Nursing Assessment Protocols


Nursing assessment protocols are used quite frequently in jails, prisons and juvenile detention facilities across the country as a tool to guide nurses in the assessment of patients. Standard E-8 (E-11 in the Juvenile Standards manual) provides guidance for the proper use of these protocols, which are defined as written instructions or guidelines that specify the steps to be taken in evaluating a patient’s health status that guide documentation in the health record. 

Protocols may include acceptable first-aid procedures for the identification and care of ailments that would ordinarily be treated with over-the-counter medicine or through self-care. They may also address more serious symptoms such as chest pain or shortness of breath. Protocols specify a sequence of steps to be taken to evaluate and stabilize the patient until a clinician is contacted and orders are received for further care.

Management of Nursing Assessment Protocols
Once developed, protocols must be reviewed annually by the nursing administrator and responsible physician. A signed and dated declaration by both parties is often used to deocument that this review has been completed. When protocols are changed, they must be individually signed and dated by the nursing administrator and responsible physician.

Nurses must be trained in the use of protocols during orientation and when protocols are introduced or revised. The training must include a demonstration of a nurse’s knowledge and skills in protocol use. There must also be an annual review of competency and skills for all nurses who use the protocols. The annual review is intended to be more than a staff in-service where all protocols are reviewed and staff sign in to show proof of attendance. Rather, the annual review is to be an individual evaluation of a nurse’s skill and competency in use of the protocols. Individual evaluations may be accomplished by the administration of written tests, documentation review and/or demonstration of knowledge and skills. The annual review must also be documented and kept on file for each nurse.

Pushing the Limits
Although the Nursing Assessment Protocols and Procedures Standard clearly defines how nursing assessment protocols should be used, the environment of correctional health care sometimes lends itself to their misuse. One example would be to permit nonhealth staff to use the protocols. Nursing assessment protocols are meant for nurses and must be appropriate to the level of skill and preparation of the nursing personnel who will carry them out. They must also comply with relevant state practice acts, including those applicable to scope of practice. They are not meant to be used by custody staff or child care workers in the absence of nurses.

Another common misuse of nursing assessment protocols is the inclusion of standing orders, which are written instructions that specify the same course of treatment for each patient suspected of having a given condition and that specify the use and amount of prescription drugs. For example, all patients who present at sick call with a suspected ear infection are given the same antibiotic without consulting a provider. Often these standing orders include a blanket statement to call a provider before initiating the treatment, but this practice may lead to nurses using the standing orders freely, without consulting a provider first. This potentially places nurses in a situation where they are acting beyond their scope of practice. Treatment with prescription medication should be initiated only on the written or oral order of a licensed clinician.

This standard does permit the use of prescription medication such as nitroglycerin or epinephrine in emergency, life-threatening situations. The types of emergency medications to include in nursing assessment protocols is a decision that must be made by the facility’s responsible physician, and the assessment protocols should clearly outline the findings that could lead to the administration of emergency medication. The assessment protocols pertaining to emergency life-threatening conditions must include immediate communication with a provider. A subsequent clinician’s order is required when emergency medication is used.

Finally, standing orders may also be used for preventive medicine practices such as immunizations, as determined by the responsible physician. 

It is important to note that treatment protocols or algorithms used by providers are not addressed in this standard. (See Standards F-01 Patients with Chronic Disease and Other Special Needs and F-04 Medically Supervised Withdrawal and Treatments.)

The intent of standard E-8 is to ensure that nurses who provide clinical services are trained to do so under specific guidelines. When used properly, nursing assessment protocols can be very helpful in the clinical management of patients.


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