6/01/22 SG Clinic Observer/Monitor II

Please arrive 15 to 30 minutes before the shift to receive Just In Time training.

Observation/Monitor

FAMILIARIZE:

1. Become familiar with the emergency supplies in the room
2. Familiarize yourself with medical response plan and forms
3. Know where AED, wheelchair and stretcher are located
4. Ensure that all emergency supplies are reference materials are accessible
   1. BP cuffs, stethoscope, pulse ox, x3 Epi pens, medical response plan, CPR mask, emesis bags, Benadryl & Pepcid.
5. Ensure that there are ice packs in black mini fridge in recovery room (boardroom).

GREET & OBSERVE:

1. Ensure that patient has a green or orange sticker with time of vaccination with them
   1. Green = 15 min observation period
   2. Orange = 30 min observation period
2. Introduce self and inform patient of observation period and to alert you if they begin to feel:
   1. Dizzy/light-headed, nausea, difficulty breathing, or just not feeling right.

ADVERSE RESPONSE (e.g vasovagal responses) – Anaphylaxis response on back.

1. Notify lead RN of a possible adverse response.
2. Assess airway, breathing, circulation and mentation and for any signs and symptoms of potential anaphylaxis.
3. Move patient to recovery area of clinic (boardroom) using wheelchair or stretcher.
4. Continue to monitor patient and ABC’s, provide juice, ice packs, or water.

SIGNS OF ANAPHLAXIS:

ANAPHLYAXIS RESPONSE:

1. Have someone call 911 requesting ambulance response at Providence Southgate Medical Center vaccination clinic. This person should also notify lead RN
2. Assess airway, breathing, circulation, and mention
   1. Place patient in supine position with feet elevated unless airway obstruction is present, or patient is vomiting.
3. Administer IM Epinephrine in thigh (can be done through clothing if necessary)
   1. 15mg (33 lbs. to less than 66lbs) CHILD
   2. 3mg (66 lbs. or more) ADULT
   3. Repeat dosage every 15-20 mins if there is no clinical improvement.
4. Administer histamine blocker and supportive care as appropriate.
5. When EMS arrives report
   1. Vaccine administration time
   2. Epinephrine administration time
   3. Patient symptoms,
   4. And other pertinent information
6. EMS will now take full agency of this patient and resume care.
7. Lead RN will perform reporting of event with patient name, DOB for VAERS (vaccine adverse event) reporting.