer IM injection into anterolateral thigh. Repeat x2 every 5-15 minutes.

• Apply oxygen. (Obtain nasal cannula from crash cart and attach to O2 tank on cart). Start at

2L and increase to 6L as needed.

• Administer 2 puffs albuterol and repeat PRN.

• Start a PIV.

• Keep patient calm while awaiting arrival of Rapid Response Team.

For detailed instructions for adults, click here. For pediatrics, click here.

ANAPHYLAXIS

14

Tourniquets are for use in life-threatening extremity hemorrhage that cannot be controlled with di-

rect pressure.

A tourniquet is available in each med room and above the crash cart in the PAS with laminated

protocols for each area.

To apply the tourniquet:

Place the tourniquet over the extremity, proximal to the wound, allowing the self-adhering

band to fit around the extremity.

Feed the band through the inner and outer slits of the buckle.

Pull the band tight and secure Velcro.

Twist the Windlass Rod until the bleeding stops. This should be 3 complete

turns or less. More than 3 turns can cause the tourniquet to break.

Lock the Rod in place with the Windlass Clip.

Secure the Rod with the Windlass Strap by pulling it tight and attaching to op-

posite hook.

When the tourniquet is in use:

Call a Rapid Response.

Do not loosen tourniquet once it is in place.

Label the date and time when the tourniquet was applied.

Do not cover the tourniquet. Wound must be in view to assess for return of bleeding.

TOURNIQUET

15

VPH is committed to providing nurses with opportunities to pursue

specialty certification in Psychiatric-Mental Health Nursing. The Psy-

chiatric-Mental Health Nursing Certification is the formal validation of

competence and recognition of excellence in standards identified by

psychiatric nurses to promote optimal health outcomes.

Nurses who achieve and maintain specialty certification validate their expert knowledge and com-

mitment to improving patient healthcare standards. Certification also gives the nurses a sense of

achievement and increases personal confidences. It is a way to inform colleagues of expert

knowledge in psychiatric nursing.

Vanderbilt University Medical Center participates in the ANCC Success Pays Program that ena-

bles qualified nurses to take the certification examination without paying the expense of the test.

For more information, practice tests, and study materials, please reach out to your education

team.

When you’re ready to take the exam, please talk to your unit manager to sign up for a testing

voucher to cover the costs.

Click here for information from the ANCC on the Psychiatric-Mental Health Nursing Certification.

Click here for seven tips on preparing for your ANCC certification Exam.

To apply for your Psychiatric-Mental Health Nursing Certification, you must:

Have 2 years of experience as a RN

Have a minimum of 2,000 hours of clinical practice in psychiatric-mental health nursing in the

last 3 years

Have 30 hours of continuing education in psychiatric-mental health nursing in the last 3 years

NURSING CERTIFICATION

16

Continuing Education credits (formerly called Contact Hours)

are provided through multiple opportunities to VUMC staff mem-

bers. Continuing Education (CE) credits are provided and

tracked through the Cloud CME system.

To obtain CEs, you need to set up a profile in the system.

Go to https://vumc.cloud-cme.com/.

Click “Sign In” on the top left and sign in using your VUMC ID and password

Click “My CE” on the top right.

Click “Profile”

Complete your profile information.

Under Credit Categories select ANCC-American Nurses Credentialing Center and Non

-Physician Attendance to receive credit.

Enter your mobile number in your profile. This allows you to text in your attendance and

receive CE for classes.

NURSING CONTINUING EDUCATION

17

Texting in Attendance at CE Sessions

Before the first time you text in attendance for a session, pair your

mobile phone to your CME profile.

Text your VUMC email address to 855-776-6263. You will receive a message like below that your

number has been updated (confirmed).

Once this is complete, you’ll be able to text in your attendance at any future classes that offer CE. Dur-

ing the CE class an activity ID or Code will be provided to you. Text that code to 855-776-6263. You

will receive a message like below that your attendance has been recorded.

Attendance must be texted within 24 hours of attending the class to receive credit.

After receiving credit, complete the evaluation of the class in the Cloud-CME system by clicking Evalua-

tions & Certificates.

After completing the Evaluation, you will be able to print out your CE certificate. The system tracks all

completed CE on your Transcript.

You can download the CloudCME App to your phone.

Your organizational code is VUMC.

You can track CE and view your transcript / certificates.

You can also access online courses that provide on-demand CE—some specific to Psychiatry.

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