Policy Manual sample

MDT Home Health Care Agency, Inc. 6 PROCEDURE: 1. For localized allergic reaction: a) Instruct the patient/caregiver to report any signs of uneasiness, agitation, itching or rash. b) Obtain vital signs and record patient’s mental status. c) Evaluate symptoms: Observe for urticaria, wheals, localized erythema. 2. For drug related anaphylactic reaction: a) Administer Benadryl PO or injection in accordance with physician’s orders. b) Document occurrence in patient’s chart. c) Report adverse drug reaction to Medwatch as indicated and complete incident report. 3. For a generalized allergic reaction (Anaphylaxis): a) Anaphylaxis may be suspected if the following signs and symptoms occur (usually within the first 15 minutes after the start of the infusion). 1) Respiratory—dyspnea, wheezing, choking, cyanosis. 2) Dermatologic—urticaria, erythema, angioedema. 3) GI—nausea, vomiting, abdominal cramps, diarrhea. 4) Vascular—rapidly falling blood pressure, chills, sweating, weakness, thready pulse, dizziness. IN THE EVENT THE PATIENT COMPLAINS OF AND/OR EXHIBITS SIGNS AND SYMPTOMS OF ANAPHYLAXIS, STOP THE INFUSION IMMEDIATELY. IF THE CLINICIAN EVALUATES THE CONDITION TO BE LIFE THREATENING, EMERGENCY MEDICAL SERVICES WILL BE CONTACTED. THE PHYSICIAN WILL BE NOTIFIED AT THE FIRST OPPORTUNITY POSSIBLE. THE NURSE WILL REMAIN WITH THE PATIENT UNTIL EMS ARRIVES. 4. Ensure the patient is in the recumbent position, elevate the extremities and establish a patent airway. 5. Administer Benadryl IV per physician’s orders. 6. Administer Epinephrine SQ or IV per physician’s orders. 7. Change the IV tubing and start infusion of IV fluids at prescribed rate per physician’s orders. If no specific rate has been obtained, then initiate IV fluids at KVO rate until further orders may be obtained. 8. Monitor vital signs frequently, at least every 15 minutes and as indicated by patient’s symptoms and initiate basic life support as needed. 9. The nurse will remain with the patient until care is transferred to EMS personnel or medical facility.