Health PREGNANCY DETECTION AND MANAGEMENT

Transcription

1 FLORIDA STATE HOSPITAL OPERATING PROCEDURE NO STATE OF FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES CHATTAHOOCHEE, December 4, 2017 Health PREGNANCY DETECTION AND MANAGEMENT 1. Purpose: To provide a comprehensive program for the early detection and optimal management of pregnancy; and safeguard the health of the pregnant resident and her unborn infant. For the purpose of this operating procedure, the term physician includes the advanced registered nurse practitioners (ARNP), and physician assistants/clinical associates. 2. Scope: This procedure applies to ALL Florida State Hospital female residents of child-bearing age. 3. References: a. Children & Families Operating Procedure , Care of Pregnant Females in State Mental Health Treatment Facilities b. Health and Rehabilitation Services Letter 205-1, Pregnancy Testing and Care of Pregnant Health and Rehabilitation Services Residents c. The Lippincott Manual of Nursing Practice, Current Edition d. Obstetric Nursing, Ziegel and Cranley, Current Edition e. Rule 64D-3, Florida Administrative Code on Sexually Transmissible Diseases f. Florida State Hospital Operating Procedure , Procedures for Management and Discharge Planning for Pregnant Individuals by Social Services Staff 4. Procedure Upon Admission, Readmission or Return from a Leave of Absence of a Female Resident of Childbearing Age: a. The Medical Physician shall: (1) order a serum pregnancy test (unless confirmation of pregnancy has already been established) and monitoring at regular monthly intervals thereafter to detect pregnancy at the earliest possible date. A pregnancy test shall be ordered as often as determined by the medical attending Physician and/or consulting Obstetrician/Gynecologist; (2) complete a sexual and menstrual history and document on the Medical History form. This history is updated at least annually and as often as indicated; and (3) order Hep B and HIV test if confirmed to be pregnant. This Operating Procedure supersedes: Operating Procedure dated December 7, 2016 OFFICE OF PRIMARY RESPONSIBILITY: Clinical Services DISTRIBUTION: See Training Requirements Matrix

2 b. The Psychiatrist shall: out; (1) withhold all psychotropic medication(s), if possible, until pregnancy is excluded/ruled (2) if pregnancy is confirmed, consult with pharmacist and the Obstetrician regarding all psychotropic medications prescribed; and (3) along with the Recovery Team, discuss with the resident, the risks and benefits of taking medications psychotherapeutic medication. c. Direct Care Staff shall: (1) report to the Nurse (Form 585): any signs of pregnancy, any unusual or off-cycle menses, absence or delayed menses for two (2) weeks or more; and (2) maintain a menstrual flow sheet and keep in the resident s record until a medical determination of menopause is made. 5. Procedures for Staff in the Care of a Pregnant Resident: All observations by the staff shall be documented in the resident s medical records. a. Role of the Physicians: (1) Make reasonable efforts to obtain the resident s consent to medical treatment and/or psychotherapeutic medications as soon as possible and as appropriate. (2) As soon as pregnancy is confirmed, the Medical Physician shall initiate a consultation/ referral request to the hospital s consulting Obstetrician and include a request for evaluation of the risks and benefits regarding the use of psychotropic medications. The Medical Physician shall confer with the Obstetrician at any time as necessary. At each subsequent visit, any additional information shall be provided to the Obstetrician. (3) The Medical Physician shall order: (a) HIV testing and counseling. HIV testing shall be offered, and again at 28 weeks to 32 weeks gestation (unless already done at the obstetrician s office). (b) Hepatitis B surface antigen test. If negative, re-test at 28 weeks to 32 weeks of gestation (unless already done at the obstetrician s office). (c) Diet during pregnancy on Form 99, in collaboration with a Dietitian. The Dietitian will also document in the Medical Nutrition Therapy Assessment (Form 170) or in the Medical Nutrition Therapy Progress Note (Form 171). (4) Prenatal education by the Medical Physician to include at least the following: information regarding fetal development, normal body changes, common discomforts during pregnancy, early signs of labor, signs and symptoms to report immediately, proper diet and hygiene and safety during pregnancy including use of mechanical restraints. (5) The consulting Obstetrician, after completing expert clinical examination of the resident, shall provide documentation to Florida State Hospital within seven (7) days of the examination to include, but not limited to diagnosis/impression and recommendations. 2

3 b. Role of Nursing Staff: (1) Complete the Pregnancy Flag (FSH Form 55) and place in the very top of the resident s chart. (2) Complete Pregnancy Flow Sheets Forms 590A, 590B, 590C, 590D. (These forms are also available electronically.) (3) Follow guidelines for individualized Nursing Care of pregnant residents to include health care teaching, nursing interventions and dietary monitoring. (4) Create the Admission OB packet, also known as the Large Brown Envelope within one month of the resident s due date or scheduled C-section. This packet/envelope will consist of the following documents: (a) A copy of the pre-admission packet from Social Services consisting of: 1. Form 11 and 11A Comprehensive Psychosocial Assessment 2. Form 61 Pre-admission Form / Infant Discharge Plan (Obstetrics) 3. Form 3044 Authorization for Release of Information (b) Copies of the following documents as compiled by Nursing staff: 1. Form 1 Medical History/Physical Examination/Neurological Exam 2. Form 52 Progress and Event Notes (minimum 30 days) 3. Form 63 Monthly Medical Summary 4. Form 64 Medical/Psychiatric Progress Notes (minimum 30 days) 5. Form 78 Nursing Monthly Summary 6. Form 201 Resident Transfer Information 7. Form 202 Request for Resident Transportation (Medical) 8. Form 220 Current Psychiatric Progress Note 9. Forms 590A, 590B, 590C, 590D Pregnancy Flow Sheets 10. Form 2006 Resident Face Sheet 11. Test Reports Ultrasound, and any test completed 12. OB reports from consultant s office visits (c) Scan contents this Admission OB packet into a shared electronic folder. (d) Place the Admission OB packet in the front section of the resident s chart. It must be sent with the resident when transported to the Obstetrician or community hospital during the time of labor and/or delivery. 3

4 necessary. (e) Add any additional medical and nursing summaries to this packet as (5) Together with a Social Services staff, make contact with the Pediatric Social Worker, Children s Protective Services or Abuse Registry to provide necessary information. c. Role of the Recovery Team: (1) Incorporate an individualized prenatal care and treatment plan into the Recovery Plan in conjunction with the consulting Obstetrician s recommendations. Implementation of this plan shall be documented in the resident s record and include the following: (a) Prenatal education and counseling by Physician and Recovery Team to address health care and procedures such as normal body changes during pregnancy, signs and symptoms to report immediately, proper diet and hygiene, and education on fetal development. (b) HIV testing and counseling. (c) Hepatitis B surface antigen test. d. Role of Social Services Staff: (1) within one month of the resident s due date or scheduled Caesarian section, shall: (a) prepare a Pre-admission packet (see 5.b.(4)(a) for list of forms/documents contained in a packet) and send a certified copy to the Pediatric Social Worker (b) together with a nurse, provide necessary information to the Pediatric Social Worker, Children s Protective Services or Abuse Registry. (2) at the time of delivery, shall: (a) notify Children's Protective Services, Pediatric Social Worker, father or family members, and/or first representative with consent from the resident. (The Medical Services Unit Nurse, with the aid of the Physician as needed, will assume this responsibility after hours and on weekends.) (FSHOP ) (b) contact the Abuse Hotline as required by Chapter , F.S. if no family or first representative is identified and placement for the infant(s) cannot be arranged. e. Role of Dietitian: (1) provide recommendations to the Medical Physician regarding Diet in pregnancy. (2) document in the Medical Nutrition Therapy Assessment (Form 170) or in the Medical Nutrition Therapy Progress Note (Form 171). f. Role of MSU (Medical Services Unit): Request for Sitter Service 6. Nursing Care in Pregnancy Less Than 20 Week Gestation: a. Complete Form 590A Pregnancy Flow Sheet Less Than 20 Week Gestation. 4

5 b. Check and document Fetal Check Heart Tones: At least once monthly and as often as needed including when the resident presents with concerns or complaints. NOTE: It is the responsibility to the MSU Nursing staff to train/retrain the home Unit Nurses on how to check for fetal heart tones. Unit Nurses will sign a S.T.A.I.R.S. form for verification of training.) c. Monitor Diet: Pregnancy increases the demand for more calories, vitamins, minerals, calcium and iron. The dietary plan shall provide specific needs and proper additional nutrients. d. Monitor Resident s Weight Pattern: A successful pregnancy is one where the weight gain usually does not exceed twenty-six (26) pounds. Certain circumstances may dictate when more than a 26-pound weight gain is desired. Consult with the medical physician and/or Obstetrician. 7. Nursing Care in Pregnancy Weeks Gestation: a. Complete Form 590B Pregnancy Flow Sheet Week Gestation. b. Check and document Fetal Heart Tones at least once monthly and as often as needed including when the resident presents with concerns or complaints. c. Monitor blood pressure at least weekly and as often as necessary. Check for Pregnancy- Induced Hypertension and/or signs and symptoms as listed on Form 590B. d. Document signs and symptoms of Pregnancy-Induced Anemia as listed on Form 590B. 8. Nursing Care in Pregnancy Weeks: a. Complete Form 590C Pregnancy Flow Sheet Week Gestation. b. Check and document Fetal Heart Tones at least weekly and as often as needed including when the resident presents with concerns or complaints. NOTE: A Doppler is kept in the Medical Services Unit Emergency Room (MSU ER). The Home Unit that needs one, will loan it from MSU ER. It is the responsibility of the Unit Nurse Managers to ensure that all their nurses are trained in the proper use of the Doppler. This training is to be documented on a S.T.A.I.R.S. form and entered in the nurse s training record. The loaned Doppler will be returned to Medical Services Unit as soon as post-partum or after discharge of the pregnant resident from Florida State Hospital, whichever comes first. c. Check and document fetal movement at least weekly. Notify the medical physician and/or the MSU Emergency Room physician and/or Obstetrician as soon as noted that baby has decreased movement. d. Document weight weekly. Observe and document any edema of extremities or face. e. Document signs and symptoms of early labor, pre-eclampsia or bleeding. f. Obtain an OB pack from MSU ER and place in a location where staff has quick access to it. 9. Nursing Care in Pregnancy 36 Weeks until Delivery: a. Document on Form 590D Pregnancy Flow Sheet 36 Week to Delivery. 5

6 b. Check and document Fetal Heart Tones weekly and as often as needed including when the resident presents with concerns or complaints. c. If the resident is acutely or psychiatrically unstable, and/or is a medically high risk, include a plan for possible early admission and delivery. d. If the resident s membranes rupture, refer the resident to the Emergency Room immediately for evaluation. Document the time, color and amount of vaginal discharge. e. Provide reassurance and guidance to the resident regarding labor and delivery procedures. f. Place resident on a one-to-one special observation a minimum of two weeks prior to the scheduled delivery date unless an assessment by the treating physician determines that the special observation is unnecessary or contraindicated. Document such an assessment in the resident s medical record. 10. Care of a Pregnant Resident during Labor and Delivery: a. Notify a nurse and/or Physician at the first signs of labor. Never leave the resident alone. b. Do not allow the resident to go to the bathroom unattended. A bedpan or pad under her are safe alternatives and very strongly recommended. c. Signs of imminent delivery may include: an urge to push, the baby is coming ; a burning, stinging or stretching sensation, a bulging perineum or a small amount of bleeding (bloody show). d. Certain medications and/or the resident s mental condition may alter their awareness; they may lack the sense of urgency or miss the signs and symptoms of impending delivery. e. Never hold the resident's legs together to delay birth or try to impede birth in any way. f. Call 7911 immediately for emergencies; call a nurse or physician immediately; and notify MSU Emergency Room. (1) Transport the resident to the Obstetrician s community hospital by County Ambulance or as determined by the MSU Emergency Room Physician. (2) The MSU ER staff will notify the Obstetrician regarding the transfer. (3) The Home Unit Social Services staff/designee will notify the resident s family and/or legal representative; and the Children s Protective Services, Abuse Registry, and Pediatric Social Worker. The MSU ER Staff will assume this responsibility after hours and on weekends. (Florida State Hospital Operating Procedure ). 11. Equipment Necessary at the Time of Delivery: These are available in Medical Services Unit. a. Pitocin (20 units) mixed in 1000 ml normal saline b. Erythromycin (0.5%) Ophthalmic Ointment c. Neonatal Ambu bag d. Infant arm band 6

7 e. Clean bunting blanket to provide warmth f. OB Pack which contains at least: baby blanket, a towel to dry infant, umbilical clamp, scissors / scalpel (to cut cord if necessary), bulb syringe, basin or zip lock bag (for used supplies), pads and sterile gloves. (NOTE: If OB Pack is not available, gather together: Sterile gloves, Bulb Syringe, Pads, Clean blankets, Linens, and a Gown.) 12. APGAR Scoring System Sign Heart rate Absent <100 beats/min >100 beats/min Respiratory effort Absent Slow, irregular Good, crying Muscle tone Flaccid Some flexion of extremities Active motion; well-flexed extremities Reflex irritability No response Grimace Vigorous cry Color Blue; pale Body pink; Extremities blue Completely pink 13. Nursing Care during Postpartum: Follow the Obstetrician s recommendations. In addition: a. Monitor up to six weeks postpartum and document to include the following: vital signs, weight, evaluation of breast and abdomen, perineal, lochia (color, amount, and consistency), evaluation for postpartum depression or other emotional factors, rest, hydration, and nutrition. b. Follow-up appointments with obstetrician as scheduled. 14. Training Requirements: A check in the box below indicates which employees within the department are required to read this operating procedure and when they will receive training at Florida State Hospital. Employees within identified departments will also be required to review the policy each time it is updated. Department All Employees Clerical Dental Dieticians, Laboratory, Special Therapy, -Ray Techs Direct Care Emergency Operations Environmental Services (Aramark) Financial Services Food Services Health Information Services Human Resources Information Systems Legal Materials Management Nursing Operations & Facilities (Aramark) Worksite Education New Employee Orientation Discipline Specific Training Annual Update 7

8 Department Pharmacy Physician/ARNP (Prescriber) Professional Development Psychology Quality Improvement Recovery Planning Rehab Services Resident Advocacy/Risk Mgt. Social Services Supervisors/Managers Volunteer Services Other: Worksite Education New Employee Orientation Discipline Specific Training Annual Update BOB QUAM Chief Hospital Administrator SUMMARY OF REVISED, ADDED OR DELETED MATERIAL This operating procedure was reviewed and reformatted for clarity; incorporated attachments into the body of the policy; and added Direct Care to Worksite Education under Training Requirement. 8