Army Action Plan: Orientation for Detainee Acute Care Unit at the Detainee Hospital at Guantanamo

DETAINEE HOSPITAL SOP NO: 0059
GUANTANAMO BAY, CUBA
Title: DACU ORIENTATION
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Effective Date: Feb 2004
SCOPE: Detention Hospital

L JOB SUMMARY
Purpose: To provide Nursing and Corp staff with guidelines to assist with the Nursing
care provided by the Detention Hospital in the Detainee Acute Care Unit.
***Keep in mind that safety is first in the Detainee Acute Care Unit; medical care will always be secondary. When working with a detainee in the Detainee Acute Care Unit ensure to always have a guard alerted and present prior to your approach to the detainee. It is vital to your safety to have a guard aware of your plans to approach any detainee at all time's. Teamwork and communication will always provide an effective and safe atmosphere. This document will serve as a turnover file and training template for incoming personnel tasked with opening and manning managing the Detainee Acute Care Unit. Whether it is responding to one or multiple casualties the principles of the medical response are the same.***
IL RESPONSIBILITIES AND AUTHORITIES
The duties and responsibilities of the Nurse Corps Officer are as follows:
1(b)(2)
Open the Detainee Acute" Care Unit and ready it for the arrival of the detainee Coordinate and administer patient care activities Exercise a substantial degree of independence in the performance of their duties; they must function without direct supervision of a doctor of medicine or osteopathy when administering care. Secure the DACU after use and report all usage of supplies to the appropriate people Be available via pager 24 hours, wheri assigned, and frequently check for pages to ensure a timely response The Nurse Corp Officers assigned to the DACU are qualified by orientation, training and experience to provide quality care. Administer scheduled and PRN medication as ordered

SOP: 059
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Administer treatments such as dressing changes, etc. Transcribe physician orders for all patients Ensure all procedures and findings are documented on appropriate forms
1:11 PROCEDURE
DACU OPENING PROCEDURES (b)(2)
4) Enter the DACU and prepare the unit as needed. (b)(2)
6) Transfer patient to unit.
DACU EQUIPMENT ORIENTATION
1) Monitor
-Hands on demonstration
-HP Monitor reference book at nurse's station
2) allibMonitor

-Hands on demonstration
-Pro-Pac reference book at nurse's station 3) IVAC Intravenous Pump
-Hands on demonstration
-IV drug calculation
-IVAC reference book in DACU SOP 4) UM Pump (Enteral Feeding Pump)
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-Hands on demonstration
5) Mechanical Ventilation and Ventilator Troubleshooting

Overview
-RELAX!!
-Ventilators are positive pressure devices that blow up the lungs like balloons and allow 02 in and CO2 out
-Ventilator settings are ordered by the physician and set by respiratory therapist
(RT) - Nurse's role is to monitor the patient and inform the physician and/or RT that the patient is not tolerating the current settings and that the patient must be assessed and changes made as necessary.

Objectives of Mechanical Ventilation
Physiologic objectives - to support or manipulate pulmonary gas exchange
-alveolar ventilation (arterial PCO2, pH)
-arterial oxygenation (P02, Sa02, CO2)
-increase lung volume 1) end-inspiratory lung inflation 2) functional residual capacity
-to reduce or otherwise manipulate the work of
breathing
Clinical Objectives - reverse hypoxemia

-reverse acute respiratory acidosis
-relieve respiratory distress
-prevent or reverse atelectasis
-reverse ventilatory muscle fatigue
-permit sedation and/or neuromuscular blockade
-decease systemic or myocardial 02 consumption
-to reduce intracranial pressure
-stabilize the chest wall

Ventilator Parameters
Mode - main difference is spontaneous vs. ventilator-assisted ventilation
-types: CMV, IMV, SIMV, Assist Control, Pressure support, CPAP, Inverse Ratio, etc.
Rate - number of breaths per minute
Trigger - amount of negative pressure needed to "trigger" the machine to deliver a breath
-sensitivity can be set as low as -0.5 to -1.5 cm H2O
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Tidal Volume - amount of air going into the lungs with each ventilation
-average tidal volume is 8-10m1/kg
Fi02 - fractional percentage of 02 delivered to the patient (.30, .50, 1.0, etc.)
Pressure Support (PS) - amount of air pressure used to augment inspiration
PEEP/CPAP - amount of air pressure the patient breathes against during exhalation
-prevents atelectasis
-normally set at 5cm H2O and increased as necessary
I:E ratio - ration of inhalation to exhalation
-normal is 1:2 to 1:3 -can be adjusted to optimize ventilation
Suctioning
1) Ventilate if possible using 100% 02 for one minute 2) Measure position of tube at level of teeth or approximate trach length (if
applicable) 3) Disconnect patient from ventilator circuit (not need if using in-line suction) 4) Introduce suction catheter and advance just beyond trach or ET tube length 5) Suction approximately 5-10 seconds or until airway clear 6) Place patient back on ventilator circuit or ventilate for one minute and
continue suctioning 7) When in doubt, or if Sp02 falls with s/s of hypoxia present, manually ventilate with BVM and call for assistance
Ventilator Troubleshooting
-RELAX!!!
-
most problems are simple in nature and can be assessed and remedied by the nurse at the bedside

-
most importan•rule is to ASSESS THE PATIENT, NOT THE MONITOR!

-use a systematic approach to assessing the patient
-work from the patient back to the ventilator
-when in doubt, ventilate using a bag-valve mask (BVM)
Pneumonic for assessing ventilator alarm or malfunction is to "check your DOPE":
D . -Dislodgement between ventilator circuit and patient Tx: attach ventilator circuit to patient and reassess TITLE:
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-Obstruction of patient airway or ventilator circuit
0
Tx: suction patient or un-kink ventilator tubing reassess
-Oxygenation failure.
1) Total loss of oxygen coming from the 02 source
2) Too low a Fi02 setting to adequately oxygenate the patient

Tx:
1)Manually ventilate patient with alternate 02 source (i.e., 02

tank)
2) Increase Fi02 setting until adequate Sp02 achieved
P -Pneumothorax caused by ventilator or organic process Tx: remove patient from ventilator, manually bag, and contact MO ASAP
E.-Equipment failure. Either mechanical or electrical failure of ventilator. Tx: manually bag patient and contact RT ASAP for ventilator change-out

DACU MEDICATION REVIEW
1) See attached sheets for over view of medications commonly used in the DACU
2) Medications not in ward stock can be obtained from the NH GTMO Pharmacy. (b)(2)
4) IV drip medication preparation information is located on the attached sheets.
DACU SUPPLY PROCEDURES
(b)(2), (b)(6)

TITLE:
Page 6 of 9 4) After working hours you may utilize the multi-service ward for supply needs with a one-for-one return policy on all supplies used the next working day. all supplies used, as well
5)Upon securing the DACU, leave a note fo
as any identified supplies needs for the futur

DACU SECURITY PROCEDURES
•
(b)(2)
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DACU CLEAN UP AND SHUT DOWN PROCEDURES
1) After discharging al patients, the DACU crew is responsible for cleaning up and

preparing the DACU to receive new patients.
2) All dirty linen is to be bagged and placed in the linen bag on the multi-service ward.

3) All beds are to be made with fresh linen.

4) All monitors, cables and accessory items are to be wiped down with a disinfecting,
germicidal solution.
5) All cables are to be stowed in the receptacles at the bedside.

6) Extra equipment shall be stored in equipment room in the back of the DACU.
7) The nurse's station is to be cleaned prior to departure. This includes removing any left over food items from both the patient and staff refrigerators, de-icing the refrigerators as needed, emptying and cleaning the coffee pot and emptying the garbage can.
8) All leftover narcotics are to be returned to pharmacy or wasted and properly
documented.

9) Red bag trash is to be bagged, twisted shut and taped closed with a "goose neck" at the top of the bag. Red bag trash containers are located
10)All lights are to be turned off. (b)(2)
12. Return the keys to the multi-service ward.
(b)(2),(b)(6)

14) Drop off regular trash in the large dumpsters(b)( 2)

0 0 5 32Z

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Detention Hospital Guantanamo Bay Cuba

DACU ORIENTATION
Preceptor Initials / Orientee Initials
Review SOP
Open DACU
Orient to Equipment/
•
HP Monitors

•
ProPaks

•
Kangaroo Pumps

•
IV Pumps

•
Ventilators

„ --Medication Review
•Critical Drip Calculations
Common Procedures
Supply Replacement
Security
Clean up / Shut Down DACU
Preceptor's Signature Orientee's Signature
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STANDARD OPERATING PROCEDURES Detention Hospital Guantanamo Bay. Cuba

REVIEWED AND APPROVED BY:
Officer In Charge Date
IMPLEMENTED BY:
Director for Administration Date
Senior Enlisted Advisor Date
ANNUAL REVIEW LOG:
By: ' Date: By: Date: By: Date: By: Date: By: Date: By: Date:
SOP REVISION LOG:
Revision to Page: Date: Revision to Page: Date: Revision to Page: Date: Revision to Page: Date: Revision to Page: Date: Revision to Page: Date:
ENTIRE SOP SUPERSEDED BY:
Title:
SOP NO: Date:

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