ADVANCE DIRECTIVE FOR HEALTH CARE r*mr1152*r (Living Will and Health Care Proxy)

Transcription

1 PROVIDENCE HOSPITAL ADVANCE DIRECTIVE FOR HEALTH CARE r*mr1152*r (Living Will and Health Care Proxy) MR1152 This form may be used in the State of Alabama to make your wishes known about what medical treatment or other care you would or would not want if you become too sick to speak for yourself. You are not required to have an advance directive. If you do have an advance directive, be sure that your doctor, family, and friends know you have one and know where it is located. Section 1. Living Will I,, being of sound mind and at least 19 years old, would like to make the following wishes known. I direct that my family, my doctors and health care workers, and all others follow the directions I am writing down. I know that at any time I can change my mind about these directions by tearing up this form and writing a new one. I can also do away with these directions by tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to write them down. I understand that these directions will only be used if I am not able to speak for myself. If I become terminally ill or injured: Terminally ill or injured is when my doctor and another doctor decide that I have a condition that cannot be cured and that I will likely die in the near future from this condition. Life sustaining treatment Life sustaining treatment includes drugs, machines, or medical procedures that would keep me alive but would not cure me. I know that even if I choose not to have life sustaining treatment, I will still get medicines and treatments that ease my pain and keep me comfortable. Place your initials by either "yes" or "no": I want to have life sustaining treatment if I am terminally ill or injured. Yes No Artificially provided food and hydration (Food and water through a tube or an IV) I understand that if I am terminally ill or injured I may need to be given food and water through a tube or an IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me. Place your initials by either "yes" or "no": I want to have food and water provided through a tube or an IV if I am terminally ill or injured. Yes No If I Become Permanently Unconscious: Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable degree of medical certainty I can no longer think, feel anything, knowingly move, or be aware of being alive. They believe this condition will last indefinitely without hope for improvement and have watched me long enough to make that decision. I understand that at least one of these doctors must be qualified to make such a diagnosis. Life sustaining treatment Life sustaining treatment includes drugs, machines, or medical procedures that would keep me alive but would not cure me. I know that even if I choose not to have life sustaining treatment, I will still get medicines and treatments that ease my pain and keep me comfortable. Place your initials by either "yes" or "no": I want to have life sustaining treatment if I am permanently unconscious. Yes No Page 1 of 4 N 5/04 NSG00016A

2 Artificially provided food and hydration (Food and water through a tube or an IV) I understand that if I am terminally ill or injured I may need to be given food and water through a tube or an IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me. I want to have food and water provided through a tube or an IV if I am permanently unconscious. Yes No Other Directions: Please list any other things you want done or not done.. In addition to the directions I have listed on this form, I also want the following: Place your initials by either "yes" or "no". No, I do not have any other directions. Section 2. If I need someone to speak for me. This form can be used in the State of Alabama to name a person you would like to make medical or other decisions for you if you become too sick to speak for yourself. This person is called a health care proxy. You do not have to name a health care proxy. The directions in this form will be followed even if you do not name a health care proxy. Place your initials by only one answer: I do not want to name a health care proxy. (If you check this answer, go to Section 3) I do want the person listed below to be my health care proxy. I have talked with this person about my wishes. First choice for proxy: Relationship to me: City: State Zip Day time phone number: Night time phone number: If this person is not able, not willing, or not available to be my health care proxy, this is my next choice: Second choice for proxy: Relationship to me: City: State Zip Day time phone number: Night time phone number: Page 2 of 4 r*mr1152*r MR1152 SHHS N 5/

3 Instructions for Proxy Place your initials by either "yes" or "no". I want my health care proxy to make decisions about whether to give me food and water through a tube or an IV. Yes No Place your initials by only one of the following: I want my health care proxy to follow only the directions as listed on this form. I want my health care proxy to follow my directions as listed on this form and to make any decisions about things I have not covered in the form. I want my health care proxy to make the final decision, even though it could mean doing something different from what I have listed on this form. Section 3. The things listed on this form are what I want. I understand the following: If my doctor or hospital does not want to follow the directions I have listed, they must see that I get to a doctor or hospital who will follow my directions. If I am pregnant, or if I become pregnant, the choices I have made on this form will not be followed until after the birth of the baby. If the time comes for me to stop receiving life sustaining treatment or food and water through a tube or an IV, I direct that my doctor talk about the good and bad points of doing this, along with my wishes, with my health care proxy, if I have one, and with the following people. Section 4. My signature Your Name: The month, day, and year of your birth: Your Signature: Date signed: r*mr1152*r MR1152 Page 3 of 4 SHHS N 5/04 NSG00016

4 Section 5. Witnesses (need two witnesses to sign) I am witnessing this form because I believe this person to be of sound mind. I did not sign the person s signature, and I am not the health care proxy. I am not related to the person by blood, adoption, or marriage and not entitled to any part of his or her estate. I am at least 19 years of age and am not directly responsible for paying for his or her medical care. Name of first witness: Signature: Date: Name of second witness: Signature: Date: Section 6. Signature of Proxy I,, am willing to serve as the health care proxy. Signature: Date: Signature of Second Choice for Proxy: I,, am willing to serve as the health care proxy if the first choice cannot serve. Signature: Date: r*mr1152*r MR1152 Page 4 of 4 SHHS N 5/04 NSG00016

5 PROVIDENCE HOSPITAL It s Your Choice... Making Advance Directives DECIDING ABOUT YOUR HEALTH CARE ~ If you are nineteen (19) years old or order, the law says you have the right to decide about your medical care If you are very sick or badly hurt, you may not be able to say what medical care you want Or you have an advance directive, your doctor and your family will know what medical care you want if you are too sick or hurt to talk of make decisions. WHAT IS AN ADVANCE DIRECTIVE? An advance directive is used to tell your doctor and your family what kind of medical care you want if you are too sick or hurt to talk or make decisions. If you do not have one, certain members of your family will have to decide on your care. You must be at least nineteen (19) years old to set up an advance directive. You must be able to think clearly and make decisions for yourself when you set it up. You do not need a lawyer to set one up, but you may want to talk with a lawyer before you take this important step. Whether or not you have an advance directive, you have the same right to get the care you need. TYPE OF ADVANCE DIRECTIVES ~ In Alabama you can set up an advance directive for healthcare. The choices you have include: A living will is used to write down ahead of time what kind of care you do or do not want if you are too sick to speak for yourself. A proxy can be part of a living will. You can pick a proxy to speak for you and make the choices you would make if you could. If you pick a proxy, you should talk to that person ahead of time. Be sure that your proxy knows how you feel about different kinds of medical treatments. Another way to pick a proxy is to sign a Durable Power of Attorney for health care. The person you choose does not need to be a lawyer.

6 You can choose to have any or all of these three advance directives ~ Living Will Proxy Durable Power of Attorney for health care. Hospitals, home health agencies, hospices and nursing homes usually have forms you can fill out if you want to set up a living will, pick a proxy or set up a Durable Power of Attorney for health care. If you have questions, you should ask your own lawyer or call your local Council on Aging for help. WHEN YOU SET UP AN ADVANCE DIRECTIVE ~ Be sure to sign your name and write the date on any form or paper you fill out. Talk to your family and your doctor now so they will know and understand your choices. Give them a copy of what you have signed. If you go to the hospital, give a copy of your advance directive to the person who admits you to the hospital. WHAT DO I NEED TO DECIDE? You will need to decide if you want treatments or machines that will make you live longer, even if you will never get better. An example of this is a machine that breathes for you. Some people do not want machines or treatments if they cannot get better, though they may want food and water through a tube or pain medication. With an advance directive, you decide what medical care you want. TALK TO YOUR DOCTOR AND FAMILY NOW ~ The law says doctors, hospitals and nursing homes must do what you want or send you to another place that will. Before you set up an advance directive, talk to your doctor ahead of time. Find out if your doctor is willing to go along with your wishes. If you doctor does not feel that he/she can carry out your wishes, you can ask to go to another doctor, hospital or nursing home. Once you decide on the care you want or do not want, talk to your family. Explain why you want the care you have decided on. Find out if they are willing to let your wishes be carried out.

7 Family members do not always want to go along with an advance directive. This often happens when family members do not know the patient s wishes ahead of time, or they are not sure about what has been decided. Talking with your family ahead of time can prevent this problem. YOU CAN CHANGE YOUR MIND ANYTIME ~ As long as you can speak for yourself, you can change your mind any time about what you have written down. If you make changes, tear up your old papers and give copies of any new forms or changes to everyone who needs to know. HOW CAN I LEARN MORE? Providence Hospital s Department of Social Work Services can answer questions and help you obtain the information you need. They can also give you information about the policies of Providence Hospital regarding end of life decisions. You can reach Social Work Services by calling (251) between the hours of 8:00 A.M. and 4:30 P.M. Monday through Friday. THE CATHOLIC PERSPECTIVE Providence Hospital, founded by the Daughters of Charity, and a member of Ascension Health, is a Catholic Hospital. Our policies regarding health care advance directives conform to both Alabama law and Catholic teaching as defined in the Ethical and Religious Directives. Additional information on the Ethical and Religious Directives may be found at the Catholic bishops web site FOR MORE INFORMATION Contact: Alabama Commission on Aging Choice in Dying Social Work Services Providence Hospital (251) Revised: October 2002 Revised: March 2010 Revised: March 2011 ADM00001c

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9 Smoking HOW TO QUIT It s never too late to quit smoking. Quitting will reduce your risk of coronary artery disease, stroke and many cancers. When you quit smoking your senses of taste and smell will improve significantly, and your physical stamina will increase, making walking, climbing stairs and doing household activities much easier. TIPS TO HELP YOU QUIT Gather information about quitting and plan ahead. Look for programs, classes and support groups. Begin an exercise program before you set a quit date. Physical activity will help you relax and can help prevent weight gain after you quit smoking. Try to quit smoking after you ve become comfortable with your exercise program. Talk to friends who have quit to find out how they did it. Keep a journal to identify your smoking triggers and behavior. Record when and where you smoke. Note if you re eating, drinking, with friends, etc. List all the reasons you want to quit. Modify your smoking habits. Stop buying cartons of cigarettes and buy one pack at a time. Set a quit date. Sign a stop smoking contract. Sit in the nonsmoking section of restaurants. Additional Contacts: During the first 24 hours: Schedule healthful activities. Brush your teeth frequently. Drink plenty of water. Throw out all ashtrays and other smoking related items from your home and workplace. Pamper yourself as much as possible. Avoid drinking alcohol. Chew gum, carrots, celery, crackers or hard candy. Exercise frequently. Keep your hands busy. Review your list of reasons why you want to quit. Call up a supportive friend. Practice stress reduction techniques, such as deep breathing and creative visualization. Go to places where smoking is prohibited (the museum, cinema, theater, library, etc.). American Heart Association: American Lung Association: Contact your Physician for information Distributed under license. Parlay International nsg00012 SHHS S 5/

10 Smoking WHY YOU NEED TO QUIT You know you need to quit smoking. But you wonder if it s too late, since you re already ill anyway. But, it s never too late to quit smoking. Here s why quitting is even more important now. Smoking and Your Lungs When you light up, tobacco smoke paralyzes the tiny hairs in your bronchial tubes called cilia that sweep foreign particles out of your lungs. The tar and cancer causing chemicals in your cigarettes form a sticky coating that damages your lung tissues. Your smaller breathing passages go into spasm. The air sacs in your lungs break down further, making it more and more difficult for oxygen to get from your lungs into your bloodstream. Every cigarette adds to the scar ring in your lungs and keeps your smoker s cough active. You catch every cold that goes around, and it takes forever to get over it. When you quit smoking, your lungs will breathe a sigh of relief. Smoking and Your Heart Your heart and blood vessels take a hit with every cigarette you smoke. Nicotine raises blood pressure and makes your blood clot more easily. Carbon monoxide in the smoke robs the blood of oxygen, starving your heart and leading to cholesterol deposits on the artery walls atherosclerosis. In addition, the poor circulation resulting from atherosclerosis can cause strokes, impotence, pain and loss of circulation in fingers and toes. Smoking doubles your risk of fatal heart attack, doubles or triples your risk of stroke and increases the effects of diabetes. If your health is already weakened by heart disease, high blood pressure, a history of strokes or diabetes, you ll live longer and better if you quit. Benefits of Quitting Here are some good effects that people experience when they quit smoking. Which ones might you benefit from? My chronic bronchitis will gradually disappear. I won t be so out of breath. I will suffer fewer complications from diabetes. I will be able to slow and perhaps stop the downward spiral of emphysema. As my immune system recovers, I will get fewer of those "bugs" that now pose a serious threat to my health. My food will taste better, so I won t need to jazz it up with salt and those high fat sauces the doctor says I can t have anymore. My angioplasty will last longer. I won t be wasting all those changes I m making to cope with heart disease: eating a nutritious, low fat diet, getting daily exercise, dealing with stress. My family will be healthier. The pains in my legs may go away. It s not easy to quit. but you can do it with help from one of many excellent programs. Ask your doctor to recommend one in your area. Distributed under license. Parlay International

11 PROVIDENCE HOSPITAL PAIN MANAGEMENT People once thought that pain was something you just had to bear. That is no longer true today. Your health care providers will work with you to help prevent or relieve pain. When your pain is controlled you: May be more comfortable as you heal May get well faster become more active sooner May be more satisfied with your care Don t worry about getting "hooked" on your pain medicines. There is no indication that this often happens unless you already have a problem with drug abuse. The amount of pain you feel may not be the same as what other feel. People react individually to similar circumstances. Some pain medications have side effects such as constipation, nausea and itching. Report these to the health care provider so they can be properly treated. Pain Control Tips When you are here for health care, don t worry about "bothering" the staff if you are experiencing discomfort. They need to know when you are hurting or your pain worsens. It is easier to prevent pain than to treat pain once it is severe. Tell the staff as soon as pain starts. You will be asked to help the health care provider measure your pain. They may ask you to rate your pain on a scale of 0 10 (0= no pain and 10= severe "unbearable" pain). Remember, pain treatment doesn t always involve medications. Your doctor may prescribe a treatment such as massage, hot or cold packs, relaxation, etc. Surgery Patients: Understand that you will experience some degree of discomfort following any surgery. Ask your doctor or nurse what to expect and how long the pain usually lasts. Find out what pain control options are available. Be sure to tell your doctor and nurse about drug allergies you may have and medicines your take regularly. The anesthesia you receive during surgery will wear off soon after surgery is completed. You will need to tell your nurse when you begin to have pain. Types of Pain Medicines: (Your doctor will tell you which type is best for you.) Non steroidal anti inflammatory drugs are pills or capsules taken by mouth which may be given to help reduce swelling or soreness and relieve mile to moderate pain. Opioids, like morphine or codeine are used for acute pain (such as after surgery) and for chronic pain. Local anesthetics are drugs given near an incision or through a small tube in your back. They block the nerves that send the pain messages to your brain. Most patients are familiar with pills, shots and injections in to the veins. When you are in the hospital, you may be given a special device that allows you to give pre measured doses of pain medication to yourself. These are called PCS (patient controlled analgesia) devices. Your nurse will explain how to use this device. ONLY the patient should push the PCA button. Please contact the nurse if you are unable to push the button yourself. NSG00017a

12 We at Providence Hospital believe that: Pain management is an integral part of quality patient care The patient s self report of pain is the most reliable indicator of pain Patients and families are involved in the pain management plan. Patients and families will be educated regarding their roles in the pain management team to include: communication about pain including the use of a pain scale pain relief options and response to options pain management plan for discharge as appropriate PAIN SCALE No Pain Worse Pain When you are Getting Ready to Go Home: Any patient, inpatient or outpatient, may experience treatments, tests or surgical procedures that may cause discomfort either during or after the procedure. Before leaving the facility, make sure you have discussed with your health care provider how to control any discomfort you may feel after you get home. If your doctor has ordered new pain medicines, make sure you have the prescriptions before you leave. Call your doctor for any new or increasing pain after you get home. NSG00017

13 ORGAN & TISSUE DONATION Donate Life DO YOU KNOW?... How many people are waiting for organ and tissue transplants? Over 77,000 Americans are waiting for organ transplants today. Over 200,000 people could benefit from a tissue transplant as you read this! Who benefits from these gifts? A young father of two is alive today; a heart donation saved his life. A teenage girl is dancing today; a bone donation saved her leg from amputation. A mother will see her child for the first time; an eye donation restored her sight. Diseases that cause loss of life, sight and limbs can afflict anyone. The people above are your friends, neighbors; maybe even you or your family! Why donor families benefit too? Donor families find great comfort in making these donations. As one mother says, "My son s purpose in life was to make others happy and that is exactly what he is doing now. Someone else s dreams for the future will come true because my son s gift made it possible." Why should you act now? Your family is likely to be asked about donation if something happens to you. What will they do? Let them know what your wishes are! NOW YOU KNOW!... Transplants are modern miracles. It only happens because people care about people and share these priceless gifts. If you haven t made a decision about donation, please think about it now. Talk to your family and let them know what your wishes are! Organ & Tissue Donation The Facts Almost everyone can donate Whatever your age or health, chances are, you will be able to donate some type of organ or tissue. This will be determined at the time of death. Donation costs nothing There is no cost to the donor or the donor family for donation. You cannot be paid for donating. It is against the law to buy or sell human organs for transplant. Religion supports donation All major religions support your right to make this gift to others. If you have special concerns, you may wish to discuss them with your clergy or one of our chaplains. Donation cannot be seen Donation does not change the donor s appearance or cause any delay in making funeral plans. What can you donate The organs and tissues most commonly transplanted today include: Kidneys, Heart, Lungs, Liver, Pancreas, Small Bowel, Heart Valves, Eyes, Long Bones, Bone Marrow, Skin and Connective Tissues. You may specify which organs and tissues you wish to donate. A reminder these donations will not change the appearance of the body. It s a Fact Organ & Tissue Donation Helps People! Approved by MEC September 28, 2004 Developed 11/04 NSG00028

14 PROVIDENCE HOSPITAL FALL PREVENTION Patient and Family Instructions At Providence Hospital, our staff are committed to keeping our patients safe. Since patient falls are a common problem in hospitals, we ask that you and your family work with us to help keep you safe. Patient falls occur in the hospital for the following reasons: * Medications your doctor orders may make you drowsy. * Your illness may cause you to be weak or unsteady on your feet. * Unfamiliar surroundings may confuse you especially at night. As a patient, you can help us prevent a fall if you... * Use your call light. We want to assist you especially if you are weak or connected to IV or other mechanical equipment. * Sit on the side of your bed for a while before trying to stand. Then, rise SLOWLY and CAREFULLY begin to walk. * Wear footwear that does not slip on the floor. (No socks please) * Call a nurse for spills on the floor. * Ask the nurse for help adjusting side rails. As a family member, you can help us if you... * Encourage the patient to use the call light. * Keep paths clear in patient s room. * Ask for assistance to adjust side rails. * If patient has a restraint in place, check with the nurse before removing. * If patient is confused, notify the nurse before leaving the patient unattended. Our staff may take other measures to help protect you such as... * Moving you to a room more visible to the nurses. * Leaving your door open to "Keep an eye on you". * Asking family or friends to stay with you and to participate in your care. Working together as a team we can make your hospital stay safe! NSG00034

15 PROVIDENCE HOSPITAL HOME SWEET HOME ~ HOME SWEET HOME ~ HOME SWEET PREPARING FOR DISCHARGE From the day you are admitted, the staff at Providence Hospital begins planning for your discharge. According to your discharge destination (home, nursing home, rehab, etc.) there will be several people (nurses, social worker, outcomes/case manager, etc.) involved in your discharge planning. Your discharge process could take 1 to 4 hours depending on the destination and the amount of caregivers involved. On the day of discharge, your doctor will write an order for your discharge. There are several things that occur before you are ready to leave the hospital. Don t hesitate to ask your nurse for a general estimate of how long your discharge will take. 1.Your doctor writes the order for you to leave the hospital. A. If a physician assistant tells you that today you will be able to leave the hospital, you probably will have to wait for the doctor to see you. B. C. If you have been seen by more than one doctor during your stay, the nursing staff must communicate with each doctor to assure that they are ready for you to be discharged. Sometimes the doctor will tell the nurse not to let you go home until he/she is able to come see you. There are times when the doctor will want his office notified that you are ready for discharge so that more orders can be received and carried through prior to you leaving. 2. If you have home care services such as medical equipment or nursing needs, the appropriate staff must assure that all plans are finalized. A. An outcomes/case manager or social work case manager will arrange for home nursing, IV therapy, tube feedings and medical equipment. B. Someone from Respiratory Care may arrange care services for home oxygen, respiratory treatments. CP AP, etc. When the items are ordered, the medical equipment company is usually required to bring them to the hospital prior to your departure. In most instances this can be completed within 1 1 1/2 hours. 3. There are times when the doctor wants you to have a certain medication prior to discharge. This medication may be one you are already scheduled to receive or a new medication. If it is a new medication, the order will be sent to the pharmacy. When the medication is received, the nurse will give it as the doctor ordered. Also, there are times when the doctor wants a certain department to provide services to you before you leave. Physical Therapy, Respiratory Therapy, Fit for Life or other personnel may need to see you prior to your discharge. 4. Your doctor will leave special instructions and prescriptions for the nurse to review with you prior to discharge. This information will be written on your discharge summary papers that the nurse reviews with you and your family. A copy of the discharge summary papers will be provided to you. 5. Once your nurse has reviewed the discharge summary papers with you, the transportation department will be notified that you are ready to leave. Transportation can provide a cart if needed. If you are going to a Nursing Home, Rehab, In House Hospice, etc., many of the above actions must occur. If you are traveling by ambulance, the nursing staff will coordinate your departure time with the facility and the ambulance service. We at Providence Hospital strive to make each experience a good one. By providing this information, you will know what to expect when preparing for discharge. As you see, there are many staff members involved in your care and preparing for the day you leave the hospital. THANKS AGAIN FOR CHOOSING PROVIDENCE Dev: 0805 Rev: 0910 HOME SWEET HOME ~ HOME SWEET HOME ~ HOME SWEET nsg00032

16 PROVIDENCE HOSPITAL N FOREMAN ROAD A I R P O R T B O U L E V A R D MAIN BUILDING EMERGENCY A BUILDING OUTPATIENT BUILDING B BUILDING C BUILDING DISCHARGE AREA D BUILDING

17 PROVIDENCE HOSPITAL Isolation Precautions are used to contain the spread of contagious illness. What I Need to Know About Isolation Precautions Isolation Precautions are used to separate patients who have a specific illness from other (patients, visitors, hospital staff) who are healthy and limit their movement in the hospital in order to stop the spread of that illness The type of isolation precautions used depends on how the illness is spread. The sign on the door to the room will provide instructions to others coming into your room. Family & visitors will be required to follow the instructions on the Isolation Precaution sign while they are in the patient s room. This will prevent visitors from becoming ill. Most importantly, it will protect their children from contamination and keep others safe as they move about the hospital. Read the sign on the door carefully and follow the instruction. If you have questions, ask your nurse. If you are instructed to wear a mask...the mask should cover the nose and mouth. DROPLET PRECAUTIONS Respiratory droplets are generated when an infected person coughs, sneezes, or talks. To prevent the spread of infection, ANYONE ENTERING THIS ROOM MUST: CONTACT PRECAUTIONS AIRBORNE PRECAUTIONS Germs are transferred from one infected Germs are carried long distances by air person to another person directly or currents and my be inhaled by others. indirectly (through a contaminated object in the room). To prevent the spread of infection, ANYONE ENTERING THIS ROOM MUST: To prevent the spread of infection, ANYONE ENTERING THIS ROOM MUST: STRICT ISOLATION Is appropriate for patients know or suspected to be infected or colonized with epidemiologically important microorganisms such as VRE and R Acinetobacter. To prevent the spread of infection, ANYONE ENTERING THIS ROOM MUST: Hand Hygiene Hand Hygiene Hand Hygiene Hand Hygiene Surgical Mask Gloves N 95 Respirator Mask Surgical Mask Gloves Gown Gloves Gown Created: 01/06/2010 Date Printed: nsg00161

18 PROVIDENCE HOSPITAL The Centers for Disease Control Guide for Isolation Precautions is used to determine if a patient needs isolation precautions and when they are needed. Having a safe and speedy recovery starts with: Hand Hygiene "SpeakUP" and ask everyone coming into your room to wash their hands before touching you. Respiratory Hygiene / Cough Etiquette If you have a transmissible respiratory infection (cough, congestions, runny nose) you will be given a mask to wear while you are being admitted and whenever you leave your room. You will be asked to cover your mouth / nose with a tissue when coughing and promptly dispose of used tissues and wash your hands. Created: 01/06/2010 Date Printed: nsg00161b

19 Created: 02/05/10 PROVIDENCE HOSPITAL FIVE THINGS YOU CAN DO TO PREVENT INFECTION Avoiding contagious diseases like the common cold, strep throat, and the flu is important to everyone. 1. Clean your hands. Use soap and warm water. Rub your hands really well for at least 15 seconds. Rub your palms, fingernails, in between your fingers, and the backs of your hands Or, if your hands do not look dirty, clean them with alcohol based hand sanitizers. Rub the sanitizer all over your hands, especially under your nails and between your fingers, until your hands are dry. Clean your hands before touching or eating food. Clean them after you use the bathroom, take out the trash, change a diaper, visit someone who is ill, or play with a pet. 2. Make sure health care providers clean their hands or wear gloves. Doctors, nurses, dentists and other health care providers come into contact with lots of bacteria and viruses. So before they treat you, ASK them if they ve cleaned their hands. Health care providers should wear clean gloves when they perform tasks such as taking throat cultures, pulling teeth, taking blood, touching wounds or body fluids, and examining your mouth or private parts. Don t be afraid to ASK them if they should wear gloves. 3. Cover your mouth and nose. Many diseases are spread through sneezes and coughs. when you sneeze or cough, the germs can travel 3 feet or more! Cover your mouth and nose to prevent the spread of infection to others. Use a tissue! Keep tissues handy at home, at work and in your pocket. Be sure to throw away used tissues and clean your hands after coughing or sneezing. If you don t have a tissue, cover your mouth and nose with the bend of your elbow or hands. If you use your hands, clean them right away. Date Printed: 4. If you are sick, avoid close contact with others. If you are sick, stay away from other people or stay home. Don t shake hands or touch others. When you go for medical treatment, call ahead and ask if there s anything you can do to avoid infecting people in the waiting room. 5. Get shots to avoid disease and fight the spread of infection. Make sure that your vaccinations are current even for adults. check with your doctor about shots you may need. vaccinations are available to prevent these diseases: Chicken Pox Measles Tetanus Shingles Flu (also known as influenza) Whooping cough (also known as Pertussis) German measles (also known as Rubella) Pneumonia (Streptococcus pneumoniae) Human papillomavirus (HPV) Mumps Diphtheria Hepatitis Meningitis nsg00163 The goal of the Joint Commission Speak Up program is to help patients become more informed and involved in their health care.

20 ASK if doctors and nurses washed their hands before touching you. ASK if you have an urinary catheter when it will be removed. ASK if you have an IV or central line how often is it changed & when it can be removed. ASK about test results and treatments. ASK: What medications am I taking and why? ASK for a detailed explanation of the medications you received during your stay and those you are expected to take after you leave. If you are having surgery ASK: The surgeon to mark the surgical site with a pen in front of you. Am I taking antibiotics immediately before and after to minimize the risk of infection? What is the plan after surgery to prevent clot formations? It s OK to Ask if you "sense" something is wrong! We ID s Name & Birth Date Do not let anyone give you medicine or blood without checking your ID bracelet. PROVIDENCE HOSPITAL Created: 02/08/10 The goal of the Joint Commission Speak Up program is to help patients become more informed and involved in their health care. Date Printed: nsg00029

21 PROVIDENCE HOSPITAL PNEUMOCOCCAL POLYSACCHARIDE VACCINE WHAT YOU NEED TO KNOW Many Vaccine Information Statements are available in Spanish and other languages. See 1 Pneumococcal disease Pneumococcal disease is caused by Streptococcus pneumoniae bacteria. It is a leading cause of vaccine preventable illness and death in the United States. Anyone can get pneumococcal disease, but some people are at greater risk than others: People 65 years and older The very young People with certain health problems People with a weakened immune system Smokers Pneumococcal disease can lead to serious infections of the: Lungs (pneumonia), Blood (bacteremia), and Covering of the brain (meningitis). Pneumococcal pneumonia kills about 1 out of 20 people who get it. Bacteremia kills about 1 person in 5, and meningitis about 3 people in 10. People with the health problems described in Section 3 of this statement may be more likely to die from the disease. 2 Pneumococcal polysaccharide vaccine (PPSV) Treatment of pneumococcal infections with penicillin and other drugs used to be more effective. But some strains of the disease have become resistant to these drugs. This makes prevention of the disease, through vaccination, even more important. Pneumococcal polysaccharide vaccine (PPSV) protects against 23 types of pneumococcal bacteria, including those most likely to cause serious disease. Most healthy adults who get the vaccine develop protection to most or all of these types within 2 to 3 weeks of getting the shot. Very old people, children under 2 years of age, and people with some long term illnesses might not respond as well, or at all. Another type of pneumococcal vaccine (pneumococcal conjugate vaccine, or PCV) is routinely recommended for children younger than 5 years of age. PCV is described in a separate Vaccine Information Statement. 3 Who should get PPSV? All adults 65 years of age and older. Anyone 2 through 64 years of age who has a long term health problem such as: heart disease lung disease sickle cell disease diabetes alcoholism cirrhosis leaks of cerebrospinal fluid or cochlear implant Anyone 2 through 64 years of age who has a disease or condition that lowers the body s resistance to infection, such as: Hodgkin s disease lymphoma or leukemia kidney failure multiple myeloma nephrotic syndrome HIV infection or AIDS damaged spleen, or no spleen organ transplant Anyone 2 through 64 years of age who is taking a drug or treatment that lowers the body s resistance to infection, such as: long term steroids certain cancer drugs radiation therapy Any adult 19 through 64 years of age who: is a smoker has asthma PPSV may be less effective for some people, especially those with lower resistance to infection. NSG00187pg1

22 PROVIDENCE HOSPITAL But these people should still be vaccinated, because they are more likely to have serious complications if they get pneumococcal disease. Children who often get ear infections, sinus infections, or other upper respiratory diseases, but who are otherwise healthy, do not need to get PPSV because it is not effective against those conditions. 4 How many doses of PPSV are needed, and when? Usually only one dose of PPSV is needed, but under some circumstances a second dose may be given. A second dose is recommended for people 65 years and older who got their first dose when they were younger than 65 and it has been 5 or more years since the first dose. A second dose is recommended for people 2 through 64 years of age who: have a damaged spleen or no spleen have sickle cell disease have HIV infection or AIDS have cancer, leukemia, lymphoma, multiple myeloma have nephrotic syndrome have had an organ or bone marrow transplant are taking medication that lowers immunity (such as chemotherapy or long term steroids) When a second dose is given, it should be given 5 years after the first dose. 5 Some people should not get PPSV or should wait Anyone who has had a life threatening allergic reaction to PPSV should not get another dose. Anyone who has a severe allergy to any component of a vaccine should not get that vaccine. Tell your provider if you have any severe allergies. Anyone who is moderately or severely ill when the shot is scheduled may be asked to wait until they recover before getting the vaccine. Someone with a mild illness can usually be vaccinated. While there is no evidence that PPSV is harmful to either a pregnant woman or to her fetus, as a precaution, women with conditions that put them at risk for pneumoccoccal disease should be vaccinated before becoming pregnant, if possible. 6 Who should get PPSV? About half of people who get PPSV have mild side effects, such as redness or pain where the shot is given. Less than 1% develop a fever, muscle aches, or more severe local reactions. A vaccine, like any medicine, could cause a serious reaction. But the risk of a vaccine causing serious harm, or death, is extremely small. 7 What if there is a severe reaction? What should I look for? Any unusual condition, such as a high fever or behavior changes. Signs of a severe allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heart beat or dizziness. What should I do? Call a doctor, or get the person to a doctor right away. Tell the doctor what happened, the date and time it happened, and when the vaccination was given. Ask your provider to report the reaction by filing a Vaccine Adverse Event Reporting System (VAERS) form. Or you can file this report through the VAERS website at or by calling VAERS does not provide medical advise. 8 How can I learn more? Ask your provider. They can give you the vaccine package insert or suggest other sources of information. Call your local or state health department. Contact the Centers for Disease Control and Prevention (CDC): Call (1 800 CDC INFO) or Visit CDC s website at Department of Health and Human Services Centers for Disease Control and Prevention PPSV (10/6/09) Vaccine Information Statement NSG00187pg2

23 PROVIDENCE HOSPITAL Influenza Vaccine What You Need to Know VACCINE INFORMATION STATEMENT (Flu Vaccine, Inactivated or Recombinant) Many Vaccine Information Statements are available in Spanish and other Languages. See Hojas de Informacion Sobre Vacunas estan disponibles en Espanol y en muchos otros idiomas. Visite 1 Why get vaccinated? Influenza ("flu") is a contagious disease that spreads around the United States every year, usually between October and May. Flu is caused by influenza viruses, and is spread mainly by coughing, sneezing, and close contact. Anyone can get flu. Flu strikes suddenly and can last several days. Symptoms vary by age, but can include: fever/chills sore throat muscle aches fatigue cough headache runny or stuffy nose Flu can also lead to pneumonia and blood infections, and cause diarrhea and seizures in children. If you have a medical condition, such as heart or lung disease, flu can make it worse. Flu is more dangerous for some people. Infants and young children, people 65 years of age and older, pregnant women, and people with certain health conditions or a weakened immune system are at greatest risk. Each year thousands of people in the United States die from flu, and many more are hospitalized. Flu vaccine can: keep you from getting flu, make flu less severe if you do get it, and keep you from spreading flu to your family and other people. 2 Inactivated and recombinant flu vaccine A dose of flu vaccine is recommended every flu season. Children 6 months through 8 years of age may need two doses during the same flu season. Everyone else needs only one dose each flu season. Some inactivated flu vaccines contain a very small amount of a mercury based preservative called thimerosal. Studies have not shown thimerosal in vaccines to be harmful, but flu vaccines that do not contain thimerosal are available. There is no live flu virus in flu shots. They cannot cause the flu. There are many flu viruses, and they are always changing. Each year a new flu vaccine is made to protect against three or four viruses that are likely to cause disease in the upcoming flu season. But even when the vaccine doesn t exactly match these viruses, it may still provide some protection. Flu vaccine cannot prevent: flu that is caused by a virus not covered by the vaccine, or illnesses that look like flu but are not. It takes about 2 weeks for protection to develop after vaccination, and protection lasts through the flu season. 3 Some people should not get this vaccine Tell the person who gives you the vaccine: If you have any severe (life threatening) allergies. If you ever had a life threatening allergic reaction after a dose of flu vaccine, or have a severe allergy to any part of this vaccine, you may be advised not to get vaccinated. Most, but not all, types of flu vaccine contain a small of amount of egg protein. If you ever had Guillain Barre Syndrome (also called GBS). Some people with a history of GBS should not get this vaccine. This should be discussed with your doctor. If you are not feeling well. It is usually okay to get flu vaccine when you have a mild illness, but you might be asked to to come back when you feel better. NSG00188pg1

24 4 Risks of a vaccine reaction With any medicine, including vaccines, there is a chance of reactions. These are usually mild and go away on their own, but serious reactions are also possible. Most people who get a flu shot do not have any problems with it. Minor problems following a flu shot include: soreness, redness, or swelling where the shot was given hoarseness sore, red or itchy eyes cough fever aches headache itching fatigue If these problems occur, they usually begin soon after the shot and last 1 or 2 days. More serious problems following a flu shot can include the following: There may be a small increased risk of Guillain Barre Syndrome (GBS) after inactivated flu vaccine. This risk has been estimated at 1 or 2 additional cases per million people vaccinated. This is much lower than the risk of severe complications from flu, which can be prevented by flu vaccine. Young children who get the flu shot along with pneumococcal vaccine (PCV13) and/or DTaP vaccine at the same time might be slightly more likely to have a seizure caused by fever. Ask your doctor for more information. Tell your doctor if a child who is getting flu vaccine has ever had a seizure. Problems that could happen after any injected vaccine: People sometimes faint after a medical procedure, including vaccination. Sittiing or lying down for about 15 minutes can help prevent fainting, and injuries caused by a fall. Tell your docotor if you feel dizzy, or have vision changes or ringing in the ears. Some people get severe pain in the shoulder and have difficulty moving the arm where a shot was given. This happens very rarely. Any medication can cause a severe allergic reaction. Such reactions from a vaccine are very rare, estimated at about 1 in a million doses, and would happen within a few minutes to a few hours after the vaccination. As with any medicine, there is a very remote chance of a vaccine causing a serious injury or death. The safety of vaccines is always being monitored. For more information, visit: www. cdc.gov/vaccinesafety/ Dev 11/2010 Rev 9/ What if there is a serious reaction? What should I look for? Look for anything that concerns you, such as signs of a severe allergic reaction, very high fever, or unusual behavior. Signs of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness. These would start a few minutes to a few hours after the vaccination. What should I do? If you think it is a severe allergic reaction or other emergency that can t wait, call and get the person to the nearest hospital. Otherwise, call your doctor. Reactions should be reported to the Vaccine Adverse Event Reporting System (VAERS). Your doctor should file this report, or you can do it yourself through the VAERS web site at or by calling VAERS does not give medical advice. 6 The National Vaccine Injury Compensation Program The National Vaccine Injury Compensation Program (VICP) is a federal program that was created to compensate people who may have been injured by certain vaccines. People who believe they may have been injured by a vaccine can learn about the program and about filing a claim by calling , or visiting the VICP website at There is a time limit to file a claim for compensation. 7 How can I learn more? Ask your healthcare provider. He or she can give you the vaccine package insert or suggest other sources of information. Call your local or state health department. Contact the Centers for Disease Control and Prevention (CDC): Call (1 800 CDC INFO) or Visit CDC s website at U.S. DEPARTMENT OF HEALTH &HUMAN SERVICES Center for Disease Control and Prevention National Immunization Program Vaccine Information Statement Inactivated Influenza Vaccine (8/07/2015) 42 U.S.C. 300aa 26 NSG00188pg2