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GUIDELINES FOR NURSING PRACTICE

Nursing department IGMH 2006

CONTENTS
FOREWORD......................................................................................................8 SECTION ONE.................................................................................................10 GENERAL GUIDELINES...............................................................................10 ADMISSION.....................................................................................................10 KNOW YOUR PATIENT................................................................................11 RECORDING OF VITAL SIGNS..................................................................12 ADMINISTRATION OF MEDICATION......................................................13 INTAKE & OUTPUT.......................................................................................15 COMMUNICATION........................................................................................16 PRE-OPERATIVE MANAGEMENT............................................................17 POST OPERATIVE MANAGEMENT........................................................18 DOCUMENTATION........................................................................................19 Telephone/ verbal order guideline:.................................................................22 TRANSFERING PATIENTS..........................................................................23 DISCHARGE....................................................................................................24 LEAVING AGINST MEDICAL ADVICE....................................................25 DEATH CARE..................................................................................................26 CARE OF DEAD FOETUS/ BABY................................................................27 FILLING DEATH FORMS AND DELIVERY FORMS..............................28 VACCINATION...............................................................................................28 APPENDIX-A / ORIENTATION ON ADMISSION....................................29 APPENDIX- B / PATIENTS RECORD /CHART ARRANGEMENT......30 APPENDIX C / FILLING DEATH FORMS AND DELIVERY FORMS ............................................................................................................................32 APPENDIX D -CHECKLIST FOR WARD SISTERS..............................33 SECTION TWO................................................................................................38

WARD SPECIFIC GUIDELINES..................................................................38 DAILY TASKS OF NURSES OF PRIVATE WARDS.................................38 DAILY TASKS OF PEDIATRIC WARD NURSES.....................................43 DAILY TASKS OF MEDICAL WARD NURSES........................................51 DAILY TASKS OF GYNAE WARD NURSES.............................................57 DAILY TASKS OF ENT WARD NURSES...................................................63 SHIFT ROUTINES FOR SURGICAL WARD NURSES.............................68 DAILY TASKS OF ISOLATION WARD NURSES.....................................73 DAILY TASKS OF ACCIDENTS AND EMERGENCY DEPARTMENT NURSES ............................................................................................................79 DAILY TASK OF ICCU NURSES.................................................................82 DAILY TASKS OF O.P.D NURSES...............................................................99 DAILY TASK FOR STAFF WORKING IN THE DIALYSIS UNIT.......101 THEATRE GUIDELINES.............................................................................105
THEATRE LISTS..............................................................................................................105 PREPARATION OF THE THEATER..............................................................................106 POINTS TO BE REMEMBERED BY THE SCRUB NURSE AND THE CIRCULATING / FLOOR NURSE..................................................................................108 PROTOCOLS TO BE FOLLOWED IN THE OPERATING ROOMS............................109 PROTOCOLS TO BE FOLLOWED WHILE IN OPERATION THEATRE COMPLEX ............................................................................................................................................110 ROUTINE CLEANING OF OPERATION THEATRE....................................................111 DAILY TASKS OF NURSES WORKING IN OPERATION THEATRE.......................112 DAILY TASKS OF ATTENDANTS WORKING IN OPERATION THEATRE............115

Acknowledgement...........................................................................................120 ADMISSION PROTOCOL FOR LABOUR PATIENTS...........................121 ON GOING CARE DURING FIRST STAGE OF LABOUR....................123 CARE OF PATIENTS WITH FOETAL DISTRESS.................................127 CARE OF PATIENTS WITH PREVIOUS LSCS IN LABOUR...............128 CARE OF PATIENT DURING SECOND STAGE OF LABOUR............129

ASSISTING A VACUUM DELIVERY........................................................134 MANAGEMENT OF THIRD STAGE OF LABOUR................................135 EXPECTANT MANAGEMENT OF THIRD STAGE: (IS NOT ENCOURAGED)............................................................................................136 RETAINED PLACENTA..............................................................................136 MANUAL REMOVAL OF PLACENTA.....................................................137 MANAGEMENT OF FOURTH STAGE OF LABOUR............................138 MANAGEMENT OF PPH.............................................................................139 PERFORMING AN EPISIOTOMY.............................................................140 REPAIR OF AN EPISIOTOMY...................................................................142 CARE OF NEW BORN.................................................................................143 NEONATAL RESUSCITATION..................................................................145
Preparation for delivery......................................................................................................145 Post resuscitation: ..............................................................................................................146

TRANSFERRING NEWBORN BABIES TO NURSERY..........................146 NURSING CARE OF PATIENTS WITH ANTE PARTUM HEMORRHAGE............................................................................................147 MANAGEMENT OF PATIENTS WITH PIH IN LABOUR.....................147 USE OF MAGNESIUM SULPHATE FOR PRE- ECLAMPSIA AND ECLAMPSIA..................................................................................................149 CARE OF PATIENTS WITH MALPRESENTATIONS...........................151 MANAGEMENT OF CORD PROLAPSE...................................................152 ADMINISTRATION OF OXYTOCIN FOR INDUCTION AND AUGMENTATION OF LABOUR................................................................153 CERVIPRIME INSTILLATION FOR INDUCTION OF LABOUR.......154 EXTRA AMNIOTIC SALINE INSTILLATION........................................155 CARE OF PATIENTS WITH INFECTIOUS DISEASE IN LABOUR....156 INFECTION CONTROL PRACTICES IN LABOUR ROOM.................158 CARE OF THE PATIENT AFTER ABORTION.......................................160

ROUTINE INVESTIGATION CHECKLIST.............................................162 Admission checklist.........................................................................................164 Emergency Pre- operative checklist .............................................................165 Documentation checklist................................................................................166 APPENDIX A: PATIENT UNIT PREPARATION....................................168
For first stage of labour: ....................................................................................................168 For second stage of labour:................................................................................................168 For Severe PIH / eclampsia: ..............................................................................................169

APPENDIX B / ORIENTATION TO LABOUR ROOM...........................170 APPENDIX C: ARTICLES/ EQUIPMENTS NEEDED FOR PROCEDURES PERFORMED IN LABOUR ROOM...............................171
Normal delivery: ...............................................................................................................171 Equipments needed for resuscitation in delivery room: ....................................................172 Medications needed for new born resuscitation:...............................................................172 Urinary Catheterization:.....................................................................................................173 Cerviprime instillation: .....................................................................................................173 Culdocentesis:....................................................................................................................173 Extra amniotic saline instillation: ......................................................................................174 Episiotomy suturing:..........................................................................................................175 Dilatation and curettage (D & C):......................................................................................175

APPENDIX D: CHECK LIST FOR WARD SISTER / WARD INCHARGE ..........................................................................................................................176 (LABOUR ROOM).........................................................................................176 APPENDIX E: RESPONSIBILITIES OF SHIFT IN-CHARGES (LABOUR ROOM) ........................................................................................180 APPENDIX F: DAILY TASKS OF NURSES WORKING IN LABOUR ROOM..............................................................................................................181 APPENDIX G: DAILY TASKS OF ATTENDANTS WORKING IN LABOUR ROOM...........................................................................................187 RHC-ROUTINES...........................................................................................193
Charging.............................................................................................................................193 5

Appointments.....................................................................................................................193 Patients who come with leaking PV, Bleeding PV, and pain abdomen.............................193 ANC registration for new clients.......................................................................................193 Registration Memo.............................................................................................................193 Investigation reports...........................................................................................................194 High Risk Pregnancies.......................................................................................................194 Family Planning Items.......................................................................................................194 NST....................................................................................................................................194 Foetal distress.....................................................................................................................195 Serum Billirubim................................................................................................................195 Urine Albumin,..................................................................................................................195 Writing nurses notes...........................................................................................................195 Vaccines.............................................................................................................................195 Ward Visits.........................................................................................................................196 Health Education................................................................................................................196 Points to be highlighted during registration for family planning.......................................196 Maintenance of Records.....................................................................................................197 Antenatal exercise .............................................................................................................197 Pelvic assessment...............................................................................................................197

QUALITY & MAINTENANCE OF WORK & WORKING ENVIRONMENT............................................................................................198


ANTENATAL CLINIC.....................................................................................................198 Breastfeeding forum...........................................................................................................198 Labour & Labour room orientation forum.........................................................................199 New born care forum..........................................................................................................199 Maintenance of Inj. Tetanus stock & record......................................................................199 ANTENATAL HIGH RISK CLINIC................................................................................200 High risk clients follow up visit.......................................................................................200 Antenatal exercise..............................................................................................................200 POSTNATAL CLINIC......................................................................................................201 FAMILY PLANNING CLINIC.........................................................................................202 WELL WOMEN CLINIC..................................................................................................203 ADOLSCENT HEALTH CLINIC.....................................................................................203

MAINTENACE OF ANTENATAL LEAFLETS.............................................................204 MAINTENACE OF POSTNATAL LEAFLETS..............................................................204 MAINTENANCE OF MODELS.......................................................................................204 MAINTENANCE OF WARD VISIT RECORDS............................................................204 SUPERVISION OF INVENTORY...................................................................................205 SUPERVISION OF RECEPTION.....................................................................................205 MAINTENANCE OF LIBRARY......................................................................................205 CLEANLINESS & ARRANGEMENT OF COMSULTATION ROOMS.......................205 CLEANLINESS & ARRANGEMENT OF REGISTRATION ROOM............................206 CLEANLINESS & ARRANGEMENT OF HEALTH EDUCATION ROOM.................206 CLEANLINESS & ARRANGEMENT OF HEALTH EDUCATION ROOM.................206 CLEANLINESS & ARRANGEMENT OF VACCINE ROOM.......................................206 CLEANLINESS & ARRANGEMENT OF TREATMENT ROOM.................................206 CLEANLINESS & ARRANGEMENT OF COUNSELLING ROOM.............................207 CLEANLINESS & ARRANGEMENT OF DEMONSTRATION ROOM.......................207 CLEANLINESS & ARRANGEMENT OF STORE ROOM............................................207

INFECTION CONTROLL GUIDELINE FOR RHC STAFF...................207 INSTRUCTIONS FOR TRAY PACKING..................................................211 UNIVERSAL PRECAUTION.......................................................................212 SHARP DISPOSAL........................................................................................213 WASTE DISPOSAL.......................................................................................213 LINEN..............................................................................................................213 BLOOD/ VOMITUS/ OTHER BODY FLUIDS..........................................214 RECEIVING A CLIENT WITH A COMMUNICABLE DISEASE.........214 SHIFT ROUTINES FOR RHC NURSES....................................................214 SHIFT ROUTINES FOR CLINICAL ASSISTANTS.................................219
RECEPTIONISTS..............................................................................................................220

FOREWORD
Improving & strengthening nursing care is an element of nursing profession. Nursing department is proud to produce a Manual of Practical Guidelines to be used by the nurses of IGMH. These guidelines are developed mainly aiming to standardize & improve the quality of nursing care. Most of the procedures, protocols, & standards included in these guidelines are already in practice. However, these guidelines will help in standardizing the practice of these procedures in all the areas of the hospital. Nursing Department greatly acknowledges the contribution of all nurses who were involved in developing these Guidelines. I am sure these guidelines will serve as a valuable reference manual for all the nurses and students working in IGMH.

Aminath Saeed Firaq Director of Nursing Nursing Department

SECTION ONE

GENERAL GUIDELINES

ADMISSION
1. 2. 3. Make the unit ready with all the necessary equipments depending on the condition / type of patient. Receive & greet the patient with a warm welcoming smile. Check the patients folder for correct name, address (temporary & permanent), treating doctor, date & time of admission, and details (name, address, contact number) of the guardian or relative. 4. 5. Call him/her by name and introduce yourself in a pleasant manner. Check doctors orders, prioritize and implement care accordingly. e.g.: a) Carry out emergency orders immediately.

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b) c) 6.

Make necessary arrangements to do urgent investigations. When necessary give special instructions such as NPO, bed rest, without delay.

Check all necessary documents. All admissions should have the following documents. a) b) c) Admission slip / Doctors prescriptions Nurses notes/observation chart /treatment chart (casualty admissions) Other documents if any e.g. Referral letters

7. 8.

Take a detail report if the patient is accompanied by a nurse. Assess the patient: a) b) c) d) e) Observe for conditions such as restless, confused, level of consciousness etc. Record Bp, pulse, respirations and check weight. Check FHS for obstetric patients. Take history of present complaint, past medical and surgical problems, ongoing treatment if any, and other relevant histories. Take obstetric and gynea history for relevant conditions.

9. 10. 11. 12. 13. 14.

Inform the medical officer or consultant. Enter the admission in the daily census & relevant registers. Orient the patient and relatives to the ward / room and hospital (refer Appendix-A). Inform about the necessary items required during the hospital stay. Instruct the relative / patient to be responsible for their own valuable items such as money and mobile phones. Inform coordinator about critically ill patients.

KNOW YOUR PATIENT


All nurses should know the following information of all patients under their care. 1. 2. 3. 4. 5. 6. 7. 8. Identification (name, age, sex, bed number, address, diagnosis (provisional & final). Past & present medical / surgical /obstetric & gynaecological history. Status such as allergies, G6PD & chronic problems. Stability of vital signs & investigation reports General condition, present complaints & prognosis of illness. Treating & other referral doctors. Previous & ongoing treatment as well as response to medications. Type of diet required.

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9. 10. 11. 12.

Urinary & bowel habits. Mobility (walking, walk with support, wheel chair, stretcher) Position to be maintained ( e.g. lateral/supine position, leg or arm elevation etc) Socio-economic status (e.g. family support, welfare assistance etc)

RECORDING OF VITAL SIGNS


1. Record vital signs every 4th hourly for all the patients & then according to the condition & necessity. 2. Follow the standard procedure for checking the vital signs, (Refer the procedure manual). 3. Take immediate actions & inform the doctor for any deviations from normal. 4. Record of vital signs under special conditions: e.g. - Before administering indicated drugs such as antihypertensive drugs, digoxin etc

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- Before performing certain procedures such as blood transfusion, before transferring the patient to the theater, endoscopy or any other major invasive procedures. 5. Document vital signs correctly and legibly in the appropriate charts in time.

ADMINISTRATION OF MEDICATION
1. Right Patient: 1. Check the patient by name, age, address and bed number. 2. Check the patient if he/she is ready or in a stable condition to receive the particular prescribed medicine. E.g. condition of vital signs, food intake, bowel movements, urine output etc 2. Right Medicine: *Check the name, dosage, route, & expiry date

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1. Check & compare the prescribed medication order in the folder (name, dosage, route & timings) and the treatment chart. 2. Check & compare the medicine (name, dosage, and route & expiry date) & the written order. 3. Clarify from the concerned doctor in any doubtful situation. 3. Right Dose: 1. Check & take or prepare the right dose of medicine. 2. Get counter checked by another nurse for indicated drugs such as insulin & narcotics etc. 3. Prepare the medication according to the instructions e.g. correct dilution, aseptic technique etc. 4. Always label the IV fluids prepared with other medications, with the added drugs name, amount, dosage, date & time. 4. Right Route 1. Check the advised route of medication. 2. Check the site IV / IM / SC, eye, ear, skin, tubings etc, for condition & patency to administer the drug. 5. Right Time: 1. Check the time & timings for medication. 2. Check the time of last dose of the particular medicine administered. 3. All medications to be administered in time.

After Medication Administration: 1. Check relevant Vital signs for indicated drugs. 2. Observe the condition & immediate response to drug. If unusual symptoms are observed check vital signs. 3. When needed give necessary instructions to the patient about the desired action of the drug and its possible side effects. Eg. Drowsines s/ sleepiness after narcotic administration Symptoms of hypoglycemia after insulin dose. Urine out put after diuretics. Etc. 4. Provide immediate care & inform to the doctor for any adverse side affects. 14

5. Document & sign in the appropriate charts /record books accurately & clearly in time. 6. Replace & store the balance (if any) medicine properly labeled with name, dosage, date and time of use (if required). Points to Remember: 1. All prescription must be written by the doctors. 2. Check the name, age, and sex and bed number before handing over a prescription. 3. Explain to the relative/patient when handing over the prescription to buy the medicine. 4. Check the prescription & medicine after receiving them. 5. All medications must be taken by the patient in the presence of a nurse. Do not leave the medicine at bedside for the patient to take at a later time. 6. Avoid administering medications prepared or taken by another nurse. 7. Hand over the balance prepared medication to the next shift nurses. 8. All medication errors of any kind must be reported to the senior nurse & the doctor in the shift. 9. All medication errors must be written in detail in the incident book & reported to the ward in charge.

INTAKE & OUTPUT


1. Maintain Intake /Output chart for all indicated patients from 7.00am to 7.00am. 2. Explain & instruct the patient and relatives about maintaining intake & output chart. 3. Provide a graduated measuring cup & a measuring jar to all necessary patients. 4. Intake should include the total amount of oral intake (foods/fluids) and parental infusions. 5. Out put should include the total amount of urine passed, aspirations, vomitus and drainages along with the total number of bowel movements. 6. Observe or ask & record the total amount, color, & consistency of output. 7. All the measurements should be seen by a nurse. 8. Take action for any abnormal observations/measurement. 15

e.g. heamaturia, hematemisis, Poor oral intake, less urine out put, constipation, loose motion etc. 9. Record the intake & output in time & complete at the end of each shift. 10. Calculate the total Intake and Output /24hours at the end of night shift.

COMMUNICATION
Nurse - Patient
1. In each shift after taking over visit all the patients. 2. Greet, smile, address by name & introduce yourself. Enquire how he/she is feeling or doing. Enquire about pain, sleep, diet, bowel movements or whatsoever related to his /her problems. 3. Explain the condition (progress / deterioration) during the doctors rounds. 4. In high risk cases keep a written record of the explanations provided for the patient/ relatives. 5. Explain to the patient and relatives about starting /discontinuing / withholding any treatment. 16

6. Explain prior to performing each procedure / investigation. 7. Communicate with patient and provide health education according to their needs (time can be given while performing procedures). 8. Explain any delay in carrying out an expected procedure e.g. cleaning, bath, handing over the discharge summery etc.

Nurses & other members of the health care team


1. Respect each other & other members of the health care team. 2. Acknowledge & greet to each other & other senior members of the team. 3. Conversations should be polite, understanding & professional. 4. Do not use mobile phones & do not share personal conversations at the time of patient care and during the ward rounds 5. Follow the telephone manners during telephone conversations. 6. Resolve conflicts according to the protocols.. 7. Help each other & other wards when they are in need.

PRE-OPERATIVE MANAGEMENT
1. Check patients identity (name, age, sex, address, bed/room number) 2. Check the type & nature of posted surgery 3. Check if instructions of anesthetists and surgeons instructions are carried out 4. Recheck validity of consent & signature by the relative/guardian 5. Check investigation results & informed to the concerned people 6. Instruct & explain the importance of the concerned relative/guardian to stay near by the theatre throughout the surgery. 7. Enquire about the donor & instruct the donor should be available in the hospital (in front of theatre) at the time of surgery

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8. Check if any of the medication of ongoing treatment to be administered before shifting to Theater. 9. Check patient preparation for surgery Skin or part preparation, Fasting status Bowel /preparation & results Pre medication Catheterization, IV cannula or IV fluids (if required) Changing clothes & removing jewelries, nail polish etc. Removal of dentures, contact lenses or other appliances that needs to be removed. Personal hygiene (bath taken /sponge given) 10 Make sure if bladder is emptied just before shifting to the theater 11. Check vital signs 12. Complete all documents

POST OPERATIVE MANAGEMENT


1. Prepare the unit according to the type of case to be received. 2. At the time of taking over from the OT nurse check the following. Level of consciousness Operation site Post-operative orders (surgeons & anesthetist) 3. After transferring the patient to the unit, carry out the following Position the patient according to the instructions. Position & secure the drainages, catheters, IV fluids etc. 4. Check vital signs once in every 15 minutes for 1 hour, if stable for half hourly for 2 hours, & then routinely. 18

5. Explain the condition & provide necessary instruction to the relatives. NPO hours, Maintenance of patient position & mobility. Purpose of catheters, drainages etc. 6. Observe & take actions for any possible complications & inform the doctor. 7. Prioritize & carry out orders.

DOCUMENTATION
Nursing documentation should have the following principles: Principle 1: Nursing documentation is aimed at serving the interests of the

patients.
The record should contain relevant and patient focused information only. Nursing records should not be used as a forum for criticizing other professionals nor should it be used as route for complaints. Avoid bias and describe observations of behavior rather than labeling the patient. (E.g. Instead of writing as patient being uncooperative document the exact behavior of the patient).

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Principles 2: Frequency of documentation: Frequency of documentation is ultimately a professional judgment. The frequency of entries depends on several factors. These include The physical and mental condition of the patient The method of documentation used by the organization Any other obligations (legal or other wise) that the health record must fulfill.

Nursing documentation should contain the initial assessment of the patient when taking over as well as the assessment done before handing over In circumstances where a client is in unstable health, it is necessary to document more frequently than in circumstances where the client is more stable condition.

Principle 3: The documentation records events chronologically and in a timely

manner.
Entries should be chronological sequence, with time, date, name, signature and designation of the staff. All entries must be made as close as possible to the care or treatment provided. Waiting until the end of a shift to write the report should be avoided as it increases the possibility of errors and omissions. Documentation should never be done ahead of time. While using electronic monitors and if the time on the printouts is not the exact time, make sure that the correct time is written on the printouts. Space should not be left in a clients record for documentation to be completed at a later time.

Principle 4: The documentation should be factual, concise, legible, and up to date.


All entries should be brief, complete and clear-cut. All entries should be made in black or blue ink and any blank areas must be ruled out. All the entries must include a date, time of documentation. A person making any documentation in a patient record must be identified. Therefore all entries in the health records including signatures should be legible. Nurses should enter their name (not the initials) and designation clearly in the space provided for the purpose. 20

When writing drug doses, as a legibility caution use leading zeros for decimals (e.g. 0.5 units of syntocinon) and avoid terminal zeros (e.g. do not write 10 units of syntocinon instead of 1 unit).

The most common reason for drug errors is illegible or questionable handwriting. Therefore, to avoid errors care should be taken to write neatly and to avoid spelling mistakes. Grammar and cleanliness are also worthwhile.

Duplication of information should be avoided. It is not necessary to repeat information that is recorded else where in the patients health record. (E.g. when medications are entered in the treatment sheet it need not be repeated in the nurses notes).

Document specific information: Dont state, Patients condition informed to doctor. Document exactly what was informed to the doctor? Avoid use of generalized phrases such as wound improved. State in objective terms: size, drainage odour.

Principle 5: Errors should be corrected accurately.


Correct errors openly and honestly. The content in question must remain visible so Errors should be corrected by drawing a line through the incorrect information. But the time, date and signature of the person altering the record should be clearly written. It is also advisable to record the reason for alteration. Correcting, modifying or altering someone elses document is illegal and is considered as professional misconduct. Under no circumstance should correction ink be used or scribble over an entry or tear off an entry. This will be considered as tampering. Tampering: Tampering is not only the willful act of destroying the record. Crossing out incorrectly or wiping out information and squeezing a little information are also forms of tampering. Leaving blank lines can help the subsequent users to tamper the records by altering them. Therefore a line should be drawn through empty spaces. that the purpose of correction is understood.

Principle 6: The documentation should be in an approved format.


Nurses should ensure that the documentation is done in a language approved by the organization. Ensure that patients name and inpatient number is written in all forms.

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Internationally acceptable abbreviations should be used in the document and no abbreviation should be used unless it has a clear meaning. All entries must be signed. A () mark indicates correct or right and it cannot be considered acceptable as a substitute for a signature. Each entry must begin with a date, time and should end with a signature, name and title.

Principle 7: The documentation should contain entries recorded by the individual nurse who provided the care.

Nurses should not document on behalf of others. All persons who provide care for the patient should make entries of their observations and interventions in the records.

Principle 8: documentation should demonstrate that the nurse has fulfilled her duty of care to the patient.
All care, advice and any specific nursing management plans should be documented clearly. Any refusal for treatment or advice should be noted.

Late entries:
Late entries can be done for information that was not recorded in a timely fashion and if omission of the information would impact the care. following needs to be documented: current date/time entry for date and time of happening Signature/name e.g. 2/3/2006, 9 a.m. late entry for March 1, 2006, 10 a.m. A late entry must be made within 24 hours with the authorization from the ward incharge. When a late entry is needed, the

Telephone/ verbal order guideline:


Clearly determine the clients name room/ bed number and diagnosis. Write down the order exactly as stated by the physician Repeat the prescribed orders back to the physician. 22

Use clarification questions to avoid misunderstanding Document in the nurses notes as a telephone order or a verbal order including date, time and name of the physician giving the order. Ensure that the physician writes the order in the patients folder later. Verbal orders should be double checked when appropriate. POINTS TO REMEMBER
Write nurses notes after taking over, in-between after care or performing a procedure and at the end of each shift. Record the attending doctors visit whenever the nurse sends a call or special visit done by the doctor Write the condition, complaints, progress and other observations E.g. after a wound dressing, write if the wound is healing, bleeding, not improving or other conditions of the wound observed during the procedure.

Do not write pending works, & investigations to be done in the nurses note, but pending works can be written and hand over to the next shift Recording should be done by the responsible nurse only Complete nurses notes & other records before leaving hospital/HC

TRANSFERING PATIENTS
While transferring patients from ward to ward or to other hospitals the following steps should be carried out. 1. Check fitness and doctors order for transfer. 2. Check and arrange a staff to accompany the patient if required. 3. Check if bed or room is available / ready with the necessary items or equipments. 4. Make transfer memo. 5. Complete & prepare all the records and other belongings. 6. Arrange means of transport. 7. Document in the census & and other registers. 8. Inform to the ward or to the concerned department / hospital (when possible) just before shifting 9. Continue IV & oxygen during the transfer if on flow. 10. Observe condition during the transfer.

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11. Provide a complete report (from the time of admission till date & time) to the receiving nurse and handover all the documents, medications, investigations such as scan, X-rays etc. 12. Inform to the patient, relatives, and to the respective ward if there is any delay.

DISCHARGE
When discharging a patient from the hospital ensure that the following steps are carried out. 1. Check discharge order. 2. Enquire if medical certificate is required. 3. Collect investigation results or result collecting slips. 4. Check the discharge summary for compete information (name age, address, diagnosis etc Check discharge summary for special information such as final diagnosis, treatment tubal ligations, IUFD, neonatal deaths etc. 5. Settle the payment. a) Write the date & time of discharge in the folder cover. b) Complete service notification including operation slips. c) Stamp discharge & mark the type of discharge.

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d) Hand over the folder cover to the concerned person after explaining to bring back the folder cover & the bill. e) Receive & enter the information to the concerned records (census & registers) 6. Discharge advice. a) Check the discharge medicine; label the drugs with the timings & dosage. b) Explain how to take drugs with proper instructions. c) Provide health education on diet, activity & exercise for all patients. d) Explain about exclusive breastfeeding for all breastfeeding mothers. e) Provide special information for clients like diabetes, hypertension, CRF, postoperative etc. f) Teach procedures like, dressing, cleaning, catheter care, sitz bath etc. g) Demonstrate & get return demonstration of procedures like Ryles tube feeding, Etc. This need to be done from the time of discharge planning. 7. Explain and handover discharge summary, investigations reports, x-rays, pending result collecting slips etc. 8. Explain about the follow up visits & appointments. 9. File the chart in order (refer Appendix B)

LEAVING AGINST MEDICAL ADVICE


1. Ensure if the risks of leaving against medial advice is clearly informed by the doctor. 2. Complete LAMA form, explains & take signature from the concerned relative or guardian. 3. Remove the appliance such as IV cannulas. 4. Complete bill settlements according to the discharge procedure. 5. Check the discharge summary if it indicates Leaving Against Medical Advice. 6. Check the discharge summary for the stated risks & brief them to the patient & relatives.

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DEATH CARE
1. Inform to the relatives / guardian immediately after death declaration (these information & explanation should be given by the concerned doctor). 2. Inform to the consultant, nurse coordinator, and to other concerned people. 3. Complete death form & hand over to the relatives/guardian to make necessary arrangements for funeral. 4. Provide brief information about the procedure to take the dead body home or cemetery. 5. Inform to the public relation coordinator & direct the relative /guardian to the public relation counter for further assistance & to arrange ambulance and for further assistance. 6. Handover the folder cover (after completing & stamping [death & discharge]) with service notification for bill settlement. Cleaning the dead body: 1. Inform to the relatives about cleaning the dead body 2. Remove the IV fluids and other tubing.

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3. A Maldivian nurse should guide or accompany during the cleaning procedure. Respect the religious and cultural values during the procedure. 4. Dead body must be handled carefully & provide special attention not to expose the dead body. 5. Clean the dead body & dress any wound. 6. Perform the procedure according to the procedure manual. Documentation: 1. Complete nurses notes, and other charts clearly with all the details of the process. 2. Document the details in the census, admission & death register. 3. Hand over the investigation reports & x-rays. 4. Order the file according to the chart arrangement protocols (refer Appendix B). Transferring the dead body 1. Confirm if ambulance is ready 2. Inform to public relation counter just before transferring. 3. A nurse should accompany to the ambulance.

CARE OF DEAD FOETUS/ BABY


Inform the mother and the relatives about the death as soon as possible. Death care should be given according to the Muslim tradition regardless of the gestational age. Clean the foetus/ baby gently with warm water and olive oil. If the baby is macerated give special attention as the skin may get peeled off while cleaning. If there is bleeding from the cord tie the cord with silk or any type of thread. Do not use a cord clamp. If possible the babys chin should be supported firmly with a bandage and the knot should be placed over the head. Fold the arms with the right hand over the left and keep over the abdomen. Tie on the wrist with a bandage. Put the legs together and tie over the ankle with a bandage. If there is excessive secretions plug the nostrils with cotton. Show the baby/ foetus to the mother and the relatives 27

Always cover the baby/foetus with a sheet and never expose the body unnecessarily. Fill delivery form and death form and hand over to the relatives (refer Appendix C). The relatives should be told to give a name to fetus and the name should be entered in the death form. When sex cannot be identified it should be taken as a male. Enter in the delivery register if the baby is more than 28 weeks of gestation and enter in the abortion register if less than 28 weeks. When the formalities for burying the baby is over and when transport is ready hand over the baby to the relatives (a nurse should accompany).

FILLING DEATH FORMS AND DELIVERY FORMS


Delivery forms and death forms should be filled in the following conditions: A delivery form and a death form should be given to each aborted fetus. All delivery forms and death forms should be filled completely before handing over to relatives. If there is no fetus, a delivery form need not be given, but a death form has to be issued with the identification of the product of conception along with mothers name. eg. Name: Aishaths (aborted membrane) If sex of the fetus is not identified, it should be taken as a male fetus.

VACCINATION
Prior to vaccination of a baby confirm the following.

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1. Check identity of the baby (check & compare the identity of the mother with the babys name tag) 2. Assess the baby & ensure that the baby is fit for vaccination 3. Reconfirm the vaccination status of the baby from the nursing records & double check with another staff. 4. Inform & give detail information to the parents about vaccinating the baby 5. Take the baby along with necessary records for vaccination 6. A bystander who could give correct information needed to complete the vaccine card should accompany the baby. After vaccination: 1. Assess the babys condition after vaccination 2. Show the BCG site to the parent (s) and give instruction related to post vaccination care 3. Ensure that the necessary documentation has been completed. 4. Hand over the vaccination card & explain the vaccination schedule to the parent(s)

APPENDIX-A / ORIENTATION ON ADMISSION


Greet & smile to the patient & relatives Tell that you will be looking after the patient in your shift. Explain that nurses will be working in four shifts Tell the patient /relatives to inform nurses regarding any problem with the patient and other problems related patient care. Orientation to place: Show the location of toilet, hot water, fridge and drinking water Explain location of the pharmacy & canteen Explain about the day room, activities and closing timings Advice the relatives to inform the nurses if any of the facilities provided by the hospital is not in working condition e.g. fan, electricity etc Explain about the rules of the hospital: Patients are not allowed to go out of the hospital Explain about the visiting hours

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Explain that other than visiting hours only one responsible bystander can stay with the patient. If the patient is sick it will be necessary for two people to stay with the patient. Advice to bring the necessary toilettries & cutleries Smoking is not allowed in the hospital premises. Explain them about the danger of smoking in close proximity to oxygen sources`

Explain about the doctors visiting trimmings depending upon the consultant and departments Explain that doctors will be visiting usually daily once & then depending upon the condition of the patient Explain that the medical officer of the department will be visiting for any complaints Room Orientation: Hand over the AC /TV remote & show other items in the room Explain about the bell-calling systems Explain how to use telephone Tell them politely to use the slippers for going to toilet Take special consent for admission of psychiatric patient

APPENDIX- B / PATIENTS RECORD /CHART ARRANGEMENT


1 2 3 4 5 6 7 History sheet Progress and management sheets Investigation reports (Lab, scan, ct, X-ray Nurses notes Observation and special sheets (diabetic /neurological) Input and output charts TPR sheets

DEATH CHART

Death summary Death certificate /Form Then 1-8

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DISCHARCH CHARTS

First, discharge summary Then 1-8

SURGICAL PATIENTS

After progress sheet PAC notes Consent Surgery notes Anaesthesia notes Then 3-8

OBSTETRIC PATIENTS CHART

After progress sheet Partogaph Labour progress Then 3-8 Service notification form Prescription in case of death Nursing assessment form Investigation result forms IV orders Personal hygiene plan Condition explain form Operation slip Referral letters Casualty prescription Transfer slip Admission slip Communicable disease notification form

Checking of death forms Coversheet

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Patient details Admission coversheet Time of death Date of death Death stamp Discharge stamp Summary filled Inside folder Death certificate with stamp

APPENDIX C / FILLING DEATH FORMS AND DELIVERY FORMS


Delivery forms and death forms should be filled in the following conditions: A delivery form and a death form should be given to each aborted fetus. All delivery forms and death forms should be filled completely before handing over to relatives. If there is no fetus, a delivery form need not be given, but a death form has to be issued with the identification of the product of conception along with mothers name. eg. Name: Aishaths (aborted membrane) If sex of the fetus is not identified, it should be taken as a male fetus.

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APPENDIX D -CHECKLIST FOR WARD SISTERS


DAILY (Section-A)
1. Check whether- daily inventory taken. - missing/borrowed items replaced. 2. 3. - census (transfer in/transfer out/discharge). - narcotics inventory taken. - narcotics cupboard locked. - narcotics register maintained regularly.

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- narcotics cupboard key with senior staff nurse. 4. 5. 6. - emergency trolley (drugs/equipments/instruments). - store room locked at all times. - temperature/intake & output chart/files filled/updated (during ward rounds and report giving) 7. 8. - all medication sheets filled accurately - all special investigations (USG, CT scan, ECG) appointments, reports etc.) 9. 10. 11. 12. 13. - all operation slips entered on OR day/latest by the first post - PACs done, consent taken (by the appropriate person) - welfare letters are given - linen checked, sent & returned - infection control practices - Waste disposal/sharp disposal - Cleanliness/disinfection of equipments & instruments
Nursing Department 2005

op-day.

14.

- patient care components according to the care plan. - patient allocation - allocated nurses go on round with doctor - all doctors orders are carried out properly - daily care given - all records completed - all registers completed. - maintenance of intake/output chart for whom all required (even if no doctors order)

15.

- all ward equipments in working order.

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16. 17. 18. 19.

- overall cleanliness /tidiness of ward - communication between shifts - follow up when things go wrong /broken items/missing items in the ward - attendants handover to next shift attendants (mops dry, buckets emptied, - dustbins emptied, kidney trays washed, dirty utility in clean state) - nurses and attendants report before going off duty (other shifts to the senior staff on duty) - update the changes in the duty register in the nursing department. - tidiness of the ward.

20. 21. 22.

Reporting- Incidents that need immediate reporting.

Nursing Department 2005

WEEKLY (Section-B)
WARD STOCK Identifying consumables required for the next week. Write & send indent book to Nsg Dept.on the previous day before 12.00nn. Send Duty Rota on Tuesday before 12.00nn to Nsg Dept. To be made by ward sister/in-charge nurse only treatment room patient unit

DUTY ROTA

CLEANLINESS (thorough cleaning/disinfection/deep cleaning)

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clean utility room dirty utility room etc. fans, windows, etc.) disinfection (trolleys/suction machine/IV stand etc.) serving of all equipments- oiling of trolley wheels et. order/replace broken items Charts arranged in order Death case sheets stamped and documents filed in order/death summary filled. Dispatch weekly or biweekly

EQUIPMENT

CASE SHEETS -DISPATCH

CHECK AUTOCLAVED ITEMS - Re-autoclaving after 2 weeks (Please allocate to senior nurses/junior nurses accordingly and do over all check).

REPORTING Necessary information (patient care/staff progress/additional requirements etc. to the Nursing Department).
Nursing Department 2005

MONTHLY (Section C)
Reviewing a nursing procedure of a case presentation C/S of treatment rooms

CHECK INVENTORY (3-6 monthly) of ward stock, Equipments / machinery DISPATCH equipments/instruments which cannot be repaired EXPIRY DATE drugs and emergency medications RECORDS & REPORTS maintenance of ward registers and files REVIEW CLASS identifying weakest area (present in the ward) MONITORING staff progress/patient care (appraisal review after 6 months)

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REPORTING

necessary information (patient care/staff progress/additional requirements

etc. to the Nursing Department). - Ward linen - Check total linen count - Maintenance of paint, lights, curtains. - Ward meetings the special events of the month.

ANNUALLY (Section-D)
FULL INVENTORY OF WARD NEW IMPROVEMENTS TO THE WARD suggestions and ideas etc. BUDGET-items required for the following year budget LEAVE SCHEDULE OF THE STAFF COMPLETING STAFF APPRAISAL

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SECTION TWO

WARD SPECIFIC GUIDELINES

DAILY TASKS OF NURSES OF PRIVATE WARDS


Morning shift: Report to the ward at 7:30 am Checking inventory, emergency trolley, Narcotics Send autoclaving items to CSSD/ collect linen from laundry Take handover from the night shift nurses Check the treatment charts, vital charts, Intake output charts and diabetic chart and kick count chart

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Visit patients, talk with the patients, ask how they are feeling, about patient diet, bowel habits Giving morning care. Prepare patients going for surgery and labour room. Check IV fluids and drainages, remove if there is any empty IV bottle/ Check the cannula site and operation site, wounds, for soakage Check fetal heart Ask mothers about breast feeding, / passed urine/me conium Check babys skin for colour and dehydration Prepare the trolley for doctors rounds Collect pending investigation reports before rounds Bed making Check and prepare for special investigations/get appointments for (Scan, CT, X-ray, endoscopy, audiometry, echo,) Assist doctors to the ward round Carry out morning orders Administer morning medications if any Check vital signs, if any alteration give SOS medications/other required interventions (tepid sponging, hot water bag) / inform to doctor Documentation Check the overall cleanliness of the ward. Give baby bath/ cord care/eye care/babys weight Give bed baths if any/ hair wash/ any other necessary interventions (back care/position changing) Wound Dressings and Episiotomy care Collect autoclaved things Visit patients and check the present conditions Complete the discharges as soon as possible Vaccination of babies before 1:00 pm Empty urinary drainages and measure/ maintain intake out put

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Complete documentation Hand over to the next shift Check overall cleanliness of the ward Go through the reading materials/message book/work assignment book Carry out special work assignments Report to shift in charge before leaving the ward

Second Shift: Report to the ward at 1:00 pm Check inventory, emergency trolley, narcotics Take over from the previous shift Check the treatment charts, vital charts, Intake output charts and diabetic chart and kick count chart Visit patients, talk with the patients, ask how they are feeling, about patient diet, bowel habits Check IV fluids and drainages, remove if there is any empty IV bottle/ Check the cannula site and operation site, wounds, for soakage Check fetal heart Ask mothers about breast feeding, / passed urine/meconium Provide breast feeding counseling Check babys skin for colour and dehydration Administer afternoon medication after lunch Check vital signs Make the patient comfortable, put off the lights, draw the curtains, make the room cozy for the patients, allow them to rest Send autoclaving items to CSSD/ collect linen from laundry Back care/change positions Wound Dressings and Episiotomy care Carry out special nursing interventions like, nebulization, steam inhalation, provide hot water bag

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Make the patient ready for the visiting hour Check the cleanliness and tidiness of the ward Complete Documentation Hand over to the next shift Check overall cleanliness of the ward Go through the reading materials/message book/work assignment book Carry out special work assignments Report to shift in charge before leaving the ward

Evening shift: Report to the ward at 6:00pm Checking inventory, emergency trolley, Narcotics Take handover from the second shift nurses Check the treatment charts, vital charts, Intake output charts and diabetic chart and kick count chart Visit patients, talk with the patients, ask how they are feeling, about patient meals, bowel movements Check IV fluids and drainages, remove if there is any empty IV bottle/ Check the cannula site and operation site, wounds, for soakage Check fetal heart Ask mothers about breast feeding, / passed urine/meconium Check babys skin for colour and dehydration Skin preparation/ give enema Advise and explain about NPO for surgery and other investigations Back care/change positions Wound Dressings and Episiotomy care Vital signs Administer medication Carry out special nursing interventions like, nebulization, steam inhalation, provide hot water bag

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Make the patient ready for sleep, draw curtains, put off the lights, Complete Documentation Hand over to the next shift Check overall cleanliness and tidiness of the ward Go through the reading materials/message book/work assignment book Carry out special work assignments Report to shift in charge before leaving the ward

Night duty: Report to the ward at 11:45pm Checking inventory, emergency trolley, Narcotics Take handover from the second shift nurses Check the treatment charts, vital charts, Intake output charts and diabetic chart and kick count chart Visit patients, see whether patients are comfortable and settled for nights sleep. Check IV fluids and drainages, remove if there is any empty IV bottle/ Check the cannula site and operation site, wounds, for soakage Check fetal heart Ask mothers about breast feeding, / passed urine/meconium Check babys skin for colour and dehydration Make census/ arrange case sheets Documentation Wash injection trays/carbolize the trolleys/arrange the treatment room/ utility rooms Give enema/prepare the patient for surgery/check skin preparation Ensure about NPO status, keep patient prepared for special investigation/surgery Morning care/bed baths Back care/change positions Vital signs Administer morning medication/pre-anesthetic medications Wound Dressings and Episiotomy care

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Carry out special nursing interventions like, nebulization, steam inhalation, provide hot water bag Check babys weight and document Check the cleanliness and tidiness of the ward Complete Documentation Hand over to the next shift

DAILY TASKS OF PEDIATRIC WARD NURSES

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Morning shift
Report to ward on time Check ward inventory of all biomedical equipments and stationeries Check narcotics inventory (Should be checked by the shift in-charge: amount & expiry date) Check emergency trolley (check drugs for the correct amount & expiry dates, equipments and other items for good working condition. Immediate action has to be taken for replacing missing drugs from emergency trolley & repairing of any equipments not in good working condition) (IF ANYTHING IS MISSING ON INVENTORY CHECKS, IT SHOULD BE WRITTEN IN THE MISSING BOOK AND REPLACED BEFORE SHIFT IS OVER) special handover Visit patients after report Communicate with patients and parents; ask regarding their condition, oral intake, whether breakfast taken or not and regarding comfort and inquire about their queries Touch the patient and feel the skin for hyperthermia or hypothermia (if felt hyperthermia check temperature, if skin is cold cover the child with sheet) Check the bedside records for correct entry of patients name, diagnosis, check the temperature sheet, observation sheets and intake out put charts for correct entry. If patients are on intravenous fluids check the IV site for any swelling, phlebitis or induration. And check the IV fluid for correct amount of drop rate For all dengue patients, pulses on dorsales pedis should be checked for volume. (If you feel that the pulses are weak or not felt, check the blood pressure immediately) Shift in charge should allocate patients and assign work for each staff Take report from the previous shift nurse Shift in-charge should check with the previous shift in-charge for any

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Check the allocation book for your assigned patients and work Visit patients and introduce yourself as their shift nurse Make the bed and give morning care for patients as required Prepare for doctors rounds (round trolley should be prepared with patients chart, treatment sheets, required investigation slips and tray with torch & tongue depressor and calculator)

Check for any pending investigations and collect the report before the rounds Take rounds with doctors ( Ensure that report regarding patient is given to doctors on round, all new reports are shown, show the treatment sheet and inquire about all the medications whether to continue or discontinue or for any other changes, ensure that parents enquiries are answered and condition is explained by the doctors)

If investigations are ordered make memo and send samples to laboratory If patients are posted for any special investigations ensure that patient is prepared and sent to the concerned department on time After rounds give prescription for all medications Give morning medications and injections Take vitals, blood pressure, temperature, pulse and respiration and if required O2 saturation. Give midday medication and injections Make the patient comfortable Check the cleanliness and tidiness of unit Receive new admissions and carry out the admission procedure Check and supervise attendants work and whereabouts Complete documentation (service notifications should be filled, all medications marked, intake output and observations should be entered, write the nurses notes as well.)

Give 2pm medication as required, inquire and assess for any new symptoms If patients are discharged Inform the medical officer for preparation of discharge summary

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Explain the discharge procedure and the time it will take for discharge preparation Remove IV cannula and prepare patient for discharge Give for payment and ensure that operation slip is attached Explain discharge medications, review dates and if any pending reports are there for collection very clearly.

Handover to next shift Check the missing book, replace any items taken in your shift Report to ward in-charge or shift in-charge before going of

Second shift
Report to ward on time Check ward inventory of all biomedical equipments and stationeries Check narcotics inventory (Should be checked by the shift in-charge: amount & expiry date) Check emergency trolley (check drugs for the correct amount & expiry dates, equipments and other items for good working condition. Immediate action has to be taken for replacing missing drugs from emergency trolley & repairing of any equipments not in good working condition) (IF ANYTHING IS MISSING ON INVENTORY CHECKS, IT SHOULD BE WRITTEN IN THE MISSING BOOK AND REPLACED BEFORE SHIFT IS OVER) special handover Visit patients after report Communicate with patients and parents; ask regarding their condition, oral intake, whether lunch taken or not and regarding comfort and inquire about their queries Touch the patient and feel the skin for hyperthermia or hypothermia (if felt hyperthermia check temperature, if skin is cold cover the child with sheet) Take report from the previous shift nurse Shift in-charge should check with the previous shift in-charge for any

46

Check the bedside records for correct entry of patients name, diagnosis, check the temperature sheet, observation sheets and intake out put charts for correct entry.

If patients are on intravenous fluids check the IV site for any swelling, phlebitis or induration. And check the IV fluid for correct amount of drop rate

For all dengue patients, pulses on dorsales pedis should be checked for volume. (If you feel that the pulses are weak or not felt, check the blood pressure immediately)

Shift in charge should allocate patients and assign work for each staff Check the allocation book for your assigned patients and work Visit patients and introduce yourself as their shift nurse Check for any pending reports and collect the reports and inform the reports to doctor Check cleanliness and tidiness of ward Prepare the unit and patient for an afternoon nap and plan nursing care so that patient is not disturbed during this period If pending or evening discharges are there attend to this immediately Inform the medical officer for preparation of discharge summary Explain the discharge procedure and the time it will take for discharge preparation Remove IV cannula and prepare patient for discharge Give for payment and ensure that operation slip is attached Explain discharge medication and review dates and if any pending reports are there for collection very clearly. Check the patients charts & compare the treatment sheet with the doctors orders for the latest changes/double check whether orders are carried out

Assess patient in-between and provide nursing care accordingly Check and supervise attendants work and whereabouts Take vital signs and give medications or injections at evening time Complete documentation (service notifications should be filled, all medications marked, intake output and observations should be entered, & write the nurses notes)

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Handover to next shift Check the missing book, replace any items taken in your shift Shift in-charge should fill their checklist Report to ward in-charge or shift in-charge before going off duty

Third shift
Report to ward on time Check ward inventory of all biomedical equipments and stationeries Check narcotics inventory (Should be checked by the shift in-charge: amount & expiry date) Check emergency trolley (check drugs for the correct amount & expiry dates, equipments and other items for good working condition. Immediate action has to be taken for replacing missing drugs from emergency trolley & repairing of any equipments not in good working condition) (IF ANYTHING IS MISSING ON INVENTORY CHECKS, IT SHOULD BE WRITTEN IN THE MISSING BOOK AND REPLACED BEFORE SHIFT IS OVER) special handover Visit patients after report Communicate with patients and parents; ask regarding their condition, oral intake, regarding comfort and inquire about their queries Touch the patient and feel the skin for hyperthermia or hypothermia (if felt hyperthermia check temperature, if skin is cold cover the child with sheet) Check the bedside records for correct entry of patients name, diagnosis, check the temperature sheet, observation sheets and intake out put charts for correct entry. If patients are on intravenous fluids check the IV site for any swelling, phlebitis or in-duration. And check the IV fluid for correct amount of drop rate Take report from the previous shift nurse Shift in-charge should check with the previous shift in-charge for any

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For all dengue patients, pulses on dorsales pedis should be checked for volume. (If you feel that the pulses are weak or not felt, check the blood pressure immediately)

Shift in charge should allocate patients and assign work for each staff Check the allocation book for your assigned patients and work Visit patients and introduce yourself as their shift nurse Check the patients charts compare the treatment sheet with the doctors orders for the latest changes or to double check whether orders are carried out Prepare the patient and unit for visitors visit Give 10pm medication and injections Identify and confirm patients who need to be fasting for investigations, surgery etc. Check for any pending reports and collect the reports and inform the reports to doctor Prepare the unit for night sleep and ensure that patients are not disturbed unnecessarily Assess patient in-between and provide nursing care accordingly ( check especially for drop rate of IV fluids and IV check site for any inflammation) Check and supervise the work of attendants work and whereabouts Complete documentation (service notifications should be filled, all medications marked, intake output and observations should be entered, write the nurses notes as well.)

Handover to next shift Check the missing book, replace any items taken in your shift Report to ward in-charge or shift in-charge before going off duty

Night shift
Report to ward on time Check ward inventory of all biomedical equipments and stationeries Check narcotics inventory (Should be checked by the shift in-charge: amount & expiry date) Check emergency trolley (check drugs for the correct amount & expiry dates, equipments and other items for good working condition. Immediate action has to be

49

taken for replacing missing drugs from emergency trolley & repairing of any equipments not in good working condition) (IF ANYTHING IS MISSING ON INVENTORY CHECKS, IT SHOULD BE WRITTEN IN THE MISSING BOOK AND REPLACED BEFORE SHIFT IS OVER) special handover Visit patients after report Communicate with patients and parents; ask regarding their condition, oral intake, whether breakfast taken or not and regarding comfort and inquire about their queries Touch the patient and feel the skin for hyperthermia or hypothermia (if felt hyperthermic check temperature, if skin is cold cover the child with sheet) Check the bedside records for correct entry of patients name, diagnosis, check the temperature sheet, observation sheets and intake out put charts for correct entry. If patients are on intravenous fluids check the IV site for any swelling, phlebitis or induration. And check the IV fluid for correct amount of drop rate For all dengue patients, pulses on dorsales pedis should be checked for volume. (If you feel that the pulses are weak or not felt, check the blood pressure immediately) Shift in charge should allocate patients and assign work for each staff Check the allocation book for your assigned patients and work Visit patients and introduce yourself as their shift nurse Explain nil per oral orders to parents as required Prepare the patient and complete everything for morning Plan nursing care so that patient is not disturbed during sleep Visit patients frequently and observe the IV sites for disconnections, swelling and IV drop rates Take report from the previous shift nurse Shift in-charge should check with the previous shift in-charge for any

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Ask the attendant to clean all areas of ward, wash trays and supervise their work Ensure that patient take a feed before morning medication Check vitals and give 6am medication/injections as required, inquire and assess for any new symptoms Send early morning investigations and collect the reports before rounds If patients are posted for any special investigations ensure that patient is prepared Check the cleanliness and tidiness of unit Receive new admissions and carry out the admission procedure Complete documentation (service notifications should be filled, all medications marked, observations entered, and intake output calculated for 24 hours and nurses notes written.)

Handover to next shift Check the missing book, replace any items taken in your shift Report to ward in-charge or shift in-charge before going off duty

DAILY TASKS OF MEDICAL WARD NURSES


FIRST SHIFT Report to ward on time. Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check narcotics inventory. (Check whether any narcotics have been used in the previous shift and see that it is entered in the narcotics register). Check the emergency trolley (check whether all equipments are in working condition). Check the daily census Check the general cleanliness of the ward Send linen to laundry/ Send Physio referral book and CSSD items Take report from the previous shift

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Visit patients after report and check patients condition (sleep, breakfast, comfort, e.t.c.) Check IV fluids/drainages/catheters) Check vital signs for necessary patients & document Prepare for doctors rounds. Collect all due investigation results from the concerned departments Give any due medications/feeding etc. Do rounds with doctors & make sure that patients condition is explained to the relatives Check & identify the necessary medications that are over Carry out due orders. Send notification for cases with communicable diseases Send required investigations and take appointments from other departments as needed Check, prepare patients going for special investigations (USG, CT scan, X- ray, endoscopy e.t.c) Check preparation & send patients for the above investigations on time See that autoclaved items are collected from the CSSD. Report any unusual incidence to the shift coordinator. Complete documentation. Sponge bath & morning care Monitor the morning care (senior nurses) Change dressing Change of tubes, catheter etc Check vitals Maintain I/O charts Carrying out doctors orders Do a round to check the patients condition Make patients comfortable 12.00 n. change of position of bed ridden patients (change nappy) Complete documentations

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Pack used trays and clean/disinfect the treatment room Check if all the above is done Make necessary preparations to send the discharged patients home Handing over to the next shift Take / assist in the special treatments (nebulizations, dressings, Ambulations, sit up on chair Check cleanliness of the ward / unit Report to the ward in charge on shift in charge going off duty

SECOND SHIFT Report to ward on time Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check narcotics inventory. (Check whether any narcotics have been used in the previous shift and see that it is entered in the narcotics register). Check the emergency trolley (check whether all equipments are in working condition). Check the census Check the general cleanliness of the ward Take report from the previous shift Visit patients after report and check patients condition (about rest / sleep, lunch, comfort, e.g.) Check IV fluids/drainages/catheters) Check vital signs for necessary patients & document Prepare for doctors rounds if necessary Do rounds & carry out orders prioritizing them Collect all due investigation results from the concerned departments Give any due medications/feeding etc. Send required investigations and take appointments from other departments as needed 53

Complete documentation. Make the patients comfortable Complete documentation. Prepare patients for afternoon rest (draw curtains) Check & prepare patients going for special investigations not completed in the morning (scan, CT, X-ray, endoscopy) Giving injections, nebulizations Administering medications, giving NG feeds Back care /change of nappy & positioning of bedridden patients Send used linen / used trays to Laundry & CSSD Collected items from the CSSD & laundry Report any unusual incidence to the shift coordinator. Maintain I/O charts and check vital signs Re-check doctors orders Complete documentations & hand over to the next shift Check the cleanliness of the ward / unit Report to the ward in charge on shift in charge going off duty

THIRD SHIFT
Report to ward on time Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check narcotics inventory. (Check whether any narcotics have been used in the previous shift and see that it is entered in the narcotics register). Check the emergency trolley (check whether all equipments are in working condition). Check the daily census Check the general cleanliness of the ward Take report from the previous shift Visit patients after report and check patients condition (about rest & comfort, e.g.) Check IV fluids/drainages/catheters

54

Check vital signs for necessary patients & document Collect all due investigation results from the concerned departments Re-check doctors orders Carry out any due orders Do a round & check patients condition Make the patients comfortable Complete documentation. Check, prepare & give specific instructions for patients going for special investigations in the next morning (e.g: fasting, full bladder ) Administer medications, and carry out procedures e.g dressing, feeding etc. Back care /change of nappy & positioning of bedridden patients Prepare patients / unit for sleep (draw curtains / switch off necessary lights) Send used linen to laundry Report any unusual incidence to the shift coordinator. Maintaining I/O charts / observation chart / vitals chart / Diabetic chart Check cleanliness & tidiness of the ward Complete documentations & hand over to the next shift Report to the ward in charge on shift in charge going off duty

NIGHT SHIFT
Report to ward on time Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check narcotics inventory. (Check whether any narcotics have been used in the previous shift and see that it is entered in the narcotics register). Check the emergency trolley (check whether all equipments are in working condition). Complete the daily census Check the general cleanliness of the ward Take report from the previous shift Visit patients after report and check patients condition (about rest & comfort, e.g.) 55

Check IV fluids/drainages/catheters Check vital signs for necessary patients & document Collect all due investigation results from the concerned departments Re-check doctors orders Carry out any due orders Do a round & check patients condition Inform the concerned doctors about any deterioration in the patients condition Make the patients comfortable Complete documentation. Check, prepare & ensure that the instructions are understood by the patients going for special investigations in the next morning (e.g: fasting, full bladder ) Administer medications, and carry out procedures e.g dressing, feeding etc. Back care /change of nappy & positioning of bedridden patients Report any unusual incidence to the shift coordinator. Complete I/O charts / observation chart / vitals chart / Diabetic chart Check cleanliness & tidiness of the ward Check the routine cleaning of the ward (washing of all the medication cups and all the trays). Check and arrange patient files Check & prepare the registers & books in the ward Identify medical patients in other wards & update the notice board Give early morning care, back care & change position Check vital signs Give early morning injections & medications Collect lab. samples make memos & send them to lab Pack used articles & keep them ready for autoclaving Check general cleanliness of the ward Complete documentations & hand over to the next shift Report to the ward in charge on shift in charge going off duty

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DAILY TASKS OF GYNAE WARD NURSES


Morning shift
Report to ward on time Check ward inventory and emergency trolley Check narcotics inventory Check FHS of the antenatal patients and whether the patient has maintained kick count chart by the allocated staff Check the treatment charts and baby charts whether medication had been given Take report form the previous shift nurses (targeted time is before 7:45am) Visit patients after report and check patients condition (about sleep, comfort, contraction, bleeding, feeding, etc.) Give morning care Assess the patients who are having contractions and inform SOS by the allocated staff

57

Check for blood investigation reports, and get them from the lab, before rounds. Prepare for doctors rounds. Check and prepare patients going for special investigations (scan, CT, X-ray, endoscopy, NST). Check, prepare and send patients for the above investigations/ surgeries on time. Give morning medications Check vitals, FHS and kick count chart Give perineal care and check for bleeding PV for cases like post natal mothers, post operative cases, threatened abortion cases etc Check IV fluids and drainages. Do rounds with Doctors. Carry out orders. Do a round and check the patients condition. Make patients comfortable Give health education for the patients Check the cleanliness and tidiness of the ward. Complete documentation. Complete the discharges as soon as possible. Give bath for babies Take babies for vaccination Send blood investigations. Send patients for other investigations.( scan, NST, BPP and surgeries as required) Take/ assist in the special treatments (nebulizations, dressings, patient activity, sit up on chair, ambulation) Give perineal care for the postnatal mothers Make patient comfortable. Give SOS medication if necessary. Maintain intake output chart Check whether back care and positions are changed as required. Complete documentation.

58

Check the cleanliness and tidiness of the ward/ unit. Hand over to next shift. Report to ward in charge or shift in charge before going off duty. Write the leaving time in the over time sheet if stayed after 2:30pm by the shift in charge

Afternoon shift
Report to ward on time Check ward inventory and emergency trolley Check narcotics inventory Check FHS of the antenatal patients and whether maintained kick count charts by the allocated staff Check the treatment charts and baby charts whether medication had been given Take report form the previous shift nurses. Visit patients after report and check patients condition (about rest, lunch, comfort repositioning, room temperature, quietness of the room, sleep etc) Prepare patients for afternoon rest (draw curtains). Check and prepare patients going for special investigations and surgeries not completed in the morning (scan, CT, X-ray, endoscopy). Check whether any patient has to be prepared for special investigation or surgeries for next day. Check, prepare patients for the above investigations. Check for blood investigation reports, and get them from the lab. Give afternoon medications Check vital signs, FHS and kick count chart Give perineal care and check for bleeding PV for cases like post natal mothers, post operative cases, threatened abortion cases etc Check IV fluids and drainages. Do a round and check the patients condition.

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Make patients comfortable. Check the cleanliness and tidiness of the ward. Give sos pain killers and keep patient ready for visitors. Complete the discharges as soon as possible. Complete documentation. Send blood investigations. Take/ assist in the special treatments (nebulizations, dressings etc.) Take/ assist in checking the vitals. Check whether back care and positions are changed as required. Make patients comfortable, and tidy the ward. Complete documentation. Check the cleanliness and tidiness of the ward. Hand over to next shift. Report to ward in charge or shift in charge before going off duty Write the time of leaving if stayed after 8:00pm by the shift inchrge

Evening shift
Report to ward on time Check ward inventory and emergency trolley Check narcotics inventory Check the treatment charts and baby charts whether medication had been given Check FHS of the antenatal patients and whether maintained kick count charts by the allocated staff Take report form the previous shift nurses. Visit patients after report and check patients condition (about rest, comfort repositioning, room temperature, quietness of the room, sleep medication, pain medication, etc.) Check for urgent blood investigation reports, and get them from the lab.. Give evening medications and injections. Make patient comfortable for dinner.

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Check the cleanliness and tidiness of the ward. Check vitals, FHS and kick count chart Give perineal care and check for bleeding PV for cases like post natal mothers, post operative cases, threatened abortion cases etc Check IV fluids and drainages. Do a round in the ward and check patients condition. Explain the procedure about IOL for the posted patients Patients who are posted for surgeries, fasting to be explained Make sure all surgery patients has done PAC, Local preparation, all routine investigation, cross match, consent etc Make patients comfortable. Carry out any emergency orders. Take/ assist in the special treatments (nebulizations, dressings, patient activity like ambulation, sit up on chair etc.) Check whether back care and positions are changed as required. Check and make patient comfortable for the night. Give SOS medication if necessary. Check the cleanliness and tidiness of the ward. Complete documentation. Hand over to next shift. Report to ward in charge or shift in charge before going off duty. Write the time of leaving if stayed later than 1pm by the shift incharge

Night Shift
Report to ward on time Check ward inventory and emergency trolley Check narcotics inventory Check FHS of the antenatal patients and whether maintained kick count charts by the allocated staff Check the treatment charts and baby charts whether medication had been given

61

Take report form the previous shift nurses. Visit patients after report and check patients condition (sleep, comfort repositioning, room temperature, quietness of the room, sleep medication, pain medication, etc.)

Complete the census. Check the cleanliness and tidiness of the ward. Check the routine cleaning of the ward for the previous day (washing of all the medication cups, all the trays like IV tray, mouth care tray, injection tray etc.). Check IV fluids, drainages etc. Do a round in the ward and check patients condition. Carry out any emergency orders. Identify and confirm patients who need to be fasting for investigations, operations etc. Complete the documentation. Check vitals, FHS and kick count chart Give perineal care and check for bleeding PV for cases like post natal mothers, post operative cases, threatened abortion cases etc Check IV fluids and drainages. Check weight for PIH patients as required Check urine sugar and urine albumin for patients with PIH and GDM Start IV fluids for all surgery cases by 6am. Give enema for patients who are posted for surgeries and IOL for major surgeries like LSCS, Hysterectomy, do catheterization Give early morning care, back care and change of positions as required. Give early morning injections and medication. Check the cleanliness and tidiness of the ward. Send things for autoclaving Complete documentation. Shift the first case to OT by the allocated staff when OT informs Start shifting IOL patient to the L/R by the allocated staff Hand over to next shift.

62

Report to ward in charge or shift in charge before going off duty. Record going off time if exceed after 8:00am by the shift in charge

Special points to remember


All the un usual incidents to be reported to the coordinator Any case of MLC admitted to the ward should be informed to the coordinator and MLC form should be completed by the GMO and send it to CEO office on the following day Send all the charts for dispatching to medical records when the patient is discharged All unmarried mothers should be informed to counseling coordinator Any IUFD, high risk patients, sick patients should be informed to coordinator Gynae ward standing order to be followed by all the staff (eg, checking FHS 2 hourly) Vaccination protocol should be followed Work as a team and build good relationship between coworkers

DAILY TASKS OF ENT WARD NURSES


Morning shift
Report to ward on time. 63

Check ward inventory. Check narcotics inventory. Take report from the previous shift nurses. Prepare for doctors rounds. Visit patients after report and check patients condition (about sleep, breakfast, comfort, etc.) Check prepare patients going for surgery. Give morning care. Check soakage of dressing color of finger of pop hand /leg. Check and prepare patients going for special investigations (scan, CT, X-ray, endoscopy). Check, prepare and send patients for the above investigations on time. Check for blood investigation reports, and get them from the lab, before rounds. Give morning medications and injections. Monitor the morning care (senior nurses). Check IV fluids and drainages. positions, tractions Do ward rounds with Doctors. Carry out orders. Do a rounds check the patients condition Make patients comfortable. Check the cleanliness and tidiness of the ward. Complete documentation. Complete the discharges as soon as possible. Send blood investigation. Send patients for other investigations. Take/assist in the special treatments (nebulizations, dressings, ambulations, sit up on chair), exercises of finger pop hand / leg. Take/ assist in checking the vitals pulse of pop hand. Make patient comfortable. Give sos medication I check soakage of dressing necessary.

64

Check whether back care and positions are changed as required. Complete documentation. Check the cleanliness and tidiness of the ward/unit. Hand over to next shift. Report to ward in charge or shift in charge going off duty, Doctors round start at 7:45am

Afternoon shift
Report to ward on time. Check ward inventory Check narcotics inventory Take report from the previous shift nurses. Visit patients after report and check patients condition (about rest, lunch, comfortrepositioning, room temperature, quietness of the room, sleep etc.) Check soakage of dressing. Prepare patients for afternoon rest (draw curtains) Check and prepare patients going for special investigations not completed in the morning (scan, CT, X-ray, endoscopy.) Check whether any patient has to be prepared for special investigation for next day. Check, prepare patients for the above investigations. Check for blood investigation reports, and get them from the lab. Give afternoon medications and injections. Check IV fluids and drainages positions of tractions Do a round and check the patients condition. Check soakage of dressing. Make patients comfortable. Check the cleanliness and tidiness of the ward. Give sos pain killers and keep patient ready for visitors. Complete the discharge as soon as possible Complete documentation.

65

Send blood investigations. Give and /assist in the special treatments (nebulizations, dressings etc), Exercise of finger of pop hand leg. Check whether back care and positions are changed as required. Make patients comfortable, and tidy the ward. Check soakage of dressings Check the cleanliness and tidiness of the ward. Hand over to next shift. Report to ward in charge or shift in charge before going off duty. Preparation of patients for surgery (shaving consent etc).

Evening shift
Report to ward on time Check ward inventory Check narcotic inventory Take report from the previous shift nurses, Visit patients after report and check patients condition (about rest, lunch, comfortrepositioning, room temperature, quietness of the room, sleep etc.) Check soakage of dressing and color of finger of pop hand /leg. Check for urgent blood investigation reports, and get them from the lab.. Give evening medications and injections Make patient comfortable for dinner. Check the cleanliness and tidiness of the ward. Check IV fluids and drainages. Do a round and check the patients condition. Carry out any emergency orders. Make patients comfortable. Complete documentation Check whether back care and positions are changed as required

66

Take/assist in the special treatments (nebulizations, dressings, Exercises of finger pop hand / leg. Give/ assist in checking the vitals and check pulse of pop hand/leg Give sos medication if necessary. Check and make patients comfortable for the night. Check the cleanliness and tidiness of the ward. Complete documentation Hand over to next shift. Report to ward in charge or shift in charge before going off duty

Night Shift
Report to ward on time Check ward inventory Check narcotic inventory Take report from the previous shift nurses, Visit patients after report and check patients condition (sleep comfort-repositioning, room temperature, quietness of the room, sleep medication sos.) Check soakage of dressing and color of fingers of pop hand /leg. Complete the census. Check the cleanliness and tidiness of the ward. Check the routine cleaning of the ward for the previous day (washing of all the medication cups, all the trays like IV tray, mouth care tray, injection tray etc. Check IV fluids and drainages position and tractions. Do a round and check the patients condition. Carry out any emergency orders. Identify and conform patients who need to be fasting for investigations, operations. Complete documentation Take/ assist in checking the vitals and pulse of pop hand/leg Give Early morning care, back care and change of positions as required, Give early morning injections and medication. Check the cleanliness and tidiness of the ward.

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Complete documentation. Hand over to next shift. Report to ward in charge or shift in charge before going off duty

SHIFT ROUTINES FOR SURGICAL WARD NURSES


FIRST SHIFT Report to ward on time. Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check narcotics inventory. (Check whether any narcotics have been used in the previous shift and see that it is entered in the narcotics register). Check the emergency trolley (check if all equipments are in working condition). Check the daily census Check the general cleanliness of the ward Send linen to laundry/ Send Physio referral book and CSSD items Take report from the previous shift Visit patients after report & check patients condition (sleep, breakfast, comfort, e.t.c.) Check IV fluids/drainages/catheters) Check & prepare patients going for surgery Send patients for surgery as per request from OT Give morning care Check soakage of dressings Check vital signs for necessary patients & document Receive patients from OT Monitor the immediate post operative cases Prepare for doctors rounds. Collect all due investigation results from the concerned departments Give due medications

68

Do rounds with doctors & make sure that patients condition is explained to the relatives Check & identify the necessary medications that are over Carry out due orders. Send notification for cases with communicable diseases Send required investigations and take appointments from other departments as needed Check, prepare patients going for special investigations (USG, CT scan, X- ray, endoscopy e.t.c) Check preparation & send patients for the above investigations on time See that autoclaved items are collected from the CSSD. Report any unusual incidence to the shift coordinator. Complete documentation. Sponge bath & morning care Monitor the morning care (senior nurses) Change dressing Change of tubes, catheter etc Check vitals Maintain I/O charts Carrying out doctors orders Do a round to check the patients condition Make patients comfortable 12.00 nn. change of position of bed ridden patients (change nappy) Complete documentations Pack used trays and clean/disinfect the treatment room / dressing trolleys Check if all the above is done Make necessary preparations to send the discharged patients home Handing over to the next shift Take / assist in the special treatments (nebulization, dressings, Ambulation, sit up on chair)

Check cleanliness & tidiness of the ward / unit

69

Report to the ward in charge on shift in charge going off duty

SECOND SHIFT Report to ward on time Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check narcotics inventory. (Check whether any narcotics have been used in the previous shift and see that it is entered in the narcotics register). Check the emergency trolley (check whether all equipments are in working condition). Check the census Check the general cleanliness of the ward Take report from the previous shift Visit patients after report and check patients condition (about rest / sleep, lunch, comfort-repositioning, room temperature, quietness of the place e.t.c) Monitor the immediate post-operative cases Check IV fluids/drainages/catheters/soakage ofdrssings) Check vital signs for necessary patients & document Prepare for doctors rounds if necessary if needed Do rounds & carry out orders prioritizing them Collect all due investigation results from the concerned departments Give any due medications/feeding etc. Send required investigations and take appointments from other departments as needed Complete documentation. Make the patients comfortable Complete documentation. Prepare patients for afternoon rest (draw curtains) Check & prepare patients going for special investigations not completed in the morning (scan, CT, X-ray, endoscopy) Prepare patients posted for surgery (shaving, consent etc) Administer medications (SOS /routine), give NG feeds 70

Check IV fluids/drainages/catheters/soakage of drssings) Back care /change of nappy & positioning of bedridden patients Send used linen / used trays to Laundry & CSSD Collected items from the CSSD & laundry Report any unusual incidence to the shift coordinator. Maintain I/O charts and check vital signs Re-check doctors orders Complete documentations Check the cleanliness of the ward / unit Handover to the next shift Report to the ward in charge on shift in charge going off duty

THIRD SHIFT
Report to ward on time Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check narcotics inventory. (Check whether any narcotics have been used in the previous shift and see that it is entered in the narcotics register). Check the emergency trolley (check whether all equipments are in working condition). Check the daily census Check the general cleanliness of the ward Take report from the previous shift Visit patients after report and check patients condition (about rest & comfort, e.g.) Check IV fluids/drainages/catheters Check vital signs for necessary patients & document Collect all due investigation results from the concerned departments Re-check doctors orders Carry out any due orders Do a round & check patients condition

71

Make the patients comfortable Complete documentation. Check, prepare & give specific instructions for patients going for special investigations in the next morning (e.g: fasting, full bladder ) Give specific instructions to patients posted for surgery Administer medications, and carry out procedures e.g dressing, feeding etc. Back care /change of nappy & positioning of bedridden patients Prepare patients / unit for sleep (draw curtains / switch off necessary lights) Send used linen to laundry Report any unusual incidence to the shift coordinator. Maintaining I/O charts / observation chart / vitals chart / Diabetic chart Check cleanliness & tidiness of the ward Complete documentations & hand over to the next shift Report to the ward in charge on shift in charge going off duty

NIGHT SHIFT
Report to ward on time Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check narcotics inventory. (Check whether any narcotics have been used in the previous shift and see that it is entered in the narcotics register). Check the emergency trolley (check whether all equipments are in working condition). Complete the daily census Check the general cleanliness of the ward Take report from the previous shift Visit patients after report and check patients condition (about rest & comfort, e.g.) Check IV fluids/drainages/catheters/soakage of dressings Check vital signs for necessary patients & document Collect all due investigation results from the concerned departments Re-check doctors orders

72

Carry out any due orders Do a round & check patients condition Check immediate post operative cases Inform the concerned doctors about any deterioration in the patients condition Make the patients comfortable Complete documentation. Check, prepare & ensure that the instructions are understood by the patients going for special investigations in the next morning (e.g: fasting, full bladder ) Administer medications, and carry out procedures e.g dressing, feeding etc. Give early morning care , back care and change of positions as required Report any unusual incidence to the shift coordinator. Complete I/O charts / observation chart / vitals chart / Diabetic chart Check cleanliness & tidiness of the ward Check the routine cleaning of the ward (washing of all the medication cups and all the trays). Check and arrange patient files Check & prepare the registers & books in the ward Give early morning care, back care & change position Check vital signs Give early morning injections & medications Collect lab. samples make memos & send them to lab Pack used articles & keep them ready for autoclaving Check general cleanliness of the ward Complete documentations & hand over to the next shift Report to the ward in charge on shift in charge going off duty

DAILY TASKS OF ISOLATION WARD NURSES


FIRST SHIFT

73

Report to ward on time. Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check narcotics inventory. (Check whether any narcotics have been used in the previous shift and see that it is entered in the narcotics register). Check the emergency trolley (check whether all equipments are in working condition). Check the daily census Check the general cleanliness of the ward Send linen to laundry/ Send Physio referral book and CSSD items Take report from the previous shift Visit patients after report and check patients condition (sleep, breakfast, comfort, e.t.c.) Take appropriate infection control measures while visiting patients Ensure if all personal protective equipments are available for the day Check IV fluids/drainages/catheters) Check vital signs for necessary patients & document Prepare for doctors rounds. Collect all due investigation results from the concerned departments Give any due medications/feeding etc. Do rounds with doctors & make sure that patients condition is explained to the relatives Check & identify the necessary medications that are over Carry out due orders. Send notification for cases with communicable diseases Send required investigations and take appointments from other departments as needed Check, prepare patients going for special investigations (USG, CT scan, X- ray, e.t.c) Check preparation & send patients for the above investigations on time See that autoclaved items are collected from the CSSD. Report any unusual incidence to the shift coordinator. Complete documentation.

74

Sponge bath & morning care Monitor the morning care (senior nurses) Change dressing Change of tubes, catheter etc Check vitals Maintain I/O charts Carrying out doctors orders Do a round to check the patients condition Make patients comfortable 12.00 n. change of position of bed ridden patients (change nappy) Complete documentations Pack used trays and clean/disinfect the treatment room trolleys Check if all the above is done Make necessary preparations to send the discharged patients home Disinfect cubicles after patients leave the room Handing over to the next shift Take / assist in the special treatments (nebulizations, dressings, Ambulations, sit up on chair Check cleanliness of the ward / unit Report to the ward in charge on shift in charge going off duty.

SECOND SHIFT Report to ward on time Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check narcotics inventory. (Check whether any narcotics have been used in the previous shift and see that it is entered in the narcotics register). Check the emergency trolley (check whether all equipments are in working condition). Check the census Check the general cleanliness of the ward 75

Take report from the previous shift Visit patients after report and check patients condition (about rest / sleep, lunch, comfort, e.g.) Take appropriate infection control measures while visiting patients Check IV fluids/drainages/catheters) Check vital signs for necessary patients & document Prepare for doctors rounds if necessary Do rounds & carry out orders prioritizing them Collect all due investigation results from the concerned departments Give any due medications/feeding etc. Send required investigations and take appointments from other departments as needed Complete documentation. Make the patients comfortable Complete documentation. Prepare patients for afternoon rest (draw curtains) Remind to mimize visitors during the visiting hours Check & prepare patients going for special investigations not completed in the morning (scan, CT, X-ray, endoscopy)

Giving injections, nebulizations Administering medications, giving NG feeds Back care /change of nappy & positioning of bedridden patients Send used linen / used trays to Laundry & CSSD Collected items from the CSSD & laundry Disinfect cubicles after patients leave the room Report any unusual incidence to the shift coordinator. Maintain I/O charts and check vital signs Re-check doctors orders Complete documentations & hand over to the next shift Check the cleanliness of the ward / unit Report to the ward in charge on shift in charge going off duty

76

THIRD SHIFT
Report to ward on time Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check narcotics inventory. (Check whether any narcotics have been used in the previous shift and see that it is entered in the narcotics register). Check the emergency trolley (check whether all equipments are in working condition). Check the daily census Check the general cleanliness of the ward Take report from the previous shift Visit patients after report and check patients condition (about rest & comfort, e.g.) Check IV fluids/drainages/catheters Check vital signs for necessary patients & document Collect all due investigation results from the concerned departments Re-check doctors orders Carry out any due orders Do a round & check patients condition Make the patients comfortable Complete documentation. Check, prepare & give specific instructions for patients going for special investigations in the next morning (e.g: fasting, full bladder ) Administer medications, and carry out procedures e.g dressing, feeding etc. Back care /change of nappy & positioning of bedridden patients Prepare patients / unit for sleep (draw curtains / switch off necessary lights) Send used linen to laundry Report any unusual incidence to the shift coordinator. Maintaining I/O charts / observation chart / vitals chart / Diabetic chart Check cleanliness & tidiness of the ward Complete documentations & hand over to the next shift Report to the ward in charge on shift in charge going off duty

77

NIGHT SHIFT
Report to ward on time Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check narcotics inventory. (Check whether any narcotics have been used in the previous shift and see that it is entered in the narcotics register). Check the emergency trolley (check whether all equipments are in working condition). Complete the daily census Check the general cleanliness of the ward Take report from the previous shift Visit patients after report and check patients condition (about rest & comfort, e.g.) Check IV fluids/drainages/catheters Check vital signs for necessary patients & document Collect all due investigation results from the concerned departments Re-check doctors orders Carry out any due orders Do a round & check patients condition Inform the concerned doctors about any deterioration in the patients condition Make the patients comfortable Complete documentation. Check, prepare & ensure that the instructions are understood by the patients going for special investigations in the next morning (e.g: fasting, full bladder ) Administer medications, and carry out procedures e.g dressing, feeding etc. Back care /change of nappy & positioning of bedridden patients Report any unusual incidence to the shift coordinator. Complete I/O charts / observation chart / vitals chart / Diabetic chart Check cleanliness & tidiness of the ward Check the routine cleaning of the ward (washing of all the medication cups and all the trays). 78

Check and arrange patient files Check & prepare the registers & books in the ward Identify medical patients in other wards & update the notice board Give early morning care, back care & change position Check vital signs Give early morning injections & medications Collect lab. samples make memos & send them to lab Pack used articles & keep them ready for autoclaving Check general cleanliness of the ward Complete documentations & hand over to the next shift Report to the ward in charge on shift in charge going off duty

DAILY TASKS OF ACCIDENTS AND EMERGENCY DEPARTMENT NURSES


Morning (1st shift), Afternoon (2nd shift) & Evening (3rd shift);
79

Report to ward on time Check inventory (ER, narcotics, dressing room, procedure room) Take report from the previous shift nurses Visit patients during taking over and check patients condition Receive the new patients and accompany/direct them to the bed Make patients comfortable; ask the patients complaints Take/assist in checking vitals, procedures Inform the concerned doctor and attend patients along with doctors Carry out doctors orders Administer stat medications immediately Monitor patients conditions frequently till stable Check IV fluids, drainages (if any) Send lab investigations on time and collect reports on time Take /assist in the special treatments (nebulizations, dressings, etc) Do a round and check patients' condition from time to time Complete documentations of all procedures (maintain the census register properly) Try and shift all admissions to the respective wards as soon as possible Complete the discharges as soon as possible Inform all incidences (minor/ major) to shift-in-charge at all times Keep ER ready at all times Maintain the cleanliness and tidiness of the casualty complex Keep casualty complex (dressing room, procedure room, blood bank,) ready at all times Maintain a professional relationship with other team members Report to shift-in-charge when ever leaving ER Hand over to next shift staff Report to next shift-in-charge before going off duty

Night (4th shift);


80

Report to ward on time Check inventory (ER, narcotics, dressing room, procedure room) Take report from the previous shift nurses Visit patients during taking over and check patients condition Receive the new patients and accompany/direct them to the bed Make patients comfortable; ask the patients complaints Take/assist in checking vitals, procedures Inform the concerned doctor and attend patients along with doctors Carry out doctors orders Administer stat medications immediately Monitor patients conditions frequently till stable Check IV fluids, drainages (if any) Send lab investigations on time and collect reports on time Take /assist in the special treatments (nebulizations, dressings, etc) Do a round and check patients' condition from time to time Complete documentations of all procedures (maintain the census register properly) Try and shift all admissions to the respective wards as soon as possible Complete the discharges as soon as possible Inform all incidences (minor/ major) to shift-in-charge at all times Clean and maintain the tidiness the casualty complex (dressing room, procedure room, blood bank) and keep ready for morning shift Keep casualty complex (dressing room, procedure room, blood bank, ER) ready at all times Maintain a professional relationship with the other team members Report to shift-in-charge when ever leaving ER Hand over to morning shift staff Report to morning shift-in-charge / ward sister before going off duty

81

DAILY TASK OF ICCU NURSES


7.30 am Report for duty 7.30 am to 7.45am Check inventories (narcotics, daily drug inventory, daily inventory, emergency trolley etc). Replace if anything is missing from emergency trolley Enquire about missing items, broken things and clear all doubts before taking the report Count and enter laundry linen Count and send CSSD things 7.45am to 8.15am Take patient report from previous shift nurses 8.15am to 8.30am - Take over special instructions and check allocated patients 8.30am 8.45 am Bedside take over of individual assigned patients Check at bedside All allocated patients chart whether it is completed or not All IV lines / IV sites / IVF balance and labels / any drugs added / CVP lines / dialysis catheter (if any) in situ. If urine catheter in situ check urine bag (colour and amount if any urine present) Loaded injections balance and labels (if any) Unit cleanliness and left over food containers If patient on ventilator check whether tubings are connected properly and water collection in the tubings and drain cups / check humidifier if water to be filled Check current settings of the ventilator

82

Check whether test lung and test tube are on the ventilator and nebuliser is attached to the ventilator Check bedside oxygen cylinder whether it is full, ambu bag with oxygen connection and reservoir bag is ready in good working condition Cardiac monitor for rhythm and whether chest leads are properly connected or not and whether finger pulse probe is connected or not Whether bedside equipments (suction machine / infusion pumps / cardiac monitor etc) are in good working conditions Whether all nursing interventions are recorded legibly / any investigations pending / any reports to be collected Specific interventions like I/O of the patient / vital signs / saturation / oxygen intake / CVP ( if on ventilator) / sleep pattern / personal hygiene / bowel 8.45am to 9.00am Check vital signs and record Assess patients conscious level and pupil reaction Assess GCS for relevant patients Endotracheal suctioning and oral suctioning (for ventilator patients) observe secretion (amount and color) Flush arterial line (if present) every hourly or as ordered Check patients file ( read nurses notes and doctors orders) Compare treatment chart with doctors orders Attend ward round Carry out doctors orders Make sure the relatives are explained about the patient condition by the treating doctor Check all medicines and get prescription from the doctors Receive laundry items and CSSD items, count and replace Inform shift in-charge if any balance remaining 9.00am to 10.00am

83

Check vital signs and record Inform any abnormalities and carry out orders Do suctioning if necessary If patient is getting RT feeding Q3hrly, give the feed list and explain the relatives (if not done previously) Give feeding and record If patient is on normal diet request the relatives to bring food and serve to the patient Empty and wash the food containers. Do not leave unfinished food in the locker For patients on ventilator, give back care and observe the skin for skin laceration, bedsores, edema, and any other skin problems Give sponge bath or toilet bath for other patients While giving mouth care check whether patient has loose teeth, bleeding gums, dry and cracked lips, tongue if coated etc While giving back care and turning the patient, check whether the air mattress is working or not (if it is there) While giving catheter and perineal care observe the perineum and catheter site for any abnormalities. Inform the duty medical officer and carry out orders Give catheter care with betadine solution by using aseptic technique Clean perineal area with soap and water Give hair wash every Saturday Flush CVP line and measure CVP (if on ventilator) and record Maintain hygiene chart Check, prepare and send patients for special investigations on time Assist in physiotherapy sos Change position as advised Start writing nurses notes 10.00am to 11.00am ET and oral suctioning if necessary Check vital signs and record 84

Any abnormalities inform to duty medical officer and carry out orders Re-check vitals after carrying out orders (eg: if temperature is high) Keep all the patients ready for visitors Check the cubicles and make the patient neat

11.00am to 12.00pm Check vital signs and record Allow one relative at a time to visit the patient Spend time to talk with them and clarify their doubts Give prescription if any If any other items like toiletries or drinking water is finished, ask the relatives to get it Receive the CSSD things, count and replace all items

Take a break of 10 -15 minutes during this time (two staff can go together) 12pm to 1.15 pm Check vital signs and record Inform and carry out orders if any abnormalities Administer due medication if any RT feed if patient is on Nasogastric feeds Serve lunch for those on normal diet Record in I/O chart Check ventilator tubings again. If water is collected empty drain cups and tubings Refill humidifier with sterile water (if necessary) Complete nurses notes and re-check whether the chart is complete or not Go through page by page and check whether all information is complete or not

85

Keep patient and cubicle clean If any bed is vacant prepare the cubicle and keep ready to receive another patient Check if any equipment or any place needs a repair work and inform If any item is borrowed make sure it is returned or else report it to the next shift nurses Report if any item is given to another ward. Try to get it back before you hand over to next shift nurses Check whether patient has to replace any drugs. If so, replace it before you hand over Check the emergency trolley and make sure it is ready to use Check all ventilators not in use and keep it ready for next use Check defibrillator and ECG machine and keep it ready for next use Check and keep the standing wreck ready. Replace all the items Check whether attendants have completed their work (sweeping, mopping, cleaning toilets, changing sodium hypochlorite, emptying dustbin, laundry, CSSD things, washing slippers, gloves washed and packing, changing rubber sheets etc) Check the over all cleanliness of the ward is maintained or not Be ready to handle any emergencies in the ward. Do not neglect other patients while you attend emergencies If patient is on ventilator, check the timings for medications and administer accordingly Collect all reports of investigations sent and enter where appropriate Complete your work and chart including round order book Complete the registers as appropriate Enter all services rendered in the service notification book

1.15 pm to 1.45 pm Give a detail report of your patients and handover to the next shift nurses Allow the next shift nurse to check patients bedside and charts Give her time to clarify her doubts before you leave

86

1.45 pm to 2.30 pm Wash and pack all the trays used Write your name and date legibly while keeping trays for autoclave Arrange nurses counter Attend any emergencies during that shift Report to shift in-charge of the next shift before leaving the ward

SECOND SHIFT 1.00 pm Report for duty 1.00 pm to 1.15 pm Check inventories (narcotics, daily drug inventory, daily inventory, emergency trolley etc). Replace if anything is missing from emergency trolley Enquire about missing items, broken things and clear all doubts before taking the report 1.15 pm to 1.45 pm Take patient report from previous shift nurses 1.45 pm to 2.00 pm - Take over special instructions and check allocated patients 2.00 pm to 2.15 pm Bedside take over of individual assigned patients Check at bedside All allocated patients chart whether it is completed or not All IV lines / IV sites / IVF balance and labels / any drugs added / CVP lines / dialysis catheter (if any) in situ. If urine catheter in situ check urine bag (colour and amount if any urine present) 87

Loaded injections balance and labels (if any) Unit cleanliness and left over food containers If patient on ventilator check whether tubings are connected properly and water collection in the tubings and drain cups / check humidifier if water to be filled Check for whether test lung and test tube are on the ventilator and nebuliser is attached to the ventilator Check current settings of the ventilator Bedside oxygen cylinder whether it is full and whether ambu bag with oxygen connection and reservoir bag is ready and in good working condition Cardiac monitor for rhythm and whether chest leads are properly connected or not and whether finger pulse probe is connected or not Whether bedside equipments (suction machine / infusion pumps / cardiac monitor etc) are in good working conditions Whether all nursing interventions are recorded legibly / any investigations pending / any reports to be collected Specific interventions like I/O of the patient / vital signs / saturation / oxygen intake / CVP ( if on ventilator) / sleep pattern / personal hygiene / bowel 2.15pm to 2.30pm Check vital signs and record Assess patients conscious level and pupil reaction (SOS) Endotracheal suctioning and oral suctioning (for ventilator patients) observe secretion (amount and color) Flush arterial line (if present) every hourly or as ordered Check patients file ( read nurses notes and doctors orders) Compare treatment chart with doctors orders Attend ward round (sos) Carry out doctors orders Make sure the relatives are explained about the patient condition by the treating doctor Check all medicines and get prescription from the doctors (if any) 2.30 pm to 3.30 pm

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Check vital signs and record Inform any abnormalities and carry out orders Do suctioning if necessary If patient is getting RT feeding Q3hrly, give the feed list and explain the relatives (if not done previously) Give feeding and record If patient is on normal diet request the relatives to bring food and serve to the patient Empty and wash the food containers. Do not leave unfinished food in the locker For patients on ventilator give back care and observe the skin for skin laceration, bedsores, edema, and any other skin problems While giving back care and turning the patient, check whether the air mattress is working or not (if it is there) While giving catheter and perineal care observe the perineum and catheter site for any abnormalities. Inform the duty medical officer and carry out orders Give catheter care with betadine solution by using aseptic technique Clean perineal area with soap and water Flush CVP line and measure CVP (if on ventilator) and record Maintain hygiene chart Change position as advised Check, prepare and send patients for special investigations on time (if not sent in the morning) Prepare patients for afternoon rest Start writing nurses notes 3.30 pm to 4.30 pm ET and oral suctioning if necessary Check vital signs and record Any abnormalities inform to duty medical officer and carry out orders Re-check vitals after carrying out orders (eg: if temperature is high) Check the cubicles and make the cubicle and patient neat Check and count the laundry things and CSSD things with the attendants Send laundry and CSSD things 89

4.30 pm to 5.30 pm Check vital signs and record Keep all the patients ready for visitors Give prescription if any If any other items like toiletries or drinking water is finished, ask the relatives to get it Receive laundry things, count and replace Inform shift in-charge if any balance remaining Take a break of 10 -15 minutes during this time (maximum two staff can go together)

5.30 pm to 6.15 pm Check vital signs and record Inform and carry out orders if any abnormalities Administer due medication if any RT feed if patient is on Naso-gastric feeds Serve a snack if on normal diet Record in I/O chart Allow one relative at a time to visit the patient Spend time to talk with them and clarify their doubts Check ventilator tubing again. If water is collected empty drain cups and tubing Refill humidifier with sterile water (if necessary) Complete nurses notes and re-check whether the chart is complete or not Go through page by page and check whether all information is complete or not Keep patient and cubicle clean If any bed is vacant prepare the cubicle and keep ready to receive another patient Check if any equipment or any place needs a repair work and inform If any item is borrowed make sure it is returned or else report it to the next shift nurses Report if any item is given to another ward. Try to get it back before you hand over to next shift nurses 90

Check whether patient has to replace any drugs. If so, replace it before you hand over Check the emergency trolley and make sure it is ready to use Check all ventilators not in use and keep it ready for next use Check defibrillator and ECG machine and keep it ready for next use Check and keep the standing rack ready. Replace all the items Check whether attendants have completed their work (sweeping, mopping, cleaning toilets, changing sodium hypochlorite, emptying dustbin, laundry, CSSD things, washing slippers, gloves washed and packing, changing rubber sheets etc) Check the over all cleanliness of the ward is maintained or not Be ready to handle any emergencies in the ward. Do not neglect other patients while you attend emergencies Communicate with the shift in-charge always If patient is on ventilator, check the timings for mediations and administer accordingly Collect all reports of investigations sent and enter where appropriate Complete your work and chart including round order book Complete the registers as appropriate Enter all services rendered in the service notification book

6.15 pm to 6.45 pm Give a detail report of your patients and handover to the next shift nurses Allow the next shift nurse to check patients bedside and charts Give her time to clarify her doubts before you leave 6.45 pm to 8.00 pm Wash and pack all the trays used Write your name and date legibly while sending trays for autoclave Arrange nurses counter Report to shift in-charge of the next shift before leaving the ward

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THIRD SHIFT
6.00 pm Report for duty 6.00 pm to 6.15 pm Check inventories (narcotics, daily drug inventory, daily inventory, emergency trolley etc). Replace if anything is missing from emergency trolley Enquire about missing items, broken things and clear all doubts before taking the report 6.15 pm to 6.45 pm Take patient report from previous shift nurses 6.45 pm to 7.00 pm - Take over special instructions and check allocated patients 7.00 pm to 7.15 pm Bedside take over of individual assigned patients Check at bedside All allocated patients chart whether it is completed or not All IV lines / IV sites / IVF balance and labels / any drugs added / CVP lines / dialysis catheter (if any) in situ. If urine catheter in situ check urine bag (colour and amount if any urine present) Loaded injections balance and labels (if any) Unit cleanliness and left over food containers If patient on ventilator check whether tubings are connected properly and water collection in the tubings and drain cups / check humidifier if water to be filled Check current settings of the ventilator Bedside oxygen cylinder whether it is full and whether ambu bag with oxygen connection and reservoir bag is ready and in good working condition Cardiac monitor for rhythm and whether chest leads are properly connected or not and whether finger pulse probe is connected or not Whether bedside equipments (suction machine / infusion pumps / cardiac monitor etc) are in good working conditions

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Whether all nursing interventions are recorded legibly / any investigations pending / any reports to be collected Specific interventions like I/O of the patient / vital signs / saturation / oxygen intake / CVP ( if on ventilator) / sleep pattern / personal hygiene / bowel 7.15 pm to 7.30 pm Check vital signs and record Assess patients conscious level and pupil reaction (SOS) Endotracheal suctioning and oral suctioning (for ventilator patients) observe secretion (amount and color) Flush arterial line (if any) every hourly or as ordered Check patients file ( read nurses notes and doctors orders) Compare treatment chart with doctors orders Carry out doctors orders Check all medicines and get prescription from the doctors (sos) a. pm to 8.30 pm Check vital signs and record Inform any abnormalities and carry out orders Do suctioning if necessary If patient is getting RT feeding Q3hrly, give the feed list and explain the relatives (if not given previously) Give feeding and record If patient is on normal diet request the relatives to bring food and serve to the patient Empty and wash the food containers. Do not leave unfinished food in the locker Give back care and observe the skin for skin laceration, bedsores, edema, and any other skin problems While giving back care and turning the patient, check whether the air mattress is working or not (if it is there) Give back care and catheter care While giving catheter and perineal care observe the perineum and catheter site for any abnormalities. Inform the duty medical officer and carry out orders Give catheter care with betadine solution by using aseptic technique Clean perineal area with soap and water

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Flush and measure CVP (if on ventilator) and record Maintain hygiene chart Change position as required Start writing nurses notes 8.30 pm to 9.30 pm ET and oral suctioning if necessary Check vital signs and record Any abnormalities inform to duty medical officer and carry out orders Re-check vitals after carrying out orders (eg: if temperature is high) Check the cubicles and make the patient neat Receive CSSD things (if ready), count and replace all items Inform shift in-charge if not received or if any balance remaining 9.30 pm to 10.30 pm Check vital signs and record Give prescription if any If any other items like toiletries or drinking water is finished, ask the relatives to get it Administer medications if any Take a break of 10 -15 minutes during this time (maximum two staff can go together) 10.30 pm to 12 midnight Check vital signs and record Inform and carry out orders if any abnormalities Administer due medication if any RT feed if patient is on Naso-gastric feeds Serve dinner for those on normal diet Empty and wash the food containers. Do not leave unfinished food in the locker Record in I/O chart Check ventilator tubing again. If water is collected, empty drain cups and tubing Refill humidifier with sterile water (if necessary) Complete nurses notes and re-check whether the chart is complete or not 94

Go through page by page and check whether all information is complete or not Keep patient and cubicle clean If any bed is vacant prepare the cubicle and keep ready to receive another patient Check if any equipment or any place needs a repair work and inform If any item is borrowed make sure it is returned or else report it to the next shift nurses Report if any item is given to another ward. Try to get it back before you hand over to next shift nurses Check whether patient has to replace any drugs. If so, replace it before you hand over Check the emergency trolley and make sure it is ready to use Check all ventilators not in use and keep it ready for next use Check defibrillator and ECG machine and keep it ready for next use Check and keep the standing rack ready. Replace all the items Check whether attendants have completed their work (sweeping, mopping, cleaning toilets, changing sodium hypochlorite, emptying dustbin, laundry, CSSD things, washing slippers, gloves washed and packing, changing rubber sheets etc) Check and count the laundry things and send to laundry Check the over all cleanliness of the ward is maintained or not Be ready to handle any emergencies in the ward. Do not neglect other patients while you attend emergencies Supervise attendants at all times Communicate with the shift in-charge always

12 midnight to 1.00 am Check vital signs and record ET and oral suctioning if necessary Administer any due medications If patient is on ventilator, check the timings for mediations and administer accordingly

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Collect all reports of investigations sent and enter where appropriate Receive laundry things, count and replace all linen Inform shift in-charge if any balance remaining Complete your work and chart including round order book Complete the registers as appropriate Enter all services rendered in the service notification book Give a detail report of your patients and handover to the next shift nurses Allow the next shift nurse to check patients bedside and charts Give her time to clarify her doubts before you leave Pack all the trays used and send it for autoclave Write your name and date legibly while sending trays for autoclave Arrange nurses counter Report to shift in-charge of the next shift before leaving the ward

NIGHT DUTY 11.45 pm Report for duty 11.45 pm to 12.00 am Check inventories (narcotics, daily drug inventory, daily inventory, emergency trolley etc). Replace if anything is missing from emergency trolley Enquire about missing items, broken things and clear all doubts before taking the report Arrange to send the service notification book to counter Make the midnight census Prepare the shift in-charge book and ward round book

12.00 am to 12.30 am Take patient report from previous shift nurses 12.30 am to 12.45 am - Take over special instructions and check allocated patients 12.45 am to 1.00 am Bedside take over of individual assigned patients

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Check at bedside All allocated patients chart whether it is completed or not All IV lines / IV sites / IVF balance and labels / any drugs added / CVP lines / dialysis catheter (if any) in situ. If urine catheter in situ check urine bag (colour and amount if any urine present) Loaded injections balance and labels (if any) Unit cleanliness and left over food containers If patient on ventilator check whether tubings are connected properly and water collection in the tubings and drain cups / check humidifier if water to be filled Check current settings of the ventilator Bedside oxygen cylinder whether it is full and whether ambu bag with oxygen connection and reservoir bag is ready and in good working condition Cardiac monitor for rhythm and whether chest leads are properly connected or not and whether finger pulse probe is connected or not Whether bedside equipments (suction machine / infusion pumps / cardiac monitor etc) are in good working conditions Whether all nursing interventions are recorded legibly / any investigations pending / any reports to be collected Specific interventions like I/O of the patient / vital signs / saturation / oxygen intake / CVP ( if on ventilator) / sleep pattern / personal hygiene / bowel 1.00 am to 1.15 am Check vital signs and record Assess patients conscious level and pupil reaction (SOS) Endotracheal suctioning and oral suctioning (for ventilator patients) observe secretion (amount and color) Check patients file ( read nurses notes and doctors orders) Arrange patient file Replace necessary sheets and file extra sheets from the chart board Compare treatment chart with doctors orders Carry out doctors orders (if any)

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Check all medicines and get prescription from the doctors (SOS) 1.15 am to 3.15 am Check vital signs and record Inform any abnormalities and carry out orders Do suctioning if necessary Start writing nurses notes ET and oral suctioning if necessary Any abnormalities inform to duty medical officer and carry out orders Re-check vitals after carrying out orders (eg: if temperature is high) Check ventilator tubing again. If water is collected empty drain cups and tubing Refill humidifier with sterile water (if necessary) Complete nurses notes and re-check whether the chart is complete or not Go through page by page and check whether all information is complete or not If any bed is vacant prepare the cubicle and keep ready to receive another patient Check if any equipment or any place needs a repair work and inform If any item is borrowed make sure it is returned or report it to the next shift nurses Report if any item is given to another ward. Try to get it back before you hand over to next shift nurses Check whether patient has to replace any drugs. If so, replace it before you hand over Check the emergency trolley and make sure it is ready to use Check all ventilators not in use and keep it ready for next use Check defibrillator and ECG machine and keep it ready for next use Check and keep the standing wreck ready. Replace all the items Check whether attendants have completed their work (sweeping, mopping, cleaning toilets, changing sodium hypochlorite, emptying dustbin, laundry, CSSD things, washing slippers, gloves washed and packing, changing rubber sheets etc) Check and count the laundry things and CSSD things with the attendants Check the over all cleanliness of the ward is maintained or not Be ready to handle any emergencies in the ward. Do not neglect other patients while you attend emergencies Communicate with the shift in-charge always 98

12 midnight to 1.00 am Check vital signs and record ET and oral suctioning if necessary Administer any due medications If patient is on ventilator, check the timings for mediations and administer accordingly Collect all reports of investigations sent and enter where appropriate Complete your work and chart including round order book Complete the registers as appropriate Enter all services rendered in the service notification book Give a detail report of your patients and handover to the next shift nurses Allow the next shift nurse to check patients bedside and charts Give her time to clarify her doubts before you leave Pack all the trays used and send it for autoclave Write your name and date legibly while sending trays for autoclave Arrange nurses counter Attend any emergencies during that shift Report to shift in-charge of the next shift before leaving the ward Flush CVP line and measure CVP (if on ventilator) and record

DAILY TASKS OF O.P.D NURSES


Morning Shift Report to ward on time. Check ward inventory. Arrange the consulting rooms for morning shifts doctors. Send and receive items from C.S.S.D. Check the temperature of fridge and record. Check the laundry linen. Start the dressings and injections on time. Sending samples to laboratory. 99

Assisting the cases with the doctors in minor O.T. Preparing for the vaccination for the new born and routine vaccination. Inspection the conditions of the patients wounds. Check the cleanliness and tidiness of the rooms and area. Washing and packing the instruments. Giving of I /V and I/M injections. Carbonizing of the beds and trolleys. Cleaning the rooms for the 2nd shift. Handing over to the 2nd shift.

Afternoon shift Report to the ward on time. Check ward inventory. Taking over from the 1st shift. Continue vaccination. Continue dressings and injections. Sending specimens to laboratory. Assisting cases in minor O.T. Sending and collecting things from C.S.S.D. Cleanliness of the rooms. Carbonizing of the beds and rooms. Check the cleanliness and tidiness of the rooms and area. Hand over to the 3rd shift.

Evening Shift ( 3rd Shift) Report to the ward on time. Check ward inventory. Taking over from the 2nd shift. Arranging the rooms. Continue of the dressings and injections.

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Assisting of minor cases in minor O.T. Check the cleanliness of the rooms and area. Carbonizing of rooms. Prepare for closing the rooms.

DAILY TASK FOR STAFF WORKING IN THE DIALYSIS UNIT


MORNING SHIFT Report ward on time Check the ward inventory Check narcotics inventory Rinse the RO machine Disinfection of dialysis machine Check pre-dialysis weight and vital signs of the patient Make the patient comfortable Check and send pre-dialysis investigations if necessary Check fistula /catheter site Start dialysis Monitor vital signs hourly Observe complications like hypotension,,nausea,vomiting,headache etc Collect blood reports Inform the doctor if necessary Carry out any emergency orders Complete documentation Check the cleanliness and tidiness of the ward / centre

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Prepare disinfectant solution ( clear surf ) Terminate the dialysis after completion Check and send post dialysis investigation if necessary Do pressure dressing to access site Disinfection of the dialysis machine Clean the dialysis machine with clear surf and carbolize the bed Keep the patient for observation( at least for 15 mnts) Send the patient home with the relative Hand over to next shift Report to ward in charge or shift in charge before going off duty

AFTERNOON SHIFT Report ward on time Check the ward inventory Check narcotics inventory Take report from previous shift nurses Visit patients after report and check patientsconditions Check pre-dialysis investigation, weight and vital signs of the patient Make the patient comfortable Check and send pre-dialysis investigations if necessary Start dialysis Monitor vital signs hourly Observe for any complications like hypotension,nausea,vomiting,headache etc Collect blood reports

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Inform doctor if necessary Carry out any emergency orders Complete documentation Check the cleanliness and tidiness of the ward / centre Terminate the dialysis after completion Check and send send post dialysis investigation if necessary Do pressure dressing to access site Disinfection of the dialysis machine Clean the dialysis machine with clear surf and carbolize the bed Keep the patient for observation( at least for 15 mnts) Send the patient home with the relative Hand over to next shift Report to ward in charge or shift in charge before going off duty

EVENING SHIFT Report ward on time Check the ward inventory Check narcotics inventory Take report from previous shift nurses Visit patients after report and check patients conditions Check pre-dialysis investigations, weight and vital signs of the patient Make the patient comfortable Check and send pre-dialysis investigations if necessary

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Start dialysis Monitor vital signs hourly Observe complications like hypotension, nausea, vomiting, headache etc Collect blood reports Inform doctor if necessary Carry out any emergency orders Complete documentation Check the cleanliness and tidiness of the ward / centre Terminate the dialysis after completion Check and send post dialysis investigation if necessary Do pressure dressing to access site Disinfection of the dialysis machine Clean the dialysis machine with clear surf and carbolize the bed Keep the patient for observation( at least for 15 mnts) Send the patient home with the relative Check the routine cleaning of ward for the next day (washing of all the medicine cups, trays and clean trolleys etc.)

Write down in communication book if anything special happens

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THEATRE GUIDELINES
THEATRE LISTS 1. Theatre list should be sent on the previous day before 17:00 hrs to theatre and wards 2. Cases with co-morbidity, (e.g. Diabetes, HTN,COPD) should be well prepared and well communicated with concern anaesthetist and concern staff, in order to avoid last minute cancellations of the case 3. Anaesthetist should do a preliminary check up of PAC workup on the night before surgery 4. The theatre list should mention any special needs the case might have (e.g. C-arm, change of or table, instruments, ICU bed) 5. Theatre list would accommodate cases such that the list should finish on time at the end of the OT day. The emergency team (anaesthetist/theatre staff) should not be over burdened with routine cases 6. If an emergency list was brought forward it should be entertained first in spite of the nature /type of surgery (there is no emergency/semi emergency or less emergency cases). 7. In case if there is an LSCS and another emergency then preference will be given to the LSCS 8. No operating department should take advantage and utilize other department ORs saying they have an emergency . i.e. they should accommodate emergency list in their ongoing list. If an emergency occupies another departments OR on their Operation day then the respective department to be given the OR which empties first. 9. The time taken by the emergency would be compensated at the end of the list (i.e. if an hour taken by the emergency case, then the theatre will function till 15:00 hrs instead of 14:hrs)

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10. If any one wants to use the theatre on days which are not theirs then permission must be obtained from the sister in-charge of the theatre and the surgeon concerned 11. In the event of a procedure has to be changed or done by the surgeon for which consent has not been obtained, this must be immediately informed by the responsible staff in that OR to the relative who had signed the consent form. After the surgery is over it is the duty of the attending surgeon to call the relative and explain the reason for the procedure.

PREPARATION OF THE THEATER


1. Cleanliness Check whether the theatre is clean enough to start surgery.

2. Sterility status Check whether the theatre is carbolized thoroughly, if it is the first case in the morning. Carbolize the bed, mayo stand instrument trolleys in between cases.

3. Anaesthesia machine Check whether the machine is functioning properly. All necessary connections are working. Check the colour of soda lime, no leakage from any tubings or breathing bag. Laryngoscope and other necessary items are available and working.

4. Drugs Keep all the necessary drugs ready and check the expiry date. Make sure the drug was stored at the correct temperature. 5. Sets and bundles Check the label for correct set, the autoclave tape for sterility and date of autoclaving. Arrange the sets and bundles in the correct places.

6. Consumables Check whether all the consumables are available and check the expiry date.

7. Equipments Connect the equipment and check whether it is working and clean.

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8. Lighting Check the light whether it is working and adjust them

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POINTS TO BE REMEMBERED BY THE SCRUB NURSE AND THE CIRCULATING / FLOOR NURSE

1. Make sure that you strictly follow the instructions which are placed on the walls of scrub area. 2. Make sure that all the aseptic procedures are followed during and after scrubbing 3. If the circulating/ floor nurse find you unsterile please change your gown & gloves. 4. Do not open the second layer of the bundle or the set unless you are scrubbed, gowned and gloved. 5. Scrub nurses gloves has to be open and given to her/his hand by the floor nurse once he /she is scrubbed & gowned 6. Do not open gloves, sutures or any sterile item straight to the operating table or field. Give them to the scrubbed nurse instead. 7. Make sure that all surgical appliances (cautry machines, suction machine, incubator, warmer, extension boards, and instruments) are in proper order. 8. Make sure that you are properly covered through out the surgery. 9. Make sure that the sterile field is maintained. 10. Be aware that you are sterile at all times. 11. When ever you or team finds that some thing is unsterile please correct it then and there. 12. Do not let unscrubbed staff to enter the sterile field. 13. Maintain proper count and documentation. 14. Scrub nurse and circulating/floor nurse should take count together.

Thank you for your cooperation .its the patient who will benefit and it is us who will be satisfied at the end of the day.

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109 PROTOCOLS TO BE FOLLOWED IN THE OPERATING ROOMS 1. Protective gloves are to be worn at all times when working with potentially contaminated materials. 2. The major door to the operation room is just being used for bringing and taking the patient only. 3. Go to the operation room when it is really necessary. 4. Use one small door for getting in and out of the operating room when cases are going on. 5. The doors to the operating rooms should always remain closed. 6. The number of staff present in OT and the staff movement should be limited to minimum. 7. Sterile gowns are to be worn after scrubbing. 8. Discussions / conversations between theatre staff during an operation should be limited. 9. The surgical hand disinfection (scrubbing) is to be followed according to the instructions which are placed on the walls of scrub area. 10. After every surgical case, the operating team must dispose their gloves and gowns in the allocated areas.

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110 PROTOCOLS TO BE FOLLOWED WHILE IN OPERATION THEATRE COMPLEX 1. All personnel should change into theatre clothes in the allocated changing rooms. 2. Under garments (like petticoat and baniyan) should not be visible. 3. The hair must be completely covered by the theatre caps. 4. Jewelries on the hands and forearms, as well as wrist watches are not permitted. 5. Nail polish (colored and colorless) is not permitted. 6. Before entering all operating areas, a face mask must be worn. this must cover the mouth the nose and all facial hair (e.g. beards moustaches). 7. To leave the operating theatre with surgical attire is prohibited. 8. The OT staffs must change their facial mask when ever necessary ( e.g. when moist) 9. Face mask should not be kept hanging at the neck, instead should be removed and kept in pocket if not wearing. 10. Used theater attire must be disposed off properly to the allocated hampers in the respective change rooms. 11. A hygienic hand disinfection is necessary before entering and leaving the operating theatre before sterile procedures after possible contamination (cleaning the nose,visiting the toilet) Before and after cleaning the patient. 12. Only the theatre staff and the surgical team can enter theatre. 13. Outside staffs should get permission from the theatre in-charge before entering the theatre at all times. 14. Foot wear is to be changed whenever soiled with body fluid 15. Eating or drinking is prohibited out side tearoom. (Pay attention to change of plans).

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111 ROUTINE CLEANING OF OPERATION THEATRE

Daily cleaning
Carbolize with carbolic solution after every case and with hypochlorite solution every morning OT 1/2/3 Scrub room 1/2/3 Clean utility 1/2 Dirty utility 1/2/3 Sterile corridor Sterile store Equipment store

Weekly cleaning
Wash with washing detergent and water and clean with hypochlorite solution. OT 1/2/3 Scrub room 1/2/3 Clean room 1/2 Sterile corridor Dirty utility Clean store Packing room Equipment store Sterile store

Monthly cleaning
Wash with washing detergent and water and clean with hypochlorite solution. Pre-op room Post-op room

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112 Outside area

DAILY TASKS OF NURSES WORKING IN OPERATION THEATRE

Morning Shift
Report to OT on time Check inventory Take report Check the daily posting Check the O T list Bring patient Check blood investigations reports PAC and consent. Prepare their respective OT/place Check narcotic inventory Check the cleanliness and the tidiness of the OT Make sure first patient for each OT is in OT by 7:50 am Start scrubbing as soon as the doctors(anaesthetists and surgeons) enter the theater Pack instrument sets and bundles whenever possible Hand over to the next shift staff before going off duty Complete documentations (report book) Report to in charge before leaving at 2:30 pm

Second shift
Report to OT time Check inventory Check narcotic inventory

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113 Take handover of their respective places and relieve the morning staff Packing of equipments, bundles sets gowns etc Replace items before packing Wash and Carbolize the OT s Clean and tidy the other areas Carbolize the stretcher and accessory stand Complete documentations and registers Check the next day OT lists and confirm the cases and their wards Check the cleanliness and the tidiness of the OT Confirm the necessary items for next days surgery are packed and autoclaved Check the machines whether in working order Wash up all items and keep ready for the next day Prepare items like gauze, D/pads packs etc Hand over to next shift staffs Report to shift in charge before leaving

Third shift
Report to OT time Check inventory Check narcotic inventory Take handover of their respective places and relieve the staff Check the next day OT lists and confirm the cases and their wards Check the cleanliness and the tidiness of the OT Confirm the necessary items for next days surgery are packed and autoclaved Receive linen, fold(properly) and packing bundles Arrange the changing rooms (male and female) and cleaning the stores

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114 Carbolize packing rooms and clean stores Check the cleanliness and the tidiness of the OT Report to shift in charge before leaving

Night shift
Report to ward time Check inventory Check narcotic inventory Take handover of their respective places and relieve the staff Complete documentations and registers Check the next day OT lists and confirm the cases and their wards Check the cleanliness and the tidiness of the OT Confirm the necessary items for next days surgery are packed and autoclaved Arrange the theaters Check the Anaesthesia machine and laryngoscope Keep the theater ready for the morning shift (routine cases) Arrange the changing rooms (male and female) and cleaning the stores Inform the wards to bring first cases by 7:40 am Patients for all theaters to be inside OT by 7:50 am Complete documentations (report book) Report to shift in charge before leaving Check the sterility of the OT (carbolize)

FRIDAYS Check the sets and bundles and sent for autoclaving those that require re autoclaving Wash the whole OT complex 114

115 Clean with sodium hypo chloride solution Replace items in sets e.g. ortho implants

NOTE During all shifts keep the whole theater clean this includes the pre op and post op with the corridor area and where we keep our gas cylinders too Replace items in sets before packing e.g. ortho implants to be replaced

DAILY TASKS OF ATTENDANTS WORKING IN OPERATION THEATRE

Morning shift
Report to OT on time Take over from the night shift attendant Check the general cleanliness of OT complex Do not keep hypo chloride solution in basin for more than 30minutes Take instruments to CSSD and collect it when autoclaved Keep equipment inside ORs e.g. Suction /Cautry and check the table Check whether dirty utility rooms are closed/locked Check paper towel dispenser and keep it filled Clean the stretchers Clean/mop ORs properly and quickly in between cases Keep stretchers ready all time with the pillows and rubber sheet Check for sharp disposals and change it when it is 2/3rd full Keep the counter slippers properly and wash it whenever dirty Give urinals to patients if asked by a nurse Assist patients to the toilet if required (ONLY WHEN ASKED BY A NURSE) Answer the bell, but DO NOT give any information regarding patients. call a nurse to give any information to the relatives

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116 Cut gauze Check patients toilet frequently and clean as needed Wash kidney trays and disinfect them if used (keep in 0.5%sodium hypochlorite solution for 10mins. DO NOT LEAVE THEM FOR MORE THAN THE SPECIFIED TIME) Wash all the toilets thoroughly Clean doors, windows and other furnitures Wash suction bottle and suction tubing after each case Clean and disinfect pre and post operative thoroughly when patients are transferred Take dirty linen to laundry DO NOT TAKE DIRTY LINEN ALONG WITH ANY THING CLEAN(STICK BIOHAZARDABLE) Take things to CSSD Wash the slippers. Out side attendant has to go to wards to bring patients to OT as well as to shift patients out when ever asked. Do not enter OR during surgery unless asked Be present outside the ORs Take linen to laundry and collect clean linen Be prompt whenever called to anyone Hand over to the next shift Report and get permission from the shift in charge before leaving the OT or going off duty. Keep drinking water in tea room

Evening shift
Report to OT on time Take over from the morning shift attendant Check the general cleanliness of the OT complex Take instruments to CSSD and collect it when autoclaved

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117 Collect clean linen from laundry(count them properly and inform to the shift in charge if there is any problem) Clean stretchers Assist patients to the toilet if required (ONLY WHEN ASKED BY A NURSE) Answer the bell, but DO NOT give any information regarding patients. Call a nurse to give any information to the relatives Check patients toilet frequently and clean as needed Wash kidney trays and disinfect them if used (keep in 0.5%sodium hypochlorite solution for 10 minutes. DO NOT LEAVE THEM FOR MORE THAN THE SPECIFIED TIME) Wash suction bottle and suction tubing after each case Clean and disinfect pre and post operative thoroughly when patients are transferred Oxygen tubing and change water in the humidifier Take dirty linen to laundry DO NOT TAKE DIRTY LINEN ALONG WITH ANY THING CLEAN(STICK BIOHAZARDABLE) Keep the store room clean Wash the slippers Keep the counter slippers properly and wash it whenever asked by a nurse Hand over to the next shift Report and get permission from the shift in charge before leaving the OT or going off duty. Keep drinking water in tea room

Night shift
Report to the OT on time Take over from the evening shift attendant Check the general cleanliness of the OT complex Assist patients to the toilet if required (ONLY WHEN ASKED BY A NURSE) 117

118 Answer the bell, but DO NOT give any information regarding patients. Call a nurse to give any information to the relatives Cut gauze Check patients toilet frequently and clean as needed Wash all kidney trays and disinfect them if used (keep in 0.5%sodium hypochlorite solution for 10 minutes. DO NOT LEAVE THEM FOR MORE THAN THE SPECIFIED TIME) Wash suction bottle and suction tubing after each case Clean and disinfect pre and post operative thoroughly when patients are transferred (change water in the humidifier) Assist the nurses in cleaning and disinfecting the ORs Take dirty linen to laundry DO NOT TAKE DIRTY LINEN ALONG WITH ANY THING CLEAN(KEEP BIOHAZARDABLE) Wash the slippers Keep the counter slippers properly and wash it whenever asked by a nurse Hand over to the next shift Report and get permission from the shift in charge before leaving the OT or going off duty. Keep drinking water in tea room

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Midwifery guidelines
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Acknowledgement
These guidelines have been prepared with the aim of providing guidance for the proper management of patients admitted to labour room. They are based on the interventions described in the manual Integrated Management of Pregnancy and Childbirth (IMPAC) published by WHO. In addition, protocols prepared by Dr. Jumailath Begam in 1995 were also used as a reference in preparing these guidelines. Nursing department greatly acknowledges Dr. Jabeen Ali Shareef and Dr. Mohamed Aseel Jaleel who gave their advice and opinion to complete these guidelines. In addition, contributions given by the doctors in the department of obstetrics and gynaecology are appreciated. Our thanks are also due to Dr. Abdullah Niyaf for his contributions on newborn care. Furthermore, nurses working in labour room have contributed immensely to make these guidelines. Nursing department wishes to thank all those who have helped to prepare them. It is hoped that these guidelines will be useful not only for the staff of IGMH but also to the students and nursing staff working throughout Maldives.

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121 Nursing department IGMH

ADMISSION PROTOCOL FOR LABOUR PATIENTS


Confirm identity of the patient (check the patients name, age and address on the folder). Make sure all ANC records are available. These records should be attached to the inpatient folder. ANC card Scan reports Blood investigation reports Urine reports Referral letters (if any) On admission take a brief history with emphasis on the following. Gravida/para LMP and EDD as per dates and scan Problems with previous pregnancies/deliveries. Rh status

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122 Allergies History of medical problems Onset of labor Membranes-ruptured or intact.

The following documents must be completed for all labour patients: Labour ward admission Daily census Partograph (when the cervical dilatation is 4cms or more.) New born sheet.

If investigations are not available send for all routine investigation. This includes: urine R/E,
Hb, PCV, blood grouping and Rh typing, RBS, G6PD, VDRL, HbsAg and HIV screening.

For all patients in labour have one pint of blood cross matched. If the patients Hb is low or
gives history of severe PPH in last deliveries arrange for 2 donors.

Do an abdominal palpation and confirm the lie, presentation and position of the fetus. Note if
the foetal movements are felt.

Record temperature, BP, pulse and FHS and uterine contraction. Note the frequency and
intensity of uterine contractions. Normal fetal heart rate ranges from 120 to 160 beats per minute. The rate may increase or decrease during a contraction, hence foetal heart should be checked only when the uterus is relaxed.

P/V examination should be done unless contraindicated, to assess if the patient is in labour. A
vaginal examination should be performed only following adequate explanation. DO NOT DO P/V in the following conditions: Ante partum hemorrhage Low lying placenta. 122

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All patients in labour should have perineum shaved and a disposable enema should be given
unless contraindicated. (Contra indications include severe PIH, cervix fully dilated, APH abnormal presentations).

Document all the findings and notify the medical officer or the gynaecologist on call.

On admission assess the patients personal hygiene and if required provide an assisted bath/
sponge bath.

Once the patient has been assessed, give an adequate explanation to the patient and the relatives.

While caring for the woman in labour give special emphasis to the principles in the ethical and professional code of conduct for nurses. This includes: Respecting the womans right to privacy and modesty while doing procedures. Draw curtains and drape the patient while performing a vaginal examination. Maintain confidentiality. Show empathy. Provide sufficient information before performing any procedures (If language is a barrier ask some one for help). Recognize professional accountability borne for actions and omission

ON GOING CARE DURING FIRST STAGE OF LABOUR


If there are no problems/ risk factors, for all patients in labour with term gestation and vertex presentation the following care is to be followed.

Assess the general condition of the patient with emphasis to edema, pallor, cyanosis and
hydration.

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Record blood pressure on admission and 4 hourly if normal. If the diastolic is more than 90
record BP every half hourly or as per the doctors advice. Notify any abnormal recordings to the duty doctor (BP is not to be taken during contraction).

Check temperature on admission and every 4-6th hourly unless otherwise indicated. If the
patient is febrile notify the doctor.

Record pulse on admission and half hourly. Notify the doctor if tachycardia is there (pulse
should not be taken during a contraction).

Record FHS on admission and every half hourly or more frequently if indicated. FHS should be
checked following a contraction and in between contractions. It should be counted for ONE FULL MINUTE. If there is any foetal tachycardia (>160 bpm), foetal bradycardia (<120 bpm) or irregular foetal heart rate notify the doctor immediately. (For additional care refer to care of patients with foetal distress).

Assess the uterine contractions on admission and every hourly in the latent phase (upto 3cm)
and every half hourly in the active phase (from 4-10cm). Contractions should be checked for its frequency and duration. Frequency of contractions is assessed by the number of contractions in a 10-minute period. Duration is measured in seconds from the time the contraction is first felt abdominally, to the time the contraction phases off. In the active phase contractions should occur at least three times every ten minutes each lasting > 40 seconds with adequate relaxation in between. If contractions are not satisfactory inform the doctor.

If there is no contra indications a P/V examination should be performed every 4 hourly in the
first stage to assess the progress of labour.

Follow aseptic techniques while performing a P/v examination and be as gentle as possible.
Ensure patients privacy during the procedure. The following findings should be recorded:

o Position, dilatation and effacement of the cervix


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o Presenting part and its level o Presence of caput or moulding o Membranes: presence or absence of membranes and the colour of liquor if
membranes are ruptured.

o Liquor: present or absent, colour o Ensure that no cord is felt


If the membranes are ruptured liquor should be carefully examined for meconium if the fetus is in the vertex presentation. A slight degree of meconium without foetal heart abnormality is a warning for the need for caution. Thick meconium may indicate the need to speed up delivery hence if meconium is present in the liquor inform the doctor. Slight green color. Thin meconium. Green to dark color Moderate meconium. Dark green with flakes of meconium Thick meconium. After each vaginal examination FHS should be recorded.

A partograph should be filled for all patients in the active phase of labour. Dilation of the cervix is plotted with an X, descent of the fetal head is plotted with an O, and uterine contractions are plotted with differential shading. The first recording on the partograph should be on the alert line and if the progress of labor is normal, plotting of cervical dilatation should remain on the Alert Line or to left of it.

Descent of the head should always be assessed by abdominal examination (by Rule of Fifths felt above the pelvic brim) immediately before doing a vaginal examination. When 2/5 or less of the fetal head is felt above the level of symphysis pubis, the head is engaged, and by vaginal examination, vertex is at the level of ischial spines (0 station).

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126 Recording of the condition of the membranes and liquor in the partograph should be as follows: Intact membranes - I Ruptured membranes + Clear liquor- C Ruptured membranes + Meconium-stained liquor - M Ruptured membranes + Blood-stained liquor- B Ruptured membranes + Absent liquor- A

Presence of moulding should be recorded in the partograph as follows: 1: Sutures opposed. 2: Sutures overlapped but reducible 3: Sutures overlapped and not reducible.

Encourage oral fluids during labour unless otherwise indicated. Encourage regular 2 hourly voiding and record when urine is passed. A full bladder is uncomfortable and may inhibit the progress of labour by inhibiting the decent of the presenting part. Where there is a palpable bladder and the woman is unable to void, consider urinary catheterization. Attend to the patients personal hygiene as required. Provide oral care every 4 hourly or as required. Provide early morning care for all patients. Perineal care should be given according to the needs of the patient. Encourage the woman to move about freely when in early labour unless contraindicated. Eg if the patient is leaking or bleeding. Teach breathing exercises for coping with labour pains. Encourage the patients not to push before full dilatation of cervix.

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The patients condition should be explained to the relatives atleast twice in each shift and at any events or changes in the treatment line. Allow the patients to talk to the relatives over phone if they wish to. If they are in labour room for too long they should be taken out to meet the relatives. Complete documentation and give proper handover when the shift changes.

CARE OF PATIENTS WITH FOETAL DISTRESS


Foetal brady cardia in the absence of contraction or persisting after a contraction and foetal tachycardia in the absence maternal tachycardia is suggestive of foetal distress. Thick meconium stained liquor in vertex presentation may also be suggestive foetal distress. If any of these conditions are observed inform a gynecologist immediately General management: Place the woman on left lateral position

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128 Administer oxygen 4-6 liters per minute. Stop oxytocin if being administered (with advice from a doctor) Record the foetal heart rate every 10- 15 minutes. Start a plain pint of ringer lactate. Explain to the patient and the relatives about the babys condition. Check for explanatory signs of foetal distress: Bleeding If vaginal examination is done feel for the cord pulsation. If felt, manage as cord prolapse. Observe the colour of liquor if the membranes are ruptured Record the findings.

CARE OF PATIENTS WITH PREVIOUS LSCS IN LABOUR


On admission collect the history and find out the indication for LSCS. Inform the gynaecologist or the medical officer as soon as possible. If the woman is in labour monitor the progress of labour using a partograph. If the cervical dilatation crosses the alert line inform a gynaecologist. Monitor the maternal pulse, foetal heart rate and uterine contractions every half hourly. Monitor the womans blood pressure every hourly and temperature every 4th hourly

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129 Encourage the woman to void every 2 hourly and observe the colour of urine. When the woman is in active labour catheterize her. If hematuria is observed inform a gynaecologist. Watch for signs of impending rupture.If any of these findings are observed inform a gynaecologist or a medical officer immediately: Rapid maternal pulse Persistant abdominal pain and scar tenderness Foetal distress. Record all the findings.

CARE OF PATIENT DURING SECOND STAGE OF LABOUR


When possible all the deliveries must be conducted in the second stage room and the following steps should be ensured. When the cervix is fully dilated, shift the patient to the second stage room. Paediatric medical officer should be informed for all the deliveries. A pediatrician must be notified in cases of Severe foetal distress

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130 Thick meconium stained liquor Instrumental deliveries Premature deliveries Undue delay Fot patients at risk (PIH, DM, IUGR, postdated pregnancy) Gynaecologist on call must be notified in cases of Foetal distress Thick meconium stained liquor with or without foetal heart abnormalities Prolonged second stage of labour (more than 1 hour in primis and more than half an hour in multis) Heart disease Multiple gestation Breech presentations Patients with bad obstetric history Undue delay patients at risk (PIH, DM, IUGR, postdated pregnancy) Prepare the delivery room. (Refer to appendix C for articles/equipments needed for delivery) Prepare the baby receiving area. The following things should be available: Baby warmer (should be kept ON) Ambu bag and mask in working condition Laryngoscope Suction machine in working condition Oxygen Meconium aspirator ET tubes, suction tubes no: 8 & 10, nasogastric tubes.

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131 Emergency drugs (Inj. Adrenalin, Inj. naloxone if the mother has received a narcotic, Inj. soda bicarb, normal saline) Warm baby sheets and sterile pads. Nursing observations: Assess the patient for signs suggestive of satisfactory progress in the second stage of labour. This includes steady descend of the presenting part and the onset of expulsive phase. Monitor the uterine contractions. If contractions are not adequate inform a gynecologist. Observe the color of liquor. If meconium is present inform the gynecologist. Record FHS every 5 minutes. If there is any foetal heart abnormalities inform a gynecologist. Perform a vaginal examination once every hour. The following things should be avoided. indicated. stage. too early Ensure cleanliness of the patient and the birthing area. 131 Teach pushing techniques to the patient If the presenting part is high keep the patient on left lateral position and encourage her to push with contractions. Do not put the patient on lithotomy position Encourage the patient to empty her bladder at the beginning of the second Premature positioning Uterine manipulation Stretching of perineum Unnecessary frequent PV Catheterization unless indicated. Maintain adequate hydration by encouraging adequate oral fluids if not contra

132 Provide a supportive and an encouraging atmosphere and ensure patients privacy and confidentiality. Do not allow unnecessary visitors inside delivery room while the patient is giving birth. Only staff and doctors on duty are allowed in second stage room. While conducting delivery the following steps should be followed: Wash hands and wear personal protective equipments. Talk to the patient and explain every procedure throughout the second stage. If the patient is to be delivered in lithotomy position while positioning put both legs together on the stirrups. Ask the patient if she is comfortable and adjust the level accordingly. Clean the patients perineum and inner thighs with an antiseptic solution (betadine). Drape the patient (with lithotomy sheet and leggings). Encourage the woman to push with contractions. If an episiotomy is needed infiltrate the perineum with 1% lignocaine and perform an episiotomy with a contraction when the foetal head crowns.(refer to guideline for performing episiotomy). Ensure the following steps during the delivery of the head: Place the fingers over the foetal head to maintain flexion. Support the perineum as foetal head is delivered. Once the head is delivered ask the woman not to push. If meconium is present suction the babys mouth and nose. Feel around the babys neck for the umbilical cord. If the cord is around the neck but loose, slip it over the babys head. If the cord is tight doubly clamp and cut it before unwinding from the neck. Ensure the following steps during the delivery of shoulders. Wait for the external rotation of the head. Place a hand on each side of the babys head and ask the woman to push with contraction.

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133 Apply downward traction to deliver the anterior shoulder. Avoid excessive tracton as this may result in brachial plexus injury. Lift the babys head anteriorly to deliver the posterior shoulder. Support the perinium during the delivery of the shoulders. In case of shoulder dystocia: Call for a gynaecologist. Ask the woman to flex both thighs bringing her knees as far a apart as possible toward her chest. Have an assistant apply suprapubic pressure downwards to assist the delivery of shoulders. Do not apply fundal pressure as it can further impact the shoulders. Clamp and cut the cord and hand over the baby to an assistant. If the mother is Rh ve collect cord blood for Hb, PCV, blood grouping and Rh typing, reticulocyte count, direct coombs test, serum bilirubin total and direct serum bilirubin. Palpate the abdomen to rule out the presence of any additional baby(s), if not already confirmed by USG. Proceed to do active management of third stage or do the expectant management.

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ASSISTING A VACUUM DELIVERY


A vacuum extraction may be needed in when there is Foetal distress Delay in second stage of labour Maternal exhaustion Maternal heart disease Explain to the women and the relatives about the need for a vacuum extraction. Assemble all equipments / instruments needed for a vacuum extraction. All instruments needed for a vaginal delivery (delivery bundle) Vacuum cup Rubber tubing Vacuum extractor Check the connections of the vacuum extractor and ensure that it is functioning well. When the vacuum cup is applied to the foetal head ask an assistant to create a vacuum of 0.8kg/cm2 negative pressure by using the pump (up to the red mark on the vaccum apparatus). Contimnue to monitor foetal heart rate in between contractions. Maintain asepsis throughout the procedure. At the delivery of the foetal head release the pressure of vacuum. After the birth of the baby assess the maternal and foetal complications:

Maternal: Tears in the genital tract may be present. Examine the woman for any tears in the vagina or the cervix (The doctor who performs the vacuum will usually do this). Foetal: All babies born by a vacuum will have a caput. Explain to the mother that it harmless. Examine for scalp abrasions. If any abrasions are there clean and determine the extent of the abrasion.

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135 Inform a pediatric medical officer and carry out any orders given. Show the baby to the mother and the relatives and explain abut the laceration.

MANAGEMENT OF THIRD STAGE OF LABOUR


Active management of third stage: Active management of third stage is encouraged as it helps to prevent PPH. This includes: Administration of oxytocin Controlled cord traction Uterine massage. The following steps must be followed in the active management of third stage: Administration of 10 units of oxytocin I.M or 5 units I.V within one minute of delivery of the baby. Clamp the cord close to the perineum. Apply controlled cord traction along with counter traction. Never pull the cord with out counter traction as it can cause uterine in version. Keep slight tension on the cord and wait for a uterine contraction. With a contraction gently pull the cord downwards to deliver the placenta while continuing to apply counter traction. contraction. As the placenta is delivered hold it in two hands and gently turn it until the membranes are twisted. completeness Once the placenta is delivered carefully examine it for If the placenta does not descend with 30- 40 seconds of controlled cord traction do not continue to pull. But gently hold the cord and wait for another

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EXPECTANT MANAGEMENT OF THIRD STAGE: (IS NOT ENCOURAGED)


Wait for signs of placental separation. This includes: Gush of blood Lenghthening of the cord Uterine contraction. Deliver the placenta using controlled cord traction. As the placenta is delivered hold it in two hands and gently turn it until the membranes are twisted. If not contra indicated, administer injection ergometrine when the placenta is delivered. Contra indications include: PIH & heart disease. Check the blood pressure before giving ergometrine. Once the placenta is delivered carefully examine it for completeness.

RETAINED PLACENTA
Inform a gynecologist Catheterize the bladder or ensure that the bladder is empty. Start an IV line. (oxytocin infusion may be started). Explain to the woman and the relatives about her condition. Watch for any undue bleeding. Accurately document the interventions carried out. 136

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MANUAL REMOVAL OF PLACENTA


Explain to the woman and her relatives and get their consent for the procedure. Provide emotional support for the woman. Carryout any advice given by the doctors. Prepare the articles necessary for manual removal of placenta: sterile gloves sterile lithotomy sheet leggings antiseptic solution dettol cream Post procedure: Administer IV ergometrine if not contraindicated. Continue oxytocin infusion as per doctors advice. Examine the placenta Monitor vital signs every half hourly or as advised. Palpate the uterine fundus to ensure that it is well contracted. watch for any undue bleeding Accurately document the interventions carried out.

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MANAGEMENT OF FOURTH STAGE OF LABOUR


Remove the drapes and soiled linen. Give a clean gown to the patient Remove both legs from the stirrups at the same time and then lower both legs down at the same time to prevent cramping Provide care of the perineum. Evaluate the perineal area for signs of developing edema and/or hematoma. Predisposing conditions includes prolonged second stage, delivery of a large infant, rapid delivery, forceps delivery. An ice pack may be applied to the perineum to reduce swelling from episiotomy and manual manipulation of the perineum during labor. Apply a clean perineal pad between the legs. Obtain a complete set of vital signs, evaluated the fundal height and firmness, and evaluate the lochia. Keep the patient in labour room for 2 hours under observation. Following observations should be made. Record blood pressure and pulse and uterine contraction every half the uterus over the abdomen. hourly. Inform the doctor if the fundus remains boggy. Encourage the patient to massage

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139 Observe for signs of hemorrhage. Causes of PPH may include Uterine atony. Vaginal or cervical lacerations. Retained placental fragments. Bladder distention. Observe patient's urinary bladder for distention. Full bladders may actually cause postpartum hemorrhage because it prevents the uterus from contracting appropriately. Assessment for perineal hematoma. Look for discoloration of the perineum. Listen for the patient's complaints or expression of severe perineal pain. Observe for edema of the area.

Observe/listen for patient's feeling the need to defecate if forming hematoma is creating rectal pressure.

Inform the doctor of abnormal findings. Discontinue IV on a normal patient once she is stable Complete notes and transfer the stable patient to the ward

MANAGEMENT OF PPH
All post partum women must be monitored closely to determine PPH. In cases of PPH the priorities in managing the patient are as follows.

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140 Call for help (call for a gynecologist or a medical officer) Start an IV line. Perform a rapid assessment of the womans general condition which should include blood pressure, pulse, respiration and temperature. Find the cause for bleeding: To find out the cause examine the cervix, vagina and perineum for tears. Check if the placenta is complete or not. Stop the bleeding: If the cause of PPH is trauma to cervix, vagina or perineum, repair it under aseptic precautions. If the cause of PPH is uterine atony, follow these steps: catheterize the bladder Massage the uterus to expel the blood clots. Start an IV infusion as per the doctors advice. Give oxytocin as per doctors order Monitor the blood pressure and pulse closely and watch for signs of shock. Explain the patients condition to the relatives. Anticipate the need for blood transfusion and arrange blood. Keep an accurate record of the blood loss and interventions carried out. If bleeding continues, check the placenta for completeness and if there are signs of retained placental fragments inform a gynecologist.

PERFORMING AN EPISIOTOMY
Apply an antiseptic solution to perineum before performing episiotomy.

Infiltrate perineum with 1% xylocaine Infiltrate beneath the vaginal mucosa, beneath the skin of perineum and deeply into the perinial muscle. Aspirate to be sure that no vessel has been penetrated. The woman can suffer convulsion and death if IV xylocain is given.

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141 Xylocain should be injected continuously while the needle is slowly withdrawn. Anesthesia is more effective when one third of the injection is given first and two further injections are made one on either side of the incision line. The needle must be redirected just before the tip is withdrawn to avoid a second prick. Xylocain takes 3-4 minutes t o take effect. Episiotomy should be performed only when crowning takes place (When the perineum is thinned out and 3-4 cm of the babys head is visible during a contraction). If episiotomy is given too early it will fail to release the presenting part and cause hemorrhage from the cut vessels. In addition the levator ani muscles will not have time to be displaced laterally and may be incised. If episiotomy is performed too late there will not be time to infiltrate the prineum with anesthetic. The incision is best made during a contraction when the tissues are stretched so that there is clear view of the area and bleeding is less likely to be severe. A single deliberate cut of 2-3 cm is made while inserting two fingers into the vagina to protect the babys head. Medio-lateral is best, as it avoids danger of damage to anal sphincture. This begins at the mid point of fourchette and is directed at 45 degree angle to the midline. The babys head and shoulders should be controlled as they deliver to prevent an extension of the episiotomy. If there is any delay before the head emerges pressure should be applied to the site to minimize bleeding.

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REPAIR OF AN EPISIOTOMY
Carefully examine the episiotomy for any extensions and other tears.

Apply an antiseptic solution around the site of the incision.

Ask the patient if she had any reaction to suture material in the earlier deliveries or at any other time.

Choose an appropriate suture material. Although 2-0 chromic catgut is commonly used for patient with history of catgut allergies vycril may be used. For patients with catgut allergy inform a gynaecologist before suturing the episiotomy.

Close the vaginal mucosa using continuous 2-0 suture. Continuous suture gives better homeostasis.

Start the repair 1cm above the apex of the episiotomy. Continue the suture to the level of the vaginal opening.

Close the perineal muscle using interrupted 2-0 sutures. Good approximation of tissues is important as the strength of pelvic floor will depend on the adequate repair of this layer.

Close the skin using interrupted stitches. Avoid too many stitches.

Sutured area should be inspected in order to confirm haemostasis.

Vaginal examination should be done to ensure that the vaginal introitus has not been narrowed.

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143 Rectal examination is made in order to ensure that no sutures have penetrated the rectal mucosa. Any such sutures to be removed to prevent fistula formation. If the episiotomy is extended through the anal sphincter or rectal mucosa call a gynecologist.

CARE OF NEW BORN


Make sure that all equipments and drugs for resuscitation are ready and in good working order, before delivery. (Refer to newborn resuscitation guideline for list of drugs and equipments.) At birth an initial assessment should be performed for all the babies and the following conditions should be observed. Clear of meconium 143

144 Breathing or crying Good muscle tone Colour pink Term gestation If the baby has no apparent problems and if all of the above criteria are met provide routine care. Routine care includes drying the baby, clearing the airway, providing warmth. If the baby is born with a problem/condition that requires urgent intervention care should provided as follows. When born with meconium stained liquor suctioning of the mouth and nose as soon as the head is born. While doing suction care should be given not to suction deep in the throat as it may cause bradycardia or the baby may stop breathing. If the baby is not breathing or crying dry and remove wet cloth, keep baby under radiant warmer, clear the air way and provide tactile stimulation. Tactile stimulation should be given by flicking the soles of the foot twice and gentle rubbing of the back. If the baby does not start breathing initiate newborn resuscitation (refer to guidelines for newborn resuscitation) If the baby has cyanosis oxygen can be administered. Assess babys condition, at 1minute, 5 minutes and 10 minutes after birth using apgar scoring. The cord should be clamped with cord clamp and cord care should be given with spirit.

Provide eye care for the baby with sterile swabs and saline For all babies with term gestation vitamin K 1mg should be administered intramuscularly to the thigh muscle. For preterm babies and babies with low birth weight dosage of vitamin K would depend on the doctors order.

Anal patency for the babies should be checked at birth using a rectal thermometer/rectal tube

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Oesophageal patency should be checked using a nasogastric tube.

Clean and dress baby.

An identification label should be attached to babys leg as soon as possible. The label should be legibly written with the following details: Mothers name and address Date and time of birth Sex weight of baby

Baby should be shown to the mother as soon as possible.

Breast feeding should be initiated within the first half an hour of birth and necessary assistance should be provided for the mother while feeding.

Inform the relatives of the babys condition and show the baby to the relatives.

The newborn sheet should be completely filled and a nurses note should attached to the newborn sheet before the baby is transferred to postnatal ward.

NEONATAL RESUSCITATION
Preparation for delivery
1. Anticipate need for resuscitation; Ante partum and intra partum history may help to identify the possibility of a depressed or asphyxiated newborn.

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146 2. Personnel; When neonatal asphyxia is expected two staff should be present in the delivery room and be prepared to work as a team to perform a complete resuscitation. The person conducting the delivery should not be considered as one of the resuscitators. 3. Initiating resuscitation should not be delayed. Equipments; Equipments and medications should be checked daily and before each delivery. Used items should be cleaned as soon as possible after resuscitation. The delivery room should be kept warm and the radiant heater should be preheated, to prevent excessive heat loss. Pre warming of towels and blankets is helpful. (Refer to appendix C for equipments and medications needed for resuscitation)

Post resuscitation: Babys condition should be explained to parents as soon as possible. If condition of the baby allows, show the baby to mother and relatives. Initiate breast feeding as soon as possible if condition allows. Keep a close observation on the baby. Accurate documentation is very important.

TRANSFERRING NEWBORN BABIES TO NURSERY


Explain to the mother why the baby is being transferred to nursery Inform the nursery before shifting the baby. Ensure that the baby is wrapped in a blanket to prevent heat loss. If the baby requires oxygen transfer the baby in the incubator.

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147 Show the baby to the mother and the relatives before shifting to nursery. Ensure the newborn sheet and the nurses notes are completed and handed over to the nursery staff. If the baby has received any medications document it in the treatment sheet.

NURSING CARE OF PATIENTS WITH ANTE PARTUM HEMORRHAGE


Assess the general condition of the woman record the vital signs including foetal heart rate. Call for a gynecologist. If foetal distress is evident, manage as for foetal distress and prepare the patient provisionally for LSCS. Send for all routine investigations including cross match (send minimum 2crossmatches) Start an IV line. Assess the amount of bleeding and restore the blood volume as advised by the doctor. Do not do a vaginal examination: Check the scan reports and rule out placenta previa. Explain the patients condition to the relatives. Monitor the foetal heart rate every 15 minutes. Accurately document the interventions carried out

MANAGEMENT OF PATIENTS WITH PIH IN LABOUR


On admission: Collect the history and check whether the patient is on any medications. Do a general examination and asses the woman for edma. Send for all routine investigation including a crossmatch. Get advice from a gynecologist or medical officer for any special investigation.

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148 Record the vital signs including foetal heart rate. If the diastolic blood pressure is more than 100 inform a gynaecologist or a medical officer. Monitor the blood pressure every hourly or as indicated Monitor foetal heart rate and uterine contractions every half hourly. If the diastolic BP is more than 100 donot allow the women to walk to the toilet alone. Offer a bedpan and monitor urine output. Maintain strict intake and out put. Start an IV line to keep the vein open. Watch for signs of impending eclampsia: Headache Blurred vision Do not leave the woman alone and keep the bed rail as a safety precaution. Keep the equipments ready for the management of a convulsion Air way Suction machine Suction tubes Oxygen Ambu bag and mask with tubing Drugs (inj Diazepam, inj Epsolin, inj magnesium sulphate)

In case of convulsion: Clear airway Adminster oxygen at 4-6 liters/ minute Inform a gynaecologist or medical officer Protect the women from injury Position the woman on her side to reduce the risk of aspiration

If any narcotic is administered carefully monitor the foetal heart sounds and inform a pediatrician at the time of delivery. Keep injection Naloxone ready to resuscitate the baby.

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USE OF MAGNESIUM SULPHATE FOR PRE- ECLAMPSIA AND ECLAMPSIA


Minimum requirements for the administration of magnesium sulphate PR greater than 16/min Urine out put atleast 30ml/hour Knee jerk should be present Preparation of 50% magnesium sulphate for use:

1. IV loading dose: 4gm magnesium sulphate over 10 minutes Magnesium sulphate is supplied in 2ml ampules and 4 ampules (8ml) would provide 4 gms. Dilute this amount to a volume of 20 ml by adding 12 ml of normal saline. Give this slowly over 10 minutes. 2. IM maintenance: 5gm of 50% magnesium sulphate solution in each buttock initially and then on alternate buttock four hourly. 5 ampules (10ml) of the solution for each 5gm to be mixed with 1ml of 2 % lignocaine syringe to be mixed in the same syringe. . Assessment & Drug Effects When magnesium sulphate is given IV, patient requires constant observation. Check BP and pulse 10-15 min or more often if indicated/ as ordered by the gynecologist. Monitor patients with high levels of magnesium very closely as cardiac arrest may occur in such cases. Plasma levels in excess of 4 mEq/L are reflected in depressed deep tendon reflexes and other symptoms of magnesium intoxication. Cardiac arrest occurs at levels in excess of 25 mEq/L. Early indicators of magnesium toxicity (hypermagnesemia) include cathartic effect, profound thirst, feeling of warmth, sedation, confusion, and depressed deep tendon reflexes.

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150 For women receiving magnesium sulphate, monitor urine out put every hourly and if it falls below 30ml/ hour inform a gynecologist Before each repeated parenteral dose, patellar reflex should be tested. Depression or absence of reflexes is a useful index of early magnesium intoxication. Also check respiratory rate and character and urinary output. Therapy is generally not continued if urinary output is less than 100ml during the 4 h preceding each dose. Newborns of mothers who received parenteral magnesium sulfate within a few hours of delivery should be observed for signs of toxicity, including respiratory and neuromuscular depression.

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CARE OF PATIENTS WITH MALPRESENTATIONS


Common mal presentations include: Breech Face Brow Trasverse lie/ oblique lie. A breech or a face presentation may be allowed for a vaginal delivery. But inform a gynecologist. General management of fist stage of labour for face presentation and breech presentation is the same as that of a vertex presentation. In a breech presentation when the membranes are ruptured perform a vaginal examination to exclude cord prolapse. Meconium stained liquor is common in a breech presentation and it is not a sign of foetal distress. In a brow presentation, trasverse lie or in an oblique lie the woman is likely to have cesarean section. Inform a gynecologist immediately when these presentations are suspected. If the woman is in labour keep her provisionally prepared for cesarean section until a gynecologist decides for the management.

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152

MANAGEMENT OF CORD PROLAPSE


Following spontaneous rupture of membranes perform a vaginal examination to exclude cord prolapse. An abnormal foetal heart rate, especially bradycardia may also indicate cord prolapse. A vaginal examination should be performed to rule out cord prolapse. Immediate action: Call for urgent help. Inform a gynecologist immediately. Explain to the woman what has happened Get an assistant to explain to the relatives what has happened and the emergency measures that may be needed. Relieve the pressure on the cord by holding the presenting part off the cord, especially during contractions. Monitor foetal heart rate carefully. Adminster oxygen at 4-6 liters /minute. Start an IV line. Position the woman with her buttocks elevated to allow the fetus to gravitate towards the diaphragm. (this position can be by keeping a pillow underneath the patients buttocks or by raising the foot end of the bed). These measures must be continued until foetus id delivered or until the patient is shifted to theater. Keep the woman prepared provisionally for cesarean section until a gynaecologist decides the management plan.

152

153

ADMINISTRATION OF OXYTOCIN FOR INDUCTION AND AUGMENTATION OF LABOUR


Oxytocin should only be administered with the advice from a gynaecologist. For routine inductions ensure the necessary investigations including crossmatch is ready. If not, inform the gynaecologist before starting the oxytocin infusion. Oxytocin should be used with caution as fetal distress can occur with hyperstimulation and rarely uterine rupture can occur. Administer Oxytocin in an IV fluid (dextrose or ringer lactate) and gradually increase the drop rate according to the doctors order until good contractions are established. Contractions are considered as good when the woman gets about 3 contractions in 10 minutes each lasting for atleast 40 seconds. When good contractions are established maintain the infusion rate. Do not leave a woman receiving oxytocin alone and check the arm position inbetween as it can alter the flow rate. Carefully monitor the women receiving oxytocin for the following: Blood pressure and pulse rate Foetal heart rate every half hourly. Always check the foetal heart immediately after a contraction. If there is foetal distress stop the oxytocin drip and inform a gynaecologist. Manage foetal distress according to the protocols provided. Uterine contractions every half hourly. If hyper stimulation occurs stop the infusion and inform a gynaecologist. Rate of infusion. Increase the infusion rate according to the doctors advice. Properly document the findings.

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154

CERVIPRIME INSTILLATION FOR INDUCTION OF LABOUR


Ensure that the necessary investigations including crossmatch are ready. If not, inform the gynaecologist. Prior to the instillation of cerviprime monitor the womans vital signs and foetal heart rate. Ask the woman to empty her bladder prior to the instillation. Prepare the articles needed (refer to appendix C) Immediately after instillation check the foetal heart rate. Ask the woman to take bed rest as per the doctors advice. Keep the woman in the labour room under observation and monitor the uterine contractions and record the foetal heart rate every 30 minutes. If there are no contraction the woman may be transferred to ward. Advice the woman to report with contractions or leaking. The woman may be allowed to take soft diet if there are no contractions Before transferring the patient to ward ensure that all the documentation is complete.

154

155

EXTRA AMNIOTIC SALINE INSTILLATION


Receive the patient and take proper hand over from the ward nurse. Check the doctors order. Check whether routine investigations and cross match is done. Check whether patient and the relatives have been explained about the procedure. If not already done, explain the procedure to the patient and a close relative and get their consent. If language is a barrier, call for help. stirrups accordingly. orders. Explain the patients condition to the relatives. Ensure that adequate privacy is provided for the patient. Assist the doctor with the procedure. While assisting the procedure ensure that strict aseptic technique is followed. After the procedure make the patient comfortable and watch for uterine contractions, leaking or bleeding PV. Disinfect the articles used, as per infection control guidelines. Properly document the procedure. While documenting follow the guidelines for nursing documentation. Monitor and record vital signs. Maintain bed rest as per doctors order and carry out any further Check and record patients vital signs. Change the patients dress to a hospital gown. Ask the patient to empty her bladder. Prepare the articles needed for the procedure (refer to appendix C) Keep the patient on lithotomy position. When positioning both legs should be put on the stirrups at the same time. Ask if the patient is comfortable and level the

155

156 Leaking Bleeding If the catheter bulb comes out /If pains increase. If the patient does not have contractions, transfer the patient to ward as per doctors advice. Before transferring the patient to ward provide information to the patient regarding the conditions that she should report to the nursing staffs. These include

CARE OF PATIENTS WITH INFECTIOUS DISEASE IN LABOUR


Patients with infectious disease in labour may either need isolation or additional precautions to prevent the spread of infection. Those with communicable diseases need to be isolated. But those with infections such as hepatitis B/ HIV and other blood bourn disease does not need isolation. Patients who need isolation in labour should be given the same nursing care given to other patients in 1st, 2nd, 3rd, and 4th stage of labour. The patient should get the same respectful treatment that is given to any other patient. Patients with communicable diseases need to be nursed in a separate room with separate equipments. All the unnecessary furniture and equipments should be removed from the room. While caring for the patient the nurse must follow the practice of medical and surgical asepsis. Wear all personal protective equipments to prevent the spread of infection. Do not let soiled linen and other articles touch the uniform. Hand washing is the most important method of controlling the spread of infection. Wash hands thoroughly using an antibacterial solution: Before and after the procedures. After contact with blood and body fluids. Things used for the patients with infectious diseases need to washed separately. Keep separate equipments for the patients where necessary. (eg bedpans). Before washing the instruments soak them in 0.5% sodium hypochlorite for 10 minutes. Put contaminated things in a separate plastic bag and label it as BIO HAZARD.

156

157 Dispose of urine, feces and vomits at once. Mop up any spilled fluids immediately using the standard precautions. (Make sure that the attendants understand the restrictions and supervise them while cleaning the spillage). Mental support for isolated patients: Carefully explain the patient and the relatives why the restriction is necessary. Make sure that the patient does not feel emotionally isolated. Communicate with patient. Support the patient to go through labour as others. Airborne transmission precaution: Patient placement: place the patient in an individual room if available. Respiratory protection: wear a mask when giving care for the patient. Patient transport: Limit patient transport to essential purpose only. If movement is necessary minimize the risk of infection to others by placing a mask on the patient. Environmental control: ensure appropriate environmental and equipment cleaning, disinfection and sterilization. All surface areas should be disinfected with 0.5% sodium hypochlorite solution

Contact transmission precaution: Use personal protective clothing and practice hand washing: When equipments are shared decontamination of the equipments are necessary before using on another patient. All surface areas should be disinfected with 0.5% sodium hypochlorite solution.

Droplet transmission precaution: Patient placement: place the patient in an individual room if available Respiratory protection: wear a mask when giving care for the patient. Environmental control: All surface areas should be disinfected with 0.5% sodium hypochlorite solution.

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158

INFECTION CONTROL PRACTICES IN LABOUR ROOM


Recommended infection control practice are based on the following principles Every person (patient or staff ) must be considered potentially infectious; Hand washing is the most practical procedure for preventing cross contamination. Wear gloves before touching anything wet broken skin, mucous membranes, blood or other body fluids (secretions or excretions). Use barriers (protective goggles, face masks and aprons) if splashes and spills of any body fluids (secretions or excretions) are anticipated. Use safe work practices, such as not recapping or bending needles, proper instrument processing and proper disposal of waste. Soak used instruments in 0.5% sodium hypochlorite for 10 minutes before washing them Handling of sharps Use each needle and syringe only once. Do not disassemble needle and syringes after use. To prevent needle stick injuries, put used disposable syringes and needles, scalpel blades and other sharp items in puncture-resistant containers for disposal immediately after use. Keep these containers as close as possible to where sharp objects will be used. Do not recap-if disposable needles are not available and if recapping need to be practiced, use the One handed recap method: General house keeping: 158

159 o The floor should be cleaned at least three times in 24 hours using 0.5% sodium hypochlorite o Thorough cleaning of delivery room should be done at least once a month. o High dusting should be done at least weekly. o All surfaces should be disinfected with 0.5% hypochlorite solution once a day and when the patient is transferred. o Toilets should be cleaned three times a day using detergent o Wash basins should be cleaned at least twice a day.

Additional precautions
The hepatitis B and/or HIV status of all the patients should be determined.

If Positive: Linen which is used should be sent to laundry marked as BIO HAZARD Post delivery: All babies born to hepatitis B surface anti body positive mothers are immunized against hepatitis B as soon as possible. If the mother is known to be HBe antigen positive inform a pediatrician.

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160

CARE OF THE PATIENT AFTER ABORTION


Death or expulsion of fetus before 28th weeks of gestation either spontaneously or by induction is termed as abortion. Rights of women: All women presenting with abortion has a right for immediate and quality care regardless of of their marital status, religion, age, socioeconomic status, sexual behaviors, political beliefs and whether tried for unsafe abortion All women have a right for INFORMATION regarding their clinical condition and the treatment planned for her They have a right to discuss their concerns and express their own views regarding their condition in a confidential environment. The information provided by the patient should be treated CONFIDENTIALY unless it is required in a life threatening situation They have a right for PRIVACY when ever undergoing any examination as it helps to protect her confidentiality and promotes a sense of security and dignity

Immediate care
160

161 If a woman is admitted with vaginal bleeding perform a rapid assessment of her clinical condition Check for signs of shock (assess all vital signs) Check the amount and duration of bleeding (passage of any clots) Signs of any infection or injury Get a detail medical and obstetric history of the patient using effective communication techniques History should include the last menstrual date History of abdominal pain History of fever History passage of clots Past medical history Secure an intravenous line keeping shock in mind Send all routine investigations and a cross match In suspected unsafe abortions observe for signs of infection and any injury Inform the consultant on call In case of the need for D&C proper explanation of the procedure and its risks should be explained both to the woman and her family/husband Women should be prepared for D&C An informed consent should be taken from the woman/husband before the procedure Woman should be made as comfortable as possible during the procedure and her stay in hospital Provide as much privacy as possible for the woman during the procedure Provide pain medication/sedation as ordered by the consultant

After care
Respect the religious and cultural beliefs of the couple Show the products of conception to the husband as well as to the woman

161

162 If a fetus is there allow the mother to touch if she wants to All the D&C has to be entered in the D&C register It is essential to provide adequate counseling to the couple after the complication is dealt with. In case of unsafe abortion provide counseling regarding the availability of family planning methods which can be started immediately Hand over a delivery/death form depending on the products of conception

ROUTINE INVESTIGATION CHECKLIST


Investigation for labour patients Hb PCV Bloog grouping and Rh typing G6PD Random blood sugar HIV screening HbsAg screening VDRL Investigations for PIH All routine investigation Blood urea Serum creatinine Uric acid 162

163 BT/CT Investigation for babies born to Rh negative mothers Hb PCV Blood grouping and Rh typing Reticulocyte count Serum bilirubin-total Serum bilirubin- direct. Direct coombs test. Investigations for septic screening (Babies) TC/DC ESR Blood culture. CRP Investigations for birth asphyxia Blood gas anal

163

164

Admission checklist

164

165

Emergency Pre- operative checklist

165

166

Documentation checklist

166

167

Appendix

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168

APPENDIX A: PATIENT UNIT PREPARATION


For first stage of labour:
Bed ready with curtains around the bed Oxygen with tubing Doppler /BP apparatus / thermometer /Stethoscope P/C bowl,Gloves, Dettol cream (for P/V examination) IV fluids and medication (listed in the daily inventory) IV tray/ injection tray/ IV stand Water Feeding cup / medicine cup Kidney tray Dustbin Relevant papers for documentation.

For second stage of labour: Delivery bed with stirupps Doppler Suction machine with tubing Suction tubes no: 8 (if liquor is clear ) no: 10 (if liquor is meconium stained) Oxygen with tubing Light IV fluids and medication (listed in the daily inventory) BP apparatus / Stethoscope IV tray/ injection tray/ IV stand Water Feeding cup / medicine cup Kidney tray Delivery set (refer to appendix C)

168

169 Newborn resuscitation equipments and medication (refer to appendix C) For Severe PIH / eclampsia: Keep the unit ready as for patients with first stage of labour. In addition keep the following things ready. Bed rails Adult Suction machine with suction tubes Air ways Splints Tongue depressor For the administration of magnesium sulphate keep the following things ready: o 50% magnesium sulpphate o 10 ml of 10% calcium gluconate. o Injection normal saline o Injection 2% lignocaine o Clinical hammer o 20 ml syringe o 10 ml syringe o Foleys catheter with syringe

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170

APPENDIX B / ORIENTATION TO LABOUR ROOM


On admission orient the patient and the relatives to the labour room with emphasis on the following points. Relatives are not allowed inside labour room. Patients are not allowed to bring in their mobile phones or any valuables to labour room. Once patient is in active labour she will stay in the labour room till delivery. All the patients will be attended by the doctor on duty/call (even if she has done her antenatal checkups by a different doctor). Relatives should stay in the place allocated for them and if they need to get any information regarding the patients condition contact a nurse or a doctor on duty. Relatives can talk to the patient over phone at any time they want (i.e if the condition of the patient allows). To keep the patients belongings a cupboard will be given. The key should be handed over to labour room when the patient gets transferred to another ward. Relatives should be advised not to keep any valuable item in this cupboard. After delivery all patients will be kept in labour room for at least 2 hours. Once patient is admitted the relatives can book for a room if they wish to. But when the patient is due for transfer from labour room she will be shifted to a general ward if the room is not due.

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APPENDIX C: ARTICLES/ EQUIPMENTS NEEDED FOR PROCEDURES PERFORMED IN LABOUR ROOM

Normal delivery: Sterile delivery set containing 1 gown with long sleeves, 1 lithotomy sheet 2 leggings 1 baby sheet 2 drapes 2 artery forceps 1 cord cutting scissor 1 episiotomy scissor (if needed) Pad, gauze Small bowl with an antiseptic solution In addition, Local anesthetics Dettol cream Personal protective equipments (plastic apron, mask, shoe cover, sterile gloves) Oxygen Doppler Bed side suction machine if meconium is present. For Vacuum extraction keep an appropriate size of vaccum cup with tubing and vaccum apparatus ready

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Equipments needed for resuscitation in delivery room: Radiant heater. Baby stethoscope. Oxygen with flow meter and tubing. Neonatal resuscitation bag. Face masks of different sizes. Oral airways Suction machine with tubing. Suction catheters: 5F or 6F, 8F & 10F. Endotracheal tubes; 2.5, 3.0, 3.5& 4.0mm. Laryngoscope with straight blade no: 0 & 1. Needles and syringes. Feeding tube 8F and syringes. Umbilical vessel catheterization tray. Umbilical catheters 3.5 & 5F.

Medications needed for new born resuscitation: Epinephrine (1:10,000). Naloxone Volume expander(normal saline). Sodium bicarbonate.

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173

Urinary Catheterization: A sterile tray containing A sponge holding forceps Gauze Cotton In addition, Urinary catheter (appropriate size) Urine bag Distilled water and syringe Antiseptic solution Xylocaine jel

Cerviprime instillation: A sterile tray containing 2 sponge holding forceps 1 speculum (sims / cuscos) Small bowl for antiseptic solution Gauze Lithotomy sheet Personal protective equipments Culdocentesis: P/ C bowl with cotton 173

174 Sterile lithotomy sheet Speculum (cuscos) Sponge holding forceps Long needles 18G, 20G, 21G (L/P needles) 10 ml syringe Antiseptic solution Antiseptic cream Personal protective equipments Extra amniotic saline instillation: A sterile tray containing 1 Speculum 1 Sponge holding forceps 1 vulsellum 1 artery forceps 1 Lithotomy sheet Small bowl with betadine solution Gauze pieces In addition, 22 FR foleys catheter 14 FR or 16 FR catheter and urine bag and 5cc of distilled water, if urinary catheterization is needed Syringes (20cc, for inflating intra cervical catheter and 5cc for inflating urinary catheter). Clamp (a cord clamp may be used) 1 pint of normal saline and IV set Johnsons Plaster (to fix the catheter) Xylocaine gel Dettol cream Personal protective equipments

174

175 Episiotomy suturing: A sterile tray containing Needle holder Artery forceps Dissecting forceps (toothed and non toothed) Scissors Gauze / tampoon In addition, Injection Xylocain 1 % 5ml Syringe with needles Antiseptic solution Personal protective equipments Dilatation and curettage (D & C): A sterile tray containing 1 set of Hegas dilators 3 Sponge holding forceps 1 Vulsellum 1 Uterine sound 1 Sims speculum Curettes (blunt & sharp) Small bowl for antiseptic solution Lithotomy sheet In addition, Pesonal protective equipments Antiseptic cream Antiseptic solution

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APPENDIX D: CHECK LIST FOR WARD SISTER / WARD INCHARGE (LABOUR ROOM)
DAILY 1. Check whether daily inventory taken Missing/borrowed items replaced 2. Check whether census(transfer in/transfer out/discharge) 3. Check whether Narcotics inventory taken Narcotics register maintained regularly Narcotics cupboard key with senior staff nurse 4. Check whether Emergency trolley (drug/equipments/instruments in both adult and neonatal resuscitation 5. Check whether store room locked at all times 6. Check whether temperature/intake& output chart/files filled/updated ( during ward rounds and report giving) 7. Check whether all medication sheets filled accurately 8. Check whether all special investigations (USG, CT scan, ECG, appointments, reports etc) 9. Check whether PACs done, consent taken (by the appropriate person)

176

177 10. Check whether welfare letters are given 11. Check whether linen checked, sent & returned 12. Check whether infection control practices waste disposal/sharp disposal cleanliness /disinfection of equipments & instruments thorough disinfection of delivery bed and trolley after each delivery disinfection of patient unit used instruments/ bundles sent for autoclaving 13. Check whether delivery forms handed over 14. Check whether patient care components according to the care plan patient allocation allocated nurses go on round with doctor all doctors orders are carried out properly daily care given all records completed all register completed malignance of intake/output chart for whom all required (even if no doctors order 15. Check whether all ward equipments in working order 16. Check whether overall cleanliness/tidiness of ward 17. Check whether communication between shifts 18. Check whether follow up when things go wrong/broken items/missing items in ward 19. Check whether attendants handover to next shift attendants(mops dry, buckets emptied, dustbins emptied, kidney tray washed, dirty utility in clean state nurses and attendants report before going off duty (other shifts to the senior staff on duty) 20. Check whether update the changes in the duty register in the nursing department 21. Reporting incidents that need immediate reporting

WEEKLY
177

178 WARD STOCK Identifying consumables required for the next week Write & send indent book to Nsg Dept. on the previous day before 12.00nn

DUTY ROTA Send duty rota on Wednesday before 12.00nn to Nsg Dept. To be made by ward sister only

CLEANLINESS treatment room patient unit clean utility room dirty utility room etc fans, windows, racks etc

EQUIPMENT serving of all equipments oiling of trolley wheels etc order/replace broken items

CASE SHEETS-DISPATCH Charts arranged in order Death case sheets stamped and documents filed in order/death summary filled Dispatch weekly or biweekly

CHECK AUTOCLAVED ITEMS Re-autoclaving after 2 weeks (Please allocate to senior nurses/junior nurses accordingly and do over all check)

REPORTING

178

179 Necessary information (patient care/staff progress/ additional requirements etc. to the nursing department )

MONTHLY
REVIEW CLASS: identifying weakest area (present in the ward) reviewing a nursing procedure of a case presentation

INFECTION CONTROL: washing and C/S of delivery room CHECK INVENTORY - (3-6monthly) of ward stock, Equipments / machinery - ward linen check total linen count - maintenance of paint, lights, curtains - ward meetings special events of the month DISPATCH equipments/instruments which cannot be repaired EXPIRY DATE of drugs and emergency medications RECORDS & REPORTS: maintenance of ward registers, files - Birth census - Narcotic report MONITORING: staff progress/patients care (appraisal review after 6 months) REPORTING: necessary information (patient care/staff progress/additional requirements etc. to the nursing department)

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180

ANNUALLY
FULL INVENTORY OF WARD ANNUAL BIRTH CENSUS NEW IMPROVEMENTS TO THE WARD suggestions and ideas etc. BUDGET- items required for the following year budget. LEAVE SCHEDULE OF THE STAFF STAFF APPRAISAL

APPENDIX E: RESPONSIBILITIES OF SHIFT IN-CHARGES (LABOUR ROOM)


Ensure that the inventory has been checked by the responsible person (according to the duty schedule). If the staff allocated for checking inventory has changed duty or has taken sick leave allocate another staff to check it. DONOT LEAVE THE INVENTORIES WITHOUT BEING CKECKED. Verify whether all items necessary for the shift is available. If not, take from the store (If it is not available in the store inform the ward in-charge). Ensure that the store room is locked at all times. Make sure that the narcotic cupboard is locked at all times and if a narcotic is used it should be entered in the register. Take hand over of all patients and make sure that the staff responsible for each patient reports the progress of their patients to you. Attend the doctors round along with the staff responsible for each patient (when appropriate). Visit all the patients as often as possible and make sure that they are not left alone.

180

181 If there is any problem with any patient make ensure that the responsible doctor is informed (if the medical officer cannot be contacted for any reason, inform the duty gynecologist directly). Make sure that the condition of patients are explained to the relatives at the given times. Any problem in the ward should be informed to the coordinator and ward in-charge without delay. Meet the shift coordinator / supervisor when she comes for rounds and inform the condition of patients. Supervise the work of attendants and other staffs and delegate their work equally. At the end or beginning of each shift check the necessary registers and make sure that the registers are completed.

APPENDIX F: DAILY TASKS OF NURSES WORKING IN LABOUR ROOM


Morning Shift
Report to ward on time. Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check narcotics inventory. (Check whether any narcotics have been used in the previous shift and see that it is entered in the narcotics register). Check the emergency trolley and neonatal resuscitation tray (check whether all equipments are in working condition). Check the general cleanliness of labour room Send instruments for autoclave. Take report from the previous shift.

181

182 Get introduced to the allocated patients and check their condition (check vital signs, FHS, FM, uterine contraction). Check IV fluids and if syntocinon drip is on flow check the drop rate and uterine contraction. Prepare for doctors rounds. Receive and prepare patients for induction of labour. Check for investigation reports and get them from laboratory (If cord blood has been sent make sure that the reports are collected without delay and handed over properly). Collect reports from the laboratory and hand over to the relevant wards with out delay. Give any due medications. Do rounds with doctors. Explain the patients condition to relatives. If any patient is kept in labour room for a long time, take her out and let the relatives meet her. Carry out orders. Complete documentation. Make the patients comfortable (mobilize the patient if possible). Monitor the patients condition (check FHS, Vital signs and uterine contraction as needed). Do not leave the patients alone when they are in pain. Inform the progress of patients to duty doctors and carry out any emergency orders. Explain the condition of patients to relatives and inform the relatives if there is any change in the line of treatment. Send the attendants to collect clean linen from laundry. Collect bed sheets and gowns from the OT/ wards. See that autoclaved items are collected from the CSSD. Hand over delivery forms of LSCS mothers. Pack used instruments, gloves etc. Check the cleanliness of labour room before handover to the next shift. Report any unusual incidence to the shift coordinator.

182

183 Complete documentation. Hand over to the next shift. Report to the ward incharge or shift incharge before leaving the ward or before going off duty.

Afternoon Shift
Report to ward on time. Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check narcotics inventory. (Check whether any narcotics have been used in the previous shift and see that it is entered in the narcotics register). Check the emergency trolley and neonatal resuscitation tray (check whether all equipments are in working condition). Check the cleanliness and tidiness of labour room. Take report from the previous shift. Get introduced to the allocated patients and check their condition (check vital signs, FHS, FM, uterine contraction). Check IV fluids and if syntocinon drip is on flow check the drop rate and uterine contraction. Complete documentation of the findings. Give any due medications Check for investigation reports and get them from laboratory (If cord blood has been sent make sure that the reports are collected without delay and handed over properly). Collect reports from the laboratory and hand over to the relevant wards with out delay. Do rounds with doctors and carry out orders Explain the patients condition to relatives. If any patient is kept in labour room for a long time, take her out and let the relatives meet her. Check if any delivery forms need to be handed over and remind the relatives to collect the forms. 183

184 Monitor the patients condition (check FHS, Vital signs and uterine contraction as needed). Do not leave the patients alone when they are in pain. Inform the progress of patients to duty doctors and carry out any emergency orders. Explain the condition of patients to relatives and inform the relatives if there is any change in the line of treatment. Check whether instruments need to be autoclaved and send to CSSD. Receive autoclaved items from the CSSD. Pack used instruments, gloves etc. Check the cleanliness of labour room before handover to the next shift Report any unusual incidence to the shift coordinator and ward incharge. Complete documentation Hand over to the next shift. Report to the shift incharge before leaving the ward or before going off duty.

Evening Shift
Report to ward on time. Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check narcotics inventory. (Check whether any narcotics have been used in the previous shift and see that it is entered in the narcotics register). Check the emergency trolley and neonatal resuscitation tray (check whether all equipments are in working condition). Check the cleanliness and tidiness of labour room. Take report from the previous shift. Get introduced to the allocated patients and check their condition (check vital signs, FHS, FM, uterine contraction). Check IV fluids and if syntocinon drip is on flow check the drop rate and uterine contraction. Complete documentation of the findings.

184

185 Give any due medications Check for investigation reports and get them from laboratory (If cord blood has been sent make sure that the reports are collected without delay and handed over properly). Collect reports from the laboratory and hand over to the relevant wards with out delay. Explain the patients condition to relatives. Make the patients comfortable. If patient is kept in labour room for a long time, take her out & let the relatives meet her. Check if any delivery forms need to be handed over and remind the relatives to collect the forms. Monitor the patients condition (check FHS, Vital signs and uterine contraction as needed). Do not leave the patients alone when they are in pain. Inform the progress of patients to duty doctors and carry out any emergency orders. Explain the condition of patients to relatives and inform the relatives if there is any change in the line of treatment. Pack used instruments, gloves etc. Check the cleanliness of labour room before handover to the next shift Report any unusual incidence to the shift coordinator and ward incharge. Complete documentation Hand over to the next shift. Report to the shift incharge before leaving the ward or before going off duty.

Night Shift
Report to ward on time. Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check narcotics inventory. (Check whether any narcotics have been used in the previous shift and see that it is entered in the narcotics register).

185

186 Check the emergency trolley and neonatal resuscitation tray (check whether all equipments are in working condition). Take report from the previous shift Get introduced to the allocated patients and check their condition (check vital signs,FHS, FM, uterine contraction). Check IV fluids and if syntocinon drip is on flow check the drop rate and uterine contraction. Complete documentation of the findings Give any due medications Check for investigation reports and get them from laboratory (If cord blood has been sent make sure that the reports are collected without delay and handed over properly). Collect reports from the laboratory and hand over to the relevant wards with out delay. Complete the census and write newborn census. Check the routine cleaning of the ward (washing of all the medication cups and all the trays). Explain the patients condition to relatives. Monitor the patients condition (check FHS, Vital signs and uterine contraction as needed). Do not leave the patients alone when they are in pain. Inform the progress of patients to duty doctors and carry out any emergency orders. Explain the condition of patients to relatives and inform the relatives if there is any change in the line of treatment. Make the patients comfortable. If patients are kept in labour room for observation switch off lights and help them to take rest. Give morning care. Prepare patients for induction of labour. Receive patients from wards for induction of labour. Pack used instruments; gloves etc and prepare it to send for autoclave. Check the cleanliness of labour room before handover to the next shift Report any unusual incidence to the shift coordinator and ward incharge. 186

187 Complete documentation Hand over to the next shift. Report to shift incharge/ward incharge before leaving the ward or before going off duty.

APPENDIX G: DAILY TASKS OF ATTENDANTS WORKING IN LABOUR ROOM

Morning Shift
187

188

Report to ward on time. Take over from the night shift attendant. Check the general cleanliness of labour room. Take instruments to CSSD and collect it when autoclaved. Collect clean linen from the laundry. Collect bed sheets and gowns from the OT/ wards. Take specimens to laboratory. DO NOT WAIT TO FINISH OTHER WORK. Clean wheel chairs and stretchers. Accompany patients to wards /OT along with a nursing staff. Collect reports from laboratory. Take investigation reports to wards and get signature of the staff who receives the report. Assist patients to toilets if required. (ONLY WHEN ASKED BY A NURSE) When asked by nurses stay with the patients. Answer the bell, but DO NOT give any information regarding patients. Call a nurse to give any information to relatives. Make gauze, swabs and pads. Check patients toilet frequently and clean as needed. Wash kidney trays and disinfect them if a patient vomits. (Keep in sodium hypochlorite solution for 10 minutes. DONOT LEAVE THEM FOR MORE THAN THE SPECIFIED TIME). Clean doors, windows and other furniture. Wash suction bottles and suction tubing after each delivery. Clean and disinfect patients unit thoroughly when patients are transferred. (wash used oxygen tubing and change water in the humidifier) Take dirty linen to laundry DO NOT TAKE DIRTY LINEN ALONG WITH ANY THING CLEAN Take things to CSSD. Check the general cleanliness of labour room 188

189 Wash the slippers. Hand over to the next shift. Report to the shift incharge/ward incharge before leaving the ward or before going off

duty.

Evening Shift
Report to ward on time. Take over from the morning shift attendant. Check the general cleanliness of labour room. Take instruments to CSSD and collect it when autoclaved. Collect clean linen from the laundry. Collect bed sheets and gowns from the OT/ wards. Take specimens to laboratory. DO NOT WAIT TO FINISH OTHER WORK. Clean wheel chairs and stretchers. Accompany patients to wards /OT along with a nursing staff. Collect reports from laboratory. Take investigation reports to wards and get signature of the staff who receives the report. Assist patients to toilets if required. (ONLY WHEN ASKED BY A NURSE) When asked by the nurses stay with patients. Answer the bell, but DO NOT give any information regarding patients. Call a nurse to give any information to relatives Make gauze, swabs and pads. Check the patients toilet frequently and clean as needed. Wash kidney trays and disinfect them if a patient vomits. (Keep in sodium hypochlorite solution for 10 minutes. DONOT LEAVE THEM FOR MORE THAN THE SPECIFIED TIME). Wash suction bottles and suction tubing after each delivery. Clean and disinfect patients unit thoroughly when patients are transferred. (wash used Oxygen tubing and change water in the humidifier)

189

190 Take dirty linen to laundry. DO NOT TAKE DIRTY LINEN ALONG WITH ANY THING CLEAN Wash the slippers. Check the general cleanliness of labour room Hand over to the next shift. Report to the shift incharge/ward incharge before leaving the ward or before going off duty.

Night Shift
Report to ward on time. Take over from the evening shift attendant. Check the general cleanliness of labour room. Take specimens to laboratory. DO NOT WAIT TO FINISH OTHER WORK. Accompany patients to wards /OT along with a nursing staff. Collect reports from laboratory. Take investigation reports to wards and get the signature of the staff who receives the report. Assist patients to toilets if required. (ONLY WHEN ASKED BY A NURSE) When asked by the nurses stay with patients. Answer the bell, but DO NOT give any information regarding patients. Call a nurse to give any information to relatives Make gauze, swabs and pads. Check the patients toilet frequently and clean as needed. Wash all the kidney trays and disinfect them. (Keep in sodium hypochlorite solution for 10 minutes. DONOT LEAVE THEM FOR MORE THAN THE SPECIFIED TIME). Wash suction bottles and suction tubing after each delivery. Clean and disinfect patients unit thoroughly when patients are transferred. (wash used Oxygen tubing and change water in the humidifier) Assist the nurses in cleaning and disinfecting the delivery room.

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191 Take dirty linen to laundry. DO NOT TAKE DIRTY LINEN ALONG WITH ANY THING CLEAN Wash the slippers. Check the general cleanliness of labour room Hand over to the next shift. Report to the shift incharge/ward incharge before leaving the ward or before going off duty.

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192

REPRODUCTIVE HEALTH CENTRE

RHC-ROUTINES QUALITY OF MAINTENANCE OF WORK & WORKING ENVIRONEMNT INFECTION CONTROL GUIDELINE DAILY TASKS OF NURSES DAILY TASKS OF SHIFT SUPERVISOR SHIFT ROUTINES FOR CLINICAL ASSISTANTS SHIFT ROUTINES FOR RECEPTIONINTS SHIFT ROUTINES FOR ATTENTANDS

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RHC-ROUTINES
Charging
All the investigation will be charged Consultations and other services such as injections are given free

Appointments
Instruct all antennal clients to confirm appointments 2 days prior to the consultation date. Notify the confirmation. Appointment with no confirmation will be cancelled & those appointments can be given to the requested clients. Extra appointments cannot be given without asking the consultant on duty.

Patients who come with leaking PV, Bleeding PV, and pain abdomen
Inform to the nurse and the doctor on duty. Quickly take history If required direct them to casualty. Inform to casualty staff before sending them If needed accompany them to casualty, provide wheel chair or stretcher Or provide an appointment depending upon the situation.

ANC registration for new clients


Pregnancy confirmation result must be there before 4 months of pregnancy. If they have confirmed with home kit ask them to do urine gravindex (give investigation slip) If they have not confirmed ask them to do beta HCG (at least one month aminorrhoea)

Registration Memo
For all new patients Registration memo must be made and the hospital number must be entered in their concerned clinic registers.

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Investigation reports
All investigation reports (including reports from islands, private clinics) which are done during the present pregnancy should be entered on the ANC card & write the date of the investigation done Investigations (G6 PD DIFICIENT, NEGATIVE BLOOD GROUP, ALLERGIC MEDICINES) should be written in RED INK.

High Risk Pregnancies


High risk patients will be consulted only on Sundays and Wednesdays of the week. A high risk list is maintained in the RHC. Due visit of all clients should be marked in the high risk list. This list will be evaluated by weekly to identify the due visits and delay visits will be reminded.

Family Planning Items.


Condoms, Oral Pills & inj, Depo must issued throughout the day from 7.30am till 10.00pm. All clients should be counseled before introducing any family planning method. Family planning drugs and devices are issued only for family planning purposes.

NST
NST can be done for the RHC patients and Inpatients only. History and condition of the patient should be assessed before receiving patients from Wards. Clarify the indication for NST. Do not receive patients on stretcher, cases such patients in active labour, with premature contraction on duvadilon drip, eclampsia, APH e.t.c. Make memo & maintain records. If you are unable to contact the consultant who advised NST, then please call the Gynae MO on duty to show the report.

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Foetal distress
If you identify foetal distress while doing NST or checking FHS, please start Oxygen immediately & inform the doctor immediately. Also double check with another staff. Document correctly & accurately

Serum Billirubim
Serum Billirubin is done according to the Doctors advice after postnatal consultation. Make memo & maintain records

Urine Albumin,
For anyone urine albumin will be done if high blood pressure is being noticed during the registration. For PIH cases urine albumin will be done for all their visits.

Writing nurses notes


Nurses notes should be written to all clients after NST, newborns admitting after Serum bilirubin results, antenatal clients admitting after urine albumin/high /low BP, high/low blood sugar identified at RHC. Clients with fainting episodes /weakness /leaking PV/ bleeding PV, active labour, diagnosed by the consultant. Note: the above mentioned patients should be accompanied by RHC nurse & proper handover should be given to the nurse of the other ward. Transfer them by wheel chair or stretcher depending upon the condition of the patient. Make necessary arrangements to transfer them as soon as possible.

Vaccines
Inj. T.T is provided in accordance with the DPH protocols for antenatal mothers and adolescents. All vaccines other than inj. T.T should be bought by clients

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Ward Visits
Ward Visits should be done daily to assess the conditions of antenatal and postnatal mothers. Health education is provided according to their needs. All the postnatal mothers will be explained about exclusive breast feeding, care of episiotomy or LSCS wound, cord care & family planning. Staff should attend to calls made by the ward staff to assist difficult cases of breast feeding.

Health Education
Health education is given to all clients according to their needs. Monthly forums are conducted according to a schedule prepared for each month. The topics for forums are breast feeding, Labour & Labour Room Orientation, Baby bath & newborn care, and to different high risk groups.

Points to be highlighted during registration for family planning


Explain about physiological changes after delivery involution of uterus pelvic floor muscle changes hemoglobin level o Time is required for the body to adjust the above mentioned processes. It is also important not to get pregnant again until the body is ready for that. So it is advisable to follow one of the family planning methods until the decision to have another baby. Inform about the family planning clinic during the postnatal visit Explain about the procedure/appointments of the family planning clinic Family planning counseling Family planning devices free of charge

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197 Available time

Maintenance of Records
All clients data are entered to RHC computer soft wear program. Pap smear reports are entered to computer program and each Pap smear report is filed with the examination form. List of high risk patients are maintained. The due visit for each patient will be marked to monitor their follow-up visits and outcome after delivery will be noted.

Antenatal exercise
For all clients ANC EXERCISE fitness form must be explained & filled at 5 months after anomaly scan. If a client requests to join the AN exercise classes, proper instructions must be given about the date, timings, payment & about the necessary items required Clients details should be entered into the registers & a copy of the completed fitness form should be given to the physiotherapy department

Pelvic assessment
Pelvic assessment form should be given to all clients at 32 weeks during the registration. Gynecologists will be fixing a date for pelvic assessment after explanation

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QUALITY & MAINTENANCE OF WORK & WORKING ENVIRONMENT


Each individual staff is allocated special work in order to maintain the quality work done at RH centre as well as to maintain a convenient working environment

ANTENATAL CLINIC
Maintenance of Antenatal registers & ANC cards Check if registers are properly labeled & neatly maintained Check if serial no. is followed correctly. Check if all information (personal identification, medical /obs. /surgical history) is complete. Check if Bp & weight are entered in each visit. Check if results (blood, urine, & scan etc) are entered on each visit. Identify & report incomplete records. The report should include the specific date, type of record date, & the name of the responsible staff. Maintenance of ANC statistics Complete statistics from January November 2006 at the end of November. Check if daily statistics are entered to the daily sheet & computer Prepare a format for statistics report during the 2nd week of October & confirm. Report the progress of statistics report once every week.

Breastfeeding forum
Make monthly schedule for breastfeeding forums. Ensure all mothers at 6 months of pregnancy are noted down& called for breastfeeding forums. Check the no. of clients called for forums. Check the no. clients attended for sessions. Check the no of husbands attending forums. Check the total no. of clients who attended to ANC at & after 6 months.

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199 Maintain statistics

Labour & Labour room orientation forum


Make monthly schedule for labor /labor room orientation forums. Ensure all mothers at 7 months of pregnancy are noted down& called for forums. Check the no. of clients called for forums. Check the no. clients attended for sessions. Check the no. of husbands attending forums Check the total no. of clients who attended to ANC at & after 7 months. Maintain statistics

New born care forum


Make monthly schedule for new born care forums. Ensure all mothers at 8 months of pregnancy are noted down& called for forums. Check the no. of clients called for forums. Check the no. clients attended for sessions. Check the no. of husbands attending forums Check the total no. of clients who attended to ANC at & after 8 months. Maintain statistics

Maintenance of Inj. Tetanus stock & record


Check condition & temperature of the fridge daily Check stock balance weekly & write requisition to DPH whenever necessary Write the total no. of doses available & total no. of doses issued at the end of each week Check if all records are entered properly Maintain cleanliness of the fridge

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ANTENATAL HIGH RISK CLINIC


Maintenance ANC High Risk statistics Complete statistics from January November 2006 at the end of November. Check if daily High Risk cases are entered to the daily sheet & computer Conduct high risk forums Maintain record of high risk outcome after delivery Report the progress of statistics report once a month

High risk clients follow up visit


Maintain record of high risk visits with follow up date Call & confirm if follow up visits are not done Arrange appointment to those who got delayed due to appointment overbooking Arrange forum or provide health education on the high risk factor

Antenatal exercise
Check antenatal exercise request book daily Always keep the AN exercise register updated Ensure if fitness forms are filled for all mothers at 5 months after anomaly scan Ensure if all forms (fitness forms, item list, and appointment slip) are in the file Ensure if all copies fitness forms are filed & a copy is sent to the physiotherapy dept.

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POSTNATAL CLINIC
Quality of maintenance of registers Check if registers are properly labeled & neatly maintained Check if serial no. is followed correctly. Check if all information (personal identification, medical /obs. /surgical history) is complete. Check if details of mother & newborn are entered in each visit. Identify & report incomplete records. The report should include the specific date, type of record date, & the name of the responsible staff. Maintenance of PNC statistics Complete statistics from January November 2006 at the end of November. Check if daily statistics are entered to the daily sheet & computer Prepare a format for statistics report during the 2nd week of October & confirm. Report the progress of statistics report once every week. Conducting forums Conduct forums on complimentary feeding after delivery between 4 & 6 months Conduct forum monthly once or twice

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FAMILY PLANNING CLINIC


Quality of maintenance of Family Planning registers & cards Check if registers are properly labeled & neatly maintained Check if serial no. is followed correctly. Check if all information (personal identification, medical /obs. /surgical history) is complete. Check if Bp, weight & other information are entered in each visit. Check if investigation results are entered if any. Identify & report incomplete records. The report should include the specific date, type of record date, & the name of the responsible staff. Maintenance of Family Planning Stock Check if daily statistics are entered Check if all the issued items are entered in the registers Check if stock balance tally with the issued item numbers. Maintain monthly stock balance /no. of users report form Sending Family Planning reports to DPH Send Family planning reports to DPH once in every 3 months Send Family planning stock request to DPH once in 6 months Conduct Family Planning Forums Start conducting family planning forums from November onwards once in a month

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WELL WOMEN CLINIC


Quality of maintenance of Well Women registers & forms Check if registers & forms are properly labeled & neatly maintained Check if serial no. is followed correctly. Check if all information (personal identification/ history & other relevant information) is complete. Check if results (Pap smear, blood, urine, & scan etc) are entered on each visit. Check if all the forms (pap smear & well women forms) are filed in order Identify & report incomplete records. The report should include the specific date, type of record date, & the name of the responsible staff. Pap smear forms Collect Pap smear forms daily from the OPD & file them in a separately. Get reports from the Laboratory weekly once, attach with Pap smear forms and file them. Enter the data to the computer program on weekly basis. Keep all files properly labeled with dates.

ADOLSCENT HEALTH CLINIC


Quality of maintenance of registers, files & forms Check if registers are properly labeled & neatly maintained 203

204 Check if serial no. is followed correctly. Check if all information (personal identification & other relevant history) is complete. Check if all the forms are complete & filed in order Check if the vaccine register is maintained properly Identify & report incomplete records. The report should include the specific date, type of record date, & the name of the responsible staff.

MAINTENACE OF ANTENATAL LEAFLETS


Arrange leaflet packs & keep ready for distributing patients Remind to request for leaflets before getting them over Keep leaflets neatly arranged

MAINTENACE OF POSTNATAL LEAFLETS


Arrange leaflets in the cupboard & in other places Remind to request for leaflets before getting them over Keep leaflets neatly arranged

MAINTENANCE OF MODELS
Check models register weekly once Maintain lending /receiving items properly

MAINTENANCE OF WARD VISIT RECORDS


Check & report if ward visits are not done daily Check if all the columns of the ward visits are filled accurately

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SUPERVISION OF INVENTORY
Check if the inventory is checked daily Check & report missing items Check & maintain lending& borrowing book

SUPERVISION OF RECEPTION
Remind all staff to keep the reception neatly &tidily Check if reception inventory is maintained Check if all appointment registers are labeled & maintained properly Ensure & report if all posted staff for the reception stay in the reception Remind about the rules of using reception telephone Report problems of reception

MAINTENANCE OF LIBRARY
Books & videos Keep the library books neatly arranged at all times Check library register once a week Maintain a record of lending / receiving items

CLEANLINESS & ARRANGEMENT OF COMSULTATION ROOMS


Check if all areas of rooms are properly cleaned Check if all items in the rooms are neatly arranged Check if all sterile items in the room are not outdated Make sure thorough cleaning is done once a week Check if all instruments working condition Identify & maintain repair & maintenance Ensure that all documents / forms & files in the room are in place

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CLEANLINESS & ARRANGEMENT OF REGISTRATION ROOM


Check if all areas of the room are cleaned properly Check if all items are arranged neatly kept in place Maintain all fliers in the registration room Ensure if all instruments are in working condition Ensure thorough cleaning is done once a week

CLEANLINESS & ARRANGEMENT OF HEALTH EDUCATION ROOM


Check if all areas of the room are cleaned properly Check if all items are complete arranged neatly Ensure thorough cleaning is done once a week

CLEANLINESS & ARRANGEMENT OF HEALTH EDUCATION ROOM


Check if all areas /tables in the waiting area is cleaned daily Check if all items are arranged neatly Ensure thorough cleaning (chairs / leaflet cupboards , TV) is done once a week

CLEANLINESS & ARRANGEMENT OF VACCINE ROOM


Check if all areas of the room are cleaned properly Check if all items are arranged neatly kept in place Ensure if all instruments are in working condition Ensure that sharps & other waste are handled properly Ensure thorough cleaning is done once a week

CLEANLINESS & ARRANGEMENT OF TREATMENT ROOM


Check if all areas of the room are cleaned properly Check if all items are arranged neatly kept in place Ensure if all instruments are in working condition 206

207 Ensure that sharps & other waste are handled properly Ensure thorough cleaning is done once a week

CLEANLINESS & ARRANGEMENT OF COUNSELLING ROOM


Check if all areas of the room are cleaned properly Check if all items are arranged neatly kept in place Ensure if FP models & other items are in place Ensure thorough cleaning is done once a week

CLEANLINESS & ARRANGEMENT OF DEMONSTRATION ROOM


Check if all areas of the room are cleaned properly Check if all items are arranged neatly kept in place Ensure if all equipments are in working condition Identify & report maintenance & repair work Ensure thorough cleaning is done once a week

CLEANLINESS & ARRANGEMENT OF STORE ROOM


Check if all areas of the room are cleaned properly Check if all items are arranged neatly kept in place Ensure thorough cleaning is done once a week

INFECTION CONTROLL GUIDELINE FOR RHC STAFF


Daily disinfection of all examination couches daily with sodium hypochlorite Hand washing solution (betadine & chlorhedexine solution) must be available in all consultation rooms Clean all rooms thoroughly once a week according to the cleaning schedule Wash all dustbins once a week Wash all hand washing solution bottles once a week

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208 Wash / through clean of both treatment rooms once a month. Clean all fans once in 2 weeks Wash curtains once a month Bring sodium hypochlorite daily from CSSD Wash all trays daily in 3rd shift Check items required for re autoclaving once a week in the 3rd shift Send forceps with jar for autoclaving everyday if it has been opened & used Follow instructions for tray packing for packing used instruments Disinfect all thermometers /stethoscopes daily in the third shift Wash & dry the mop after every use Ensure if mop bucket is washed after every use Supervise (shift in charge) attendants during & after cleaning Supervise attendants - handling of linens, waste, & autoclaved items All staff should follow universal precaution during procedures All staff should use sterillium for hand disinfection in-between procedures if hand washing is not possible e.g before giving inj. T.T All staff should present self neatly, should maintain short nails & no jewelries Through cleaning & washing of RH centre once in 3 months

Reception & waiting area Clean & mop the reception area daily twice. Clean & arrange all tables daily Clean the top of the counter with sodium hypochlorite daily at the end of all clinics. Clean the telephones with spirit at the end of all clinics. Clean thoroughly the reception area & counter once in a week. Registration room Clean & mop daily

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209 Clean the weighing machine, height scale and table tops daily Clean the stethoscope daily with spirits Thorough cleaning once a week Dust & clean inside the cupboard, table drawers Wash table top with soap & water Disinfect with sodium hypochlorite Health Education Room Clean all areas of the room & mop the room daily Clean all equipments in the room daily Thorough cleaning once a week Dust & clean leaflet cupboard Dust & clean the TV rack Wash table top with soap & water Treatment room (down stairs) Clean all areas of the room & mop the room daily Carbolize the examination couch with sodium hypochlorite Clean inside the cupboard Disinfect NST machine daily / wash cloth belt once a week Treatment room (up stairs) Clean all areas of the room & mop the room daily Carbolize the examination couch with sodium hypochlorite daily Change sheets in-between patients Clean the cupboard & cardiac table top daily with sodium hypochlorite Keep sterile items separately from non sterile items Through cleaning once a week -Dust and clean all areas of the room with sodium hypochlorite including walls & fans Demonstration Room Clean all areas of the room & mop the room daily 209

210 Clean all equipments in the room daily Thorough cleaning once a week Clean inside the cupboard once a week Clean all chairs once a week Clean all areas of the room once a week All consultation rooms Clean & mop all rooms daily Clean table tops daily Wash table tops with soap & water once a week Ensure the wash basin is cleaned well Disinfect all examination couches daily with sodium hypochlorite Keep hand -washing solutions & sterillium solution in all rooms Disinfect dopplers /Bp apparatus daily Disinfect baby mat & measuring tape daily in the 3rd shift

Counseling Room Clean all areas of the room & mop the room daily Clean all equipments in the room daily Thorough cleaning once a week Clean inside the cupboard once a week Clean all chairs once a week Clean all areas of the room once a week Store Room Clean all areas of the room & mop the room daily Clean all equipments in the room daily Thorough cleaning once a week Clean inside & top of the cupboards once a week

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211 Office Clean all areas of the room & mop the room daily Clean all equipments in the room daily Wash the table top daily Thorough cleaning once a week Clean inside & top of the cupboards once a week

INSTRUCTIONS FOR TRAY PACKING


Wash instruments / article with diluted soap solution. Dry immediately with a clean towel Handle the instruments / article care fully and gently. Check for proper functioning of instruments / articles. Keep only sufficient amount of instruments in the tray. Make sure instruments are enough for a particular procedure. Keep cotton balls / gauze enough for a particular procedure. 211

212 Keep autoclaving indicator before closing the tray Make sure the wrapper is large enough to cover the tray completely. Check and label properly. Fix the autoclaving indicator outside the label (not on the tray cover) and write the date and name (who packs tray) on the plaster. Make sure all the trays and articles are accurately written in the book before sending for autoclaving.

Special instructions Soak soiled instruments in 0.5% sodium hypochlorite solution for 5 minutes before washing.

UNIVERSAL PRECAUTION
Protect health care providers from exposure to disease spread by blood, other body fluids such as HIV, hepatitis B, MRSA e.t.c

Procedures for universal or standard precaution


1. Hand washing 2. Clothing (uniform/gown) 3. Shoes 4. Caps 5. Mask-patient & staff protection 6. Safe injection practices 212

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Additional precaution
1. Air borne, Contact, Inoculation or Parenteral, 2. Faeco-oral routes, multiple routes. Transmission- based precautions are special precautions taken in addition to standard precautions for known infections based on the mode of transmission of the infection.

SHARP DISPOSAL
1. Use sharps container for disposing cotaminated needles, blades e.t.c 2. Do not pass sharps to one another 3. Do not recap/if recapping use the correct method 4. Practice safe injection practices 5. Discard sharps container when 2/3 full

WASTE DISPOSAL
1. Double bag/biohazard labeled infectious waste/ attendant must wear rubber gloves for transferring waste materials 2. Send out of the place as soon as possible Soiled material after procedure (norlant /copper-T insertion) Small dressings-episiotomy/surgical wounds.etc Motion cleaning/nappies

LINEN
1. Put soiled linen directly into black bag 2. Count the amount of linen correctly

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214 3. Double bag/biohazard labeled soiled linen 4. Send to laundry as soon as possible

BLOOD/ VOMITUS/ OTHER BODY FLUIDS


1. Put sodium hypocrite over the spilled fluid 2. Cover with newspaper and leave for a few minutes 2. Attendant must wear rubber gloves for taking them put them into a plastic bag 3. Mop the area use the separate mop 4. Wash, clean the mop in bleach & dry

RECEIVING A CLIENT WITH A COMMUNICABLE DISEASE


1. If a client is notified with any communicable disease, she should be taken to one of the free OPD consultation for consultation. 2. Inform the gynaecologist on duty. 3. Inform to the OPD nurses station & arrange the room 4. All appropriate measures should be taken by the staff 5. Preferably an immuned staff should accompany if possible. 6. If the diagnosis is confirmed after consultation, then used instruments, sheets & examination couch, chair must be disinfected before next patient

SHIFT ROUTINES FOR RHC NURSES


FIRST SHIFT Report to ward on time. Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check appointments, staff on duty & doctors duty rota Check allocated areas of all staff & prepare to start work according to the clinics of the day Check if rooms are ready for consultations

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215 Check the general cleanliness of the place Send attendant to collect linen & autoclaved items Check report & statistics of the previous day Check the message book Take delivery list of the previous day & send to the physiotherapy department Check & record the vaccines & fridge temperature Prepare for registration & health education Check & distribute linen & autoclaved items to rooms Ensure all clients who need health education are given health education. Report any unusual incidence to the nurse in charge & shift coordinator. Clean & arrange consultation rooms at the end of the clinics Wash & pack used intruments Complete report & statistics Handing over to the next shift Complete other assigned works / assist in registration of patients if necessary Check cleanliness & tidiness of all the areas Report to the ward in charge on shift in charge going off duty

SECOND SHIFT Report to ward on time. Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check appointments, staff on duty & doctors duty rota Check allocated areas of all staff & prepare to start work according to the clinics of the day

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216 Check the general cleanliness of the place Check if rooms are ready for consultations Take report from the previous shift Check if statistics report is correct & complete Check vaccines & fridge temperature Prepare for registration & health education Ensure all clients who need health education are given health education. Do ward visits Help family planning clinic Report any unusual incidence to the nurse in charge & shift coordinator. Clean & arrange consultation rooms at the end of the clinics Complete report & statistics Handing over to the next shift Complete other assigned works Check cleanliness & tidiness of all the areas Report to the ward in charge on shift in charge going off duty

THIRD SHIFT Report to ward on time. Check ward inventory (check whether all the equipments are in working condition and if there are any thing missing get it replaced by the previous shift nurses). Check appointments, staff on duty & doctors duty rota 216

217 Check allocated areas of all staff & prepare to start work according to the clinics of the day Check the general cleanliness of the place Check if rooms are ready for consultations Check the total number & type of family planning procedures Take report from the previous shift Check if statistics report is correct & complete Check vaccines & fridge temperature Prepare for counseling, procedure, registration Prepare for adolescent health clinic Report any unusual incidence to the nurse in charge & shift coordinator. Clean & arrange consultation rooms at the end of the clinics Check & replace all necessary items for the consultation rooms Count & maintain family planning stock Wash all trays Disinfect all articles stethoscope, telephones, baby mat, measuring tape etc. Complete report & statistics Complete other assigned works Check cleanliness & tidiness of all the areas Write special reports on the message book or on the notice board Swtich off all lights, air-conditions (except demonstration room & treatment room), close all doors & recheck before closing the place

SHIFT SUPERVISOR
(Shift supervisor will be one of the nurses on duty)

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JOB DESCRIPTION
Check the total number of staff (nurses, clinical assistants, doctors) on duty. Check the total number of appointments and the number of doctors on duty. All staff should inform to the SHIFT SUPERVISOR regarding any information (order) given by a doctor, from other departments, or any other staff. Receptionists should inform to the SHIF SUPERVISOR regarding any information (order) given by a doctor or other staff. SHIFT SUPERVISOR must take action regarding any delay in doctors consultation, delay in attending to duty by staff etc. All staff must inform their sick leaves to the SHIFT SUPERVISOR. Ensure that staff posted to all areas, and remain in their posts during clinic hours. And also ensure all the clinics function properly on time. Any staff who leaves the posted area for any valid reason (e.g. treatment room) must inform to the SHIFT SUPERVISOR. Check the reception for any new Memos, Letters, cards etc. We all are responsible to minimize the telephone and computer use. However the SHIFT SUPERVISOR has the authority to observe long telephone calls (>3 minutes) and remind about the IGMH rules for telephone and internet use. Monitor and check if the following records are maintained. Inventory book / Report & statistics file FP Books HE books and lists ANC/PNC Computer data etc: Supervise the cleanliness of all the areas. Identify repair work and missing items.

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SHIFT ROUTINES FOR CLINICAL ASSISTANTS


Check posted consultation room according the particular room check list. Make the consultation rooms ready according to the type of clinic Call patients according to their serial numbers after Doctors arrival. Translate & explain what doctors wants to explain patients Guide the patient for doctors examination. Assist to the doctor to complete investigation forms, prescription for the doctor and explain to the patient. Enter each patients record for the computer data system. Maintain cleanliness of the room throughout the consultation. Completing other allocated tasks (eg: entering records for the data system, assisting to prepare health education materials) during the off time

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FLOOR STAFF
(Floor staff will be one of the clinical assistant on duty.)

JOB DESCRIPTION
Greet & smile people whoever comes inside the RH centre. Guide them to the counter. Explain the procedure for the new comers. (ie: they have to go through the registration, health education, and then consultation.) Identify and guide people who need registration, health education, and consultation (address/call them by their names). Identify and guide to people who requires breast feeding. Inform to a nurse about inj. T.T. NST etc. & other procedures Direct or explain how to go to other departments and their procedures (eg: scan, x-ray) Check health education check list before they go home. Maintain health education status file.

RECEPTIONISTS
Greet who ever enters into the Reproductive Health Centre Enquire the purpose of visit and provide information or make arrangements to fulfill their needs. Giving appointments to those who need to attend to the concerned clinics. Maintaining record of appointments. Distribute appointments according to the doctors duty roster. Receive & handover items (eg: letters/cards/circulars) to the concerned staff in time.

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221 Maintain stationeries /books for the reception.

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