Académique Documents
Professionnel Documents
Culture Documents
Yemen 48Modern
48
Hospital
Republic of
Yemen 48Modern
Hospital
48
Table of Contents
CHAPTER 1 DEPARTMENTAL PROFILE
Title: Admission
NURSING
SERVICE
DEPARTMENT ORGANIZATIONAL
Procedures
.............................................................................................3
CHART..................................1
Title: Discharge of
NURSING
MISSION-VISION
Client....................................................................................................6
STATEMENT.......................................................................2
Title: Discharge
NURSING
SHARED
Planning..................................................................................................
9
MISSION..........................................................................................
2
Title: Transfer of
NURSING
SHARED
Client.....................................................................................................
13
VISION.............................................................................................
2
CHAPTER
2
POLICIES
AND
PROCEDURES
Title: Answering Telephone
NURSING
DEPARTMENT GOALS AND
Call......................................................................................16
OBJECTIVES..................................................
3
Title: Clients Identification
NURSING
DEPARTMENT'S
SCOPE
OF
NURSING ADMINISTRATIVE POLICIES AND PROCEDURES
Band....................................................................................
18
SERVICE..........................................................4
Title: Code Blue
Procedures............................................................................................ 20
Title: Doctors
Orders.......................................................................................................
24
Title: Informed
Consent.....................................................................................................2
8
Title: Patients
Confidentiality...........................................................................................3
1
Title: Provision of Patients
Privacy................................................................................ 33
Title: Patients and Family Rights and
Responsibilities................................................. 35
Title: Patient
Education....................................................................................................
39
Title: Safety For Patients and
Staff...................................................................................41
Title: Security for Hospital
Equipment.............................................................................45
Title: Standard
Abbreviations..........................................................................................
47
GENERAL WARD INTERNAL POLICIES AND PROCEDURES
Title: Prevention of Medication
Title:
General Wards Staff Competency
Errors............................................................................
53
Assessment...................................................67
Title: Pain
Title:
Scope of Service - In-Patient Nursing
Management................................................................................................
Units........................................................
71
.....57
Title: Isolation
Clients Personal
2
Standards/Precautions..........................................................................
74
Belongings................................................................................ 60
Title: Waived and Point of Care
Testing......................................................................... 62
Title: Absconding of
Clients............................................................................................78
Title: Answering Call
Bells..............................................................................................
80
Republic of
Title:
Yemen 48Modern
48
Kardex.........................................................................................................
Hospital
............. 82
Title: Comprehensive Nursing
Assessment.................................................................. 84
Title: Nursing Care
GENERAL
NURSING INTERNAL POLICIES AND PROCEDURES 87
Plan...................................................................................................
Title: Nursing
Documentations........................................................................................9
0
Title: Nursing
Endorsement.............................................................................................9
4
Title: Assessing Patients Psychological
Needs.......................................................... 96
Title: Unit
Rounds........................................................................................................
.... 99
Title: Calling For a
Physician.......................................................................................... 101
Title: Airway
Management..............................................................................................
104
Title: Applying an External
Catheter...............................................................................107
Title: Assessing the Neurological
System......................................................................110
Title: Application of Skin
Traction...................................................................................117
Title: Back Care / Back
Rub.............................................................................................120
Title:
Bathing.......................................................................................................
..............123
Title: Bed
Making........................................................................................................
......128
Title:
Breastfeeding..............................................................................................
............133
Title: Blood
Extraction....................................................................................................
.137
Title: Blood
Transfusion..................................................................................................
.140
Title: Care of the Unconscious
Client.............................................................................146
Title: Cast
Application..................................................................................................
...150
Title: Cast
Removal......................................................................................................
... 153
Title: Cleaning a Sutured Wound and Applying
a Sterile
3
Dressing ........................... 155
Title: Cold
Compress....................................................................................................
... 160
Title: Insulin
Therapy......................................................................................................
245
Title: Intravenous Cannula
GENERAL NURSING INTERNAL POLICIES AND PROCEDURES
Insertion.............................................................................
249
Title: Intravenous Fluid
Therapy.................................................................................... 253
Title: Implementing Seizure
Precautions.......................................................................262
Title: Management of
Burns........................................................................................... 264
Title: Management of Client for Electroconvulsive Therapy
(ECT) ............................270
Title: Management of Foreign Body Airway
Obstruction.............................................273
Title: Managing Patient With PCA
Pump...................................................................... 276
Title: Measuring Fluid Intake and
Output..................................................................... 279
Title: Medication Preparation and
Administration....................................................... 281
Title: Mouth/Oral
Care.................................................................................................... 298
Title: Nail Care / Foot
Care............................................................................................. 303
Title: Nasogastric Tube
Feeding....................................................................................306
Title: Nasogastric Tube
Insertion...................................................................................310
Title: Nasogastric Tube
Removal.................................................................................. 314
Title: Nursing Care of Epileptic
Client...........................................................................317
Title: Obtaining a Wound Drainage
Specimen .............................................................321
Title: Obtaining Specimens for Culture and
Sensitivity.............................................. 324
Title: Offering and Removing Bedpan or
Urinal...........................................................327
Title: Oxygen
Therapy.....................................................................................................3
29
Title: Perineal
Care.........................................................................................................
333
Title: Positioning and Mobilizing The
Client................................................................ 336
Title: Post Mortem
Care................................................................................................. 345
Title: Post-Operative
Care.............................................................................................. 349
Title: Post-Operative Teaching: Moving, Leg Exercises, Deep Breathing and
4
Coughing.....................................................................................................
..............352
Title: Post Thyroidectomy
Care......................................................................................355
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
MACHINES
Title: Dinamap Blood Pressure
Monitor.........................................................................536
Title: Electrocardiography
Machine............................................................................... 538
Title: Infusion
Pump........................................................................................................
540
Title: IVAC Temperature
Plus..........................................................................................543
Title: Multiparameter (NELLCOR PURITAN BENNETT4000)...................................... 546
Title: Pulse
Oximeter......................................................................................................
. 550 OTHER DEPARTMENTS POLICIES AND PROCEDURES
Title: Septic AFFECTING
Fluid Aspirator
Medap
NURSING
PRACTICE
P7040.................................................................... 552
Title:
Title:Syringe
Arterial Blood
Pumps.......................................................................................................
Gas.................................................................................................... 568
555
Title: Ultrasonic
Nebulizer.............................................................................................. 559
Title: Suction
Machine .....................................................................................................
561
Title: Optium Xceed
Glucometer.....................................................................................563
Republic of
Yemen 48Modern
48
Hospital
CHAPTER
1
DEPARTMENTA
L
PROFILE
Republicof
of
Republic
Yemen48Modern
48Modern
Yemen
84
84
Hospital
Hospital
48MODERN HOSPITAL
Nursing Services
Organizational Chart
Republic of
Yemen 48Modern
48
Hospital
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
1.5.1 The patient is the corner stone for nursing services. So all planning and
administration should be directed to meet his/her needs and contribute to
his/her best
outcome, rehabilitation, and to add to his knowledge about maintaining
his/her
health.
1.5.2
The plan for nursing service personnel should be on a continuous basis,
24-hoursa-day, seven days a week, and serving the out patient 10 hours per day.
Nursing
personnel need to consider long and short-term planning with the medical
staffThe
andnursing department has a major responsibility to maintain an
1.5.3
patients for
most effective health care delivery.
environment
that
is clean and conducive to recovery and safety. Each nursing personnel
makes a
contribution to the disease prevention by the way she carries her works
with patients
1.5.4
to assess
and study
and Nurses
family. are
Theexpected
work of the
nurse begins
withthe
thesocio-economic,
diagnosis of the patient,
psychological,
conditions ofand
illness, prescribed treatment and home long-term care.
emotional needs of people and to take steps to consider his/her needs
according to
these
facts.must
Then,
the plan
care
should
beprocedures
made.
1.5.5
Nurses
abide
withof
the
policies
and
to be the bases for
the
standards of services.
1.5.6 Appropriate supervision will increase or promote the fulfillment of the
purpose of
the individual and the group.
1.5.7 The total environment in the hospital should be conducive to teaching
and learning
for patients, visitors, and staff in the unit.
2 THE SGHG NURSING SERVICE PROFESSIONAL STAFFS MUST:
2.1 Go through the hiring processes, procedures, and credential
verifications by:
2.1.1 Checking the staffs educational work experience
backgrounds.
2.2 Consider the worth and dignity of
mankind.
2.3 Be aware of the basic needs of the
people.
2.4 Apply principles to promote feeling of mental and physical comfort, safety,
and respect.
2.5 Assist people to get the best results in sickness and
in health.
2.6 Have the attitude, knowledge, and skills to do quality
nursing care.
2.7 Develop plans to meet the needs of the
people.
2.8 Understand her role in the preventive, restorative, and curative program in
comprehensive health services.
12
Republic of
Yemen 48Modern
48
Hospital
13
Republic of
Yemen 48Modern
48
Hospital
14
Republic of
Yemen 48Modern
48
Hospital
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
17
Republic of
Yemen 48Modern
48
Hospital
CHAPTER
POLICIES
2
AND
PROCEDURE
S
18
Republic of
Yemen 48Modern
48
Hospital
NURSING
ADMINISTRATIV
E
POLICIES AND
PROCEDURES
19
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Issued Effective: Replaces:
Title: Admission ProceduresDue for Review: Page 1 of 3
CONTENTS: This General Ward Internal Policy and Procedure (IPP) discusses about the
procedure of
admitting patients in the ward units.
1 DEFINITION:
1.1 Admission - a means of accepting patient in the hospital unit/area for observation,
treatment or
management of patients illness/disease condition.
1.2 Types of Admission:
1.2.1 Routine Admission the patient admission that may start from the Outpatient
clinic or
Emergency room, passing through the Admission and Discharge Office.
1.2.2 Emergency Admission - the admission of a client on an emergency basis. These
clients
present a condition which unless promptly treated on an inpatient basis would
cause the
following condition:
1.2.2.1 put clients life in danger
1.2.2.2 can cause serious damage to bodily function
2 PURPOSES:
2.1 To provide healthcare services that is not possible to be rendered at home or as an
outpatient.
2.2 For further observation, treatment or management of the patients presented
condition.
3 POLICIES:
3.1 Patient is admitted at anytime of the day passing through Admission/Discharge
Office.
3.2 Admission Advice Sheet is generated from Admission Office as a proof of acceptance.
3.3 Admission/Discharge Officer on duty informs the area where the patient will be
admitted.
3.4 Preventive isolation cases should be admitted in a single room.
3.5 On cases where patients cannot afford a first class rooms the following should be
observed:
3.5.1 ENT cases should not be placed in a room with febrile patients.
3.5.2 Pediatrics, obstetrics and gynecology cases should not be mixed with oncology
patients
or those undergoing chemotherapy treatments.
3.6 Every patient should have an individual medical file and PIN card.
3.7 Follow standard file arrangement.
20
Republic of
Yemen 48Modern
48
Hospital
PROCEDURES:
4.1 Check for Admission Advice Sheet, admitting documents, and PIN card.
4.2 Ensure proper identity of patient.
4.3 Accompany to the room assigned and make patient comfortable.
4.4 Provide hospital gown and assist patient in wearing it.
4.5 Orient the patient on the following:
4.5.1 how to access assistance such as call bell signal, telephone number, or other
electronic
alerting
4.5.2 physical environment and healthcare arrangements
4.5.3 basic care equipment
4.5.4 frequency of contact with care provider
4.6 Enforce hospital policy on valuables.
4.7 Obtain vital signs, height and weight as baseline information.
4.8 Identify the right patient:
4.8.1 Apply ID band on patients right wrist, unless contraindicated.
4.8.2 Put patients name on bed and outside room door.
21
Republic of
Yemen 48Modern
48
Hospital
REFERENCES:
5
5.1 LD Policy # 41.12
5.2 Fundamentals of Nursing, Ruth F. Craven, Constance J. Hirnle,
pp. 28
22
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Issued Effective:Replaces:
Title: Discharge of ClientDue for Review:Page 1 of 3
CONTENTS: This General Ward policy and procedure serves as a guideline in discharging
client.
1 DEFINITION:
1.1 Discharge refers to the process of activities that involve the patient and a team of
individuals
from various disciplines working together to facilitate the transition of that client
from one level
of care to another.
1.2 Types of Discharge:
1.2.1 Medically Advised (Routine) when the attending clinician considers that the
client no
longer requires in-patient care. The client may be transferred to another facility
for
ongoing care, or in most cases, discharged home.
1.2.2 Against Medical Advice (AMA) when the client / relatives request and insists
on
discharge and refuses further in-patient care despite clear explanation by the
attending
POLICIES:
clinician
the client
is for
notdischarge
ready for from
discharge.
3
3.1.There should
bethat
a written
order
the Attending Physician.
23.2.
PURPOSES:
A Discharge Form should be filled up completely by the nurse taking care of the
2.1 Encourage the patient/relative to participate actively in the nursing/medical treatment
patient
at home.
indicating all necessary information reflected in the form.
2.23.2.1.
To foster
a senseplanning
of belongingness
among
family
members.
Discharge
should start
from
the first
day of patients admission.
2.3 To ensure safety and continuity of care at all times.
3.2.2. A copy of the discharge form should be given to the patient/relative upon
discharge.
3.2.3. A patient/relative level of understanding on health education provided
should be reevaluated on their level of understanding.
3.2.3.1.Necessary information should be provided to the patient regarding
his/her
medication; safe use of medical equipment and self-care methods for
activities of daily living. All of these should be documented.
3.3.All necessary documents must be completed before discharge.
3.3.1. For discharge against medical advice:
3.3.1.1.Waiver for Discharge Against Medical Advice (Form M1019) should be
signed by the patient/relative witnessed by the attending physician or
resident on duty.
3.3.1.1.1. If patient is a minor and his relative still insist on DAMA, the
matter shall be referred to the following services: Clinician,
Social Worker and Medical Director to make reasonable attempt
to dissuade the patient / relative from DAMA or refusal of care.
3.3.1.2.The Chief of the Medical Operations (CMO) and the Nurse Supervisor
should be informed regarding patients desire to be discharged against
medical advice.
3.3.1.3.The treating doctor must fill up
23the dama form on the same day to be
submitted to the executive medical director by the nursing supervisor.
3.4.Remaining medicines of patient discontinued for use should be returned back to
Pharmacy.
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
25
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Issued Effective:Replaces:
Title: Discharge PlanningDue for Review:Page 1 of 4
CONTENTS: This General Ward policy and procedure deals with the guidelines procedure
planning
patients discharge.
1.0 DEFINITION:
1.1 Discharge Planning - is the process of activities that involve the client and a team
of
individuals from various disciplines working together to facilitate the transition of
that client
from one environment to another. It includes a systematic process of assessing the
assets and
limitations of the client during hospitalization, planning for continuity in his/her
health care
upon discharge from the hospital, and coordinating needed individual, family,
hospital and
community resources to implement the discharge plan.
1.2 Extended Medical Care Level I are those services provided to clients who require
maintenance, medications, minimal laboratory/radiological support, rehabilitative
services,
nutritional support (e.g. oral, intravenous, or enteral feeds), continuous skilled
nursing care and
infrequent clinician intervention. This level of care is usually the after effect of
disease or
injury, or any medical condition requiring ongoing chronic care interventions.
1.3 Extended Medical Care Level II are those services provided to clients who have
unexpected acute care requirements (excluding mechanical ventilation) beyond the
parameters
stated in paragraph 1.2.
1.4 High Risk Discharge Clients comprise of those diagnosed with CVA, neurological
deficit,
3.0 POLICIES:
carcinoma or other debilitative, terminal or respiratory condition, dementia and
3.1 Discharge planning should start prior to admission (for planned admissions), or at
Alzheimers
the time
of
disease
and orthopedic cases with limited activities of daily living.
admission (for unplanned admissions).
2.0 PURPOSES:
3.2
patientstandards
and his/her
shall be planning
included which
in identifying
realistic
goalsand
and all
2.1The
To define
forfamily
collaborative
prepares
the patient
efforts
his/her family for
shall
be directed
towards and
helping
patient to achieve these goals.
discharge
from hospital
carethe
at home.
3.3
plan for patients
discharge
shall
be discharge
reassessed
at appropriate
intervals and shall be
2.2The
To identify
for
whom
planning
is critical.
documented
and unplanned re-admissions due to incomplete course of treatment or
2.3 To reduce
updated
in the clients medical record.
recourse
gaps and
3.4 prevent
Discharge
planning isadmissions.
critical when patient or his/her significant others are assessed
unnecessary
to have
2.4 To plan for better quality of life and health outcomes.
knowledge
deficit
regarding
the
condition,
and treatment needs.
2.5
To promote
integration
and
continuity
of prognosis,
care.
Conditions may
include:
3.4.1 Patients having deviations in growth
26 pattern.
3.4.2 Child with special needs.
3.4.3 Patients who have undergone surgical interventions.
3.4.4 Patients undergoing organ transplantation.
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
Assists the client in planning for his/her diet so that cultural and religious
4.4.3
customs
can be maintained.
4.4.4 Interprets how and when the client can substitute cultural foods in
therapeutic diets.
4.4.5 Documents in the clients file and diet instructions given to the client on the
order of
the attending clinician.
4.4.6 Anticipate and recommend what diet and tests will be needed after
discharge/transfer as part of the follow up nutrition reassessment plan.
4.5 Nursing Administration:
4.5.1
Ensures
that discharge planning is a part of everyday care given by nursing
4.6
Physical
Therapist:
staff. 4.6.1 Evaluate clients needs for rehabilitation related special medical item such
as
wheelchairs, splints, pressure garments or adaptive equipment in order to
maximize
client function.
4.6.2 Teach client and their families the exercise / activities of daily living and
skills
needed to function effectively and independently within the limitations of
their
disability.
28
Age
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Circle all that apply and total the score. Refer to the Risk Factor Index at the
bottom.
Name of Patient:__________________________ ____Age:__________ Attending Physician:___________________
Chief Complaint/s:________________________ Diagnosis:_____________________ Room No.:________________
0=55 years or less
1=56 to 64 years
2= 65 to 79 years
3= 80+ years
Living Situation/Social Support
0 =lives only with spouse
1 = Lives with family
2 = Lives alone with family support
3 = Lives alone with friends support
4 = Lives alone with no support
5 = Nursing home or residential care
Functional Status
0 = Independent in activities of daily living and
Instrumental activities of daily living
Dependent in:
1 = Eating/feeding
1 = Bathing/grooming
1 = Toileting
1 = Transferring
1 = Incontinent of bowel function
1 = Incontinent of bladder function
1 = Meal preparation
1 = Responsible for own medication
administration
1 = Handling own finances
1 = Grocery shopping
1 = Transportation
Cognition
0 = Oriented
1 = Disoriented to some spheres, some of the
time
2 = Disoriented to some spheres all of the time
3 = Disoriented to all spheres some of the time
4 = Disoriented to all spheres all of the time
5 = Comatose
Behavior Pattern
0 = Appropriate
1 = Wandering
1 = Agitated
1 = Confused
1 = Other
Mobility
0 = Ambulatory
1 = Ambulatory with mechanical assistance
2 = Ambulatory with human assistance
3 = Nonambulatory
Sensory Deficit
0 = None
29
Republic of
Yemen
Visits
0 = None in the last 3 months
1 = One in the last 3 months
2 = Two in the last 3 months
3 = More than two in the last 3 months
Number of Active Medical Problems
0 = Three medical problems
1 = Three to five medical problems
2 = More than five medical problems
Number of Drugs
0 = Fewer than three drugs
1 = Three to five drugs
2 = More than five drugs
TOTAL SCORE:__________
Risk Factor Index:
Score of 10 = at risk for home care resources; score of 11 to 19 = at risk for extended discharge
planning; score
grater than 20 = at risk for placement other than home. For score 10 or greater, refer the patient to the
discharge
planning team.
30
Republic of
Yemen 48Modern
4. PROCEDURES:
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Issued Effective: Replaces:
Title: Transfer of ClientDue for Review:Page 1 of 3
CONTENTS: this general ward policy and procedure discusses about the system
implemented in
transferring of p patient from one unit to another or from SGH to other hospital.
1DEFINITION:
1.1 Transfer - a systematic process of handing over patient from one unit/hospital
to
another for continuity of medical/nursing care management.
1.2 Types:
1.2.1 Within the Hospital:
1.2.1.1. Transfer Out - transfer of patient from one unit to another.
1.2.1.2.Transfer In - transfer of patient to the unit from another.
1.2.2 Hospital to Hospital:
1.2.2.1. Transfer From - transfer of patient coming from another health care
facility
to SGH, considered as admission (to follow admission process).
1.2.2.2. Transfer To - transfer of patient to another health care facility, this
follows
the discharge process.
2. PURPOSES:
2.1For continuity of care.
2.2 To support patients treatment that needs life-saving equipment/machines.
2.3 For further medical/nursing observation and management.
2.4 For patient convenience (proximity of the residence).
3. POLICIES:
3.1 Transfer order should be documented.
3.2 Prior information to the receiving unit/hospital should be provided. Doctor to
doctor for
hospital to hospital transfer and nurse to nurse communication is needed for
patient transfer
within the hospital.
3.3 Proper endorsement of patients condition is given to the receiving nurse.
3.4 Discharge and Transfer Form (Form M1196) should be properly accomplished
filling up
all necessary documents.
3.5 For Hospital Transfer:
3.5.1 Original copy of Discharge/Transfer Summary (Form M1196) should be
signed
and handed over to the receiving nurse and a copy should be kept to clients
file in our
Hospital.
3.5.2 Client is escorted by a nurse via SGH ambulance.
3.5.3 For critical case, a nurse and doctor shall accompany the client.
3.5.4 Safety measures should be followed.
4.1 Obtain a written order prior to transfer. In emergency situation, documentation could be
31
Republic of
done later.
Yemen
48Modern
48
4.2 Explain
to client/relatives
regarding the transfer and prepare client physically.
4.3 For Hospital
to Hospital Transfer :
Hospital
32
Republic of
Yemen 48Modern
48
Hospital
33
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Issued Effective: Replaces:
Title: Answering Telephone CallDue for Review:Page 1 of 2
CONTENTS: This General Ward policy and procedure deals with the procedure of answering
telephone
calls.
1.0 DFEINITION:
1.1 Answering of Telephone Calls- the professional manner/conduct of receiving
incoming
telephone calls observing the hospital telephone protocol
2.0 PURPOSES:
2.1 To facilitate ease of communication.
2.2 To receive inter/intra department/unit call.
3.0 POLICIES:
3.1 Telephone call should be answered after 2 rings.
3.2 Telephone protocol should be followed. See attach telephone protocol.
4.0 PROCEDURES:
4.1 Answer the telephone after 2 rings.
4.2 Greet by saying hello, tell your department, introduce yourself and say may I
help you.
4.3 Speak in a clear, well-modulated voice.
4.4 Listen attentively on the messages that are being delivered by the sender, jot
down notes if
needed.
4.4.1 Confirm the correctness of the message received by repeating the
information given.
4.4.2 Identify name of the calling party.
4.5 After the conversation is over, end by saying Goodbye or Bye.
4.6 Put the telephone down properly, making sure you dont bang it.
5.0 SPECIAL CONSIDERATIONS:
5.1 If the message is to be relayed to another person, ensure that communication is
passed on
correctly to the proper person.
5.2 Secrecy or confidentiality of the issue is observed when needed.
34
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
4.7 For newborn, check the ID band attached on the right arm where babys
permanent PIN is
written against the file and/or medication card embossed with the PIN.
4.8 Upon discharge, remove patients ID band before leaving the room.
4.8.1 For post partum mother:
4.8.2 ID band is retained with the mother and to be removed only by the
Newborn Unit
staff upon claiming the baby.
4.8.3 If the mother is discharged without the baby, instruct the mother to
keep her ID
band and present it to the NewBorn Unit staff when she will claim the baby.
4.9 For newborn, upon discharge remove the 2 ID bands attached to both legs
simultaneously
with the mothers ID band on her wrist. Correctly identify the mothers name and
PIN printed
5.0
CONSIDERATIONS:
onSPECIAL
the tag against
the tag of the newborn. Both ID bands should match the
5.1
For
patient
mothers name
and treated in Emergency Room staying 1-4 hours for ER-OR or; for
observation,
PIN.
should have ID band applied, plus a bed tag with proper identification.
5.2 Never let discharged client go home with ID band still attached to the wrist or leg
except
for identical twins where one (1) ID band will be retained on the leg until the parents
can
identify the twins properly.
36
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
37
6.1.4
Republic
Initiate 1 rescuer
of CPR while waiting for the code blue team to arrive.
6.1.5 Open airway (head tilt chin lift maneuver).
Yemen 48Modern
48
6.1.6 Assess for breathing (look, listen & feel) 10 seconds.
Hospital
6.1.6.1
Give 2 initial ventilation (1second each) with the aid of an ambu
bag
6.1.6.2 Attach connecting tubing from flow meter and nipple adapter to
resuscitation bag.
6.1.6.3 Turn oxygen flow meter to 8L/min. Attach reservoir bag to
resuscitation
bag.
6.1.6.4 If not contraindicated, tilt back patients head or raise on a pillow to
better
achieve a sniffing position.
6.1.6.5 Insert an oropharyngeal airway to keep clients mouth open and
prevent
airway obstruction that maybe caused when the tongue falls back.
6.1.6.6 Use proper size oxygen mask and apply it over the clients mouth
and nose.
6.1.6.7 Support the mask with your left hand and compress the bag with
your right
hand.
6.1.6.8 Check carotid pulse (10 seconds).
6.1.6.9 Locate the area (lower half of the sternum) and start giving
compression and
ventilation at 30:2 ratio.
6.1.6.10 Check pulse after 2 minutes, if no pulse continue CPR until the
help arrive.
6.2 Nurse assigned for crash cart
6.2.1 As soon as the code blue is announced by the operator, crash cart
should be
brought to the location of the code blue.
6.2.2 Put the cardiac board at the back of the client.
6.2.3 Connect ambu bag to oxygen and apply to the client.
6.2.4 Assist in 2 rescuer CPR with 30 : 2 ratio until the Code Blue Team arrive.
6.2.5 Connect client to cardiac monitor.
6.2.6 CPR will be continued by the Code Blue Team as soon as they arrive.
6.3 Assigned Nurse
6.3.1 Will give a brief information to the Code Blue Team regarding the
diagnosis and
the condition of the client prior to code blue.
6.3.2 Keep vein open by starting IVF according to clients condition.
6.3.3 Take blood pressure and do suction as needed.
6.4 Code Blue Team function as follows:
6.4.1 Cardiologist
6.4.1.1 Continue with chest compression
6.4.1.2 Order emergency medicines
6.4.1.3 Monitor cardiac status of the client
6.4.1.4 Apply external defibrillator if indicated with specified number of
joules.
6.4.2 Anesthesiologist
6.4.2.1 Continue ventilation (ambu bag)
6.4.2.2 Intubate if needed and maintain client airway
6.4.2.3 Establish and maintain IV access if none
6.4.3 ICU Nurse
6.4.3.1 Assist the anesthesiologist in intubation
6.4.3.2 Administer emergency medicines as prescribed.
6.4.4 Nursing Supervisor
6.4.4.1 Document in Mock/Real Code and Cardiopulmonary Evaluation
form.
6.4.4.2 Obtain additional equipment and help as necessary.
6.4.4.3 Clear the room of all personnel who are not involve in the Code
Blue
38
Team.
6.4.4.4 Communication with clients family.
6.4.5 Head Nurse/Charge Nurse
Republic of
Yemen 48Modern
48
Hospital
39
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Issued Effective:Replaces:
Title: Doctors OrdersDue for Review:Page 1 of 4
CONTENTS:This General Ward policy and procedure of 48 MODERN HOSPITAL serves as
guidelines in receiving doctors orders in whatever forms.
1 DEFINITION:
1.1 Doctors Orders - Are prescribed treatments/procedures given by the Attending
Physician
according to the patients condition.
1.1.1 Mode:
1.1.1.1 Written Order - treatments/Procedure documented in the Doctors Order
Sheet
(Form M1043).
1.1.1.2 Verbal Order - treatments/Procedure verbally stated or instructed on
emergency
cases only.
1.1.1.3 Telephone Orders - treatments/Procedure being conveyed by the Attending
Physician over the phone (in emergency situation).
1.1.2 Types:
1.1.2.1 Standing - an order that is carried out as specified until it is discontinued
or
cancelled by another order.
1.1.2.2 Single - an order that is carried out only once, at a time specified needed
by the
patient.
1.1.2.3 Stat (Latin word statim meaning immediately) a single order but one
that is
carried out at once.
1.1.2.4 prn (Latin word pro re nata) an order, which is carried out when patient
requires it. It does not indicate a specific time of administration of
medication.
2 PURPOSES:
2.1 To serve as legal document to support clients health treatment during his/her
hospitalization and
to protect the health personnel.
2.2 To provide guidelines in treatment or management of client.
2.3 To provide validation for clinicians order given verbally or by telephone.
40
Republic of
Yemen 48Modern
Hospital
48
POLICIES:
3.5 All doctors order should be documented in the patients file.
3.5.1 Written order should:
3.5.1.1 bear the date and time
3.5.1.2 include complete description or instruction
3.5.1.3 be clear and legible
3.5.1.4 duly signed by the attending physician
3.5.2 Verbal/telephone order is given and received only during emergency situation.
3.5.3 Telephone order is given and received only when the doctor is unable to come
and assess
the client.
3.5.3.1 Telephone orders should be received by two (2) RNs. A verification readback of the
entire order to the physician is done by the person/s receiving the order.
3.5.3.2 To exclude telephone order on radiology, laboratory investigations and
procedures.
3.6 The physician should sign verbal/telephone orders within 24 hours.
3.7 When receiving doctors orders, nurses accept only approved list of abbreviations
and
41
standardized approved drip preparation for parenteral medications such as heparin,
etc.
3.8 Nurses check with the physicians for any medication orders that are not clear.
Republic of
Yemen 48Modern
Hospital
48
3.9 In addition to the standard abbreviations approved for use in the hospital
prescribing doctors
should be prompted when using the following abbreviations in order to avoid error in
Resolutions
the
Rationale
transcription. Write unit
Abbreviations
Mistaken
Write international unitas 0 or cc
U
Mistaken as IV or 10
Write daily
IU
(International
Unit)
Mistaken
Write every other
day for QOD
QD
Mistaken
QD
Do not write zero
by itselffor
after
QOD
Decimal
point
is
decimal point.
Trailing zero (X.0mg)
Decimal point is missedAlways writemissed
a zero before a
decimal point
Lack of leading zero (.Xmg)
Confusion between Morphine Write morphine
sulfate
and Magnesium
MS
Confusion between Morphine Write morphine
MSO4
sulfate
MgSO4
and Magnesium
Confusion between Morphine Write magnesium
Ug
sulfate
Cc
and Magnesium
OD
Mistaken for mgWrite mcg
Mistaken for UWrite ml
Mistaken for each other: daily Write daily or
3.10When dealing with medication dosages, a zero should always precede a decimal
right eye
point right
(0.5mg)
for
versus
eye
clarity.
3.11Doctors orders should be read and reviewed by a registered nurse.
3.12Orders that are not clear or doubtful should be clarified before carrying out.
3.13The assigned registered nurse should carry out every order immediately;
checks/counterchecks
and draws a line on the space after the last order and sign as the order is carried out
on the space
PROCEDURES:
4
provided.
4.1 On Routine Orders (written)
4.1.1 Treating physician writes the order on the doctors order sheet Form M1043
with date and
time. Ordering doctor duly signs the order.
4.1.2 Nurse reads and interprets immediately the doctors order and clarifies if
needed.
4.1.3 Nurse carries out and processes the order as required.
4.1.3.1 Tick () every order to ensure that it is done and nothing is left unnoticed.
4.1.3.2 Transcribe or update orders to kardex, treatment sheet and medication
card.
4.1.4 Ensure that orders are implemented as:
4.1.4.1 Medication and treatment (Refer to policy of Medication Preparation and
Administration)
4.1.4.2 Procedure order process should be entered in the computer (X-ray, lab)
4.1.4.3 Diet entered to computer
4.1.4.4 Nurse executing the order should affix his/her name legibly with date and
time
carried out
4.2 Verbal Order:
4.2.1 Registered nurse transcribes the order directly in the doctors order sheet by
indicating the
42
date, time, and complete order and writing V.O. (verbal order) and writes the
name of the
ordering doctor countersigned by the receiving nurse.
Republic of
Yemen 48Modern
48
Hospital
43
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
44
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
46
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
4.2 Staff:
4.2.1 Avoids posting patients identity in a public area.
4.2.2 Not allowing public postings with patients personal information in view.
4.2.3 Not allowing personnel not immediately concerned in providing care to the
patient to have
an access with the patients file.
4.2.4 Returns patients file to file rack when not in use.
48
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
50
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Issued Effective:Replaces:
Title: Patients and Family Rights and ResponsibilitiesDue for Review:Page 1 of 4
CONTENTS: This General Ward policy and procedure deals with the patients and family
rights and
responsibilities while acquiring services from 48 MODERN HOSPITAL.
1 DEFINITIONS:
1.1 Patients Rights natural and legal privileges of every patient while admitted in the
hospital to
meet their basic human needs as a person and medical needs as a patient.
1.2 Patients Responsibilities obligations and accountabilities that a patient is liable
during the
course of stay in the hospital.
1.3 Patient an individual who comes to the facility to seek treatment and services for
his/her health
problems.
1.4 Family a patients significant others (immediate or extended family).
2 PURPOSES:
2.1 To protect patients individuality as a person.
2.2 To act for the best interest of the patient.
2.3 To protect patient from harmful procedure/ situation.
2.4 To respect patients rights at all times.
2.5 To impart to the patient the process of the informed consent.
PATIENTS
RIGHTS:
2.6 To provide
information concerning health promotion and maintenance to the patient
3.1
Right
to
and family. meet basic physiological survival requirements air, water, food,
elimination,
rest, basic
sleep,premises on the patients expectations in terms of his/her health
2.7 To explain
3
etc.
management.
3.22.8
Right
to stay in
a quiet and
safe
environment.
It includes
promotion
of adequate
To promote
confidence
and
trusting
relationship
between
patient/family
and rest
and
sleep,
members of the
prevention
of accidental
falls/trauma,
etc. the treatment procedure and during the entire
health team
to gain cooperation
during
3.3 Right
for
respect
and
dignity
to:
hospitalization.
3.3.1 receive guests known to patient during visiting hours unless contraindicated.
3.3.2 treat patient with human touch by being heard, felt with sympathy to illness.
3.3.3 get the same treatment as others regardless or religion, culture and tradition.
3.4 Right for love and security. Give patients appropriate attention to feel being loved
and secured.
Communicate, listen, and touch with sympathy.
3.5 Right for privacy and confidentiality:
3.5.1 All medical records and investigations are treated highly confidential and are
stored in
computer on line accessible only by authorized persons.
3.5.2 Members of healthcare team avoid talking about patients in areas that can be
overheard.
3.5.3 Public postings with patients personal information in view are prohibited.
3.5.4 The treating doctor provides privacy during medical examination.
3.5.5 To have medical staff of the same gender performs or assists during the
procedure.
3.5.6 No individuals nor guests not concerned with patients care to be present
during
examination or treatment without appropriate
permission.
51
3.5.7 Healthcare personnel knock on the door and announce themselves prior to
entry in the
patients room.
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
53
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
54
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
57
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Issued Effective: Replaces:
Title: Security for Hospital EquipmentDue for Review:Page 1 of 2
CONTENTS: This General Ward policy and procedure serves as methods to prevent losses of
medical
equipment.
1 DEFINITIONS:
1.1 Medical Equipment devices used to help health care professionals in the diagnosis,
therapy,
surgery, and other procedures aiming to provide quality health care to patients.
1.2 Borrowers Logbook a logbook maintained in the unit used in recording and tracking
of
equipment/devices borrowed by other units.
2 PURPOSES:
2.1 To keep intact all issued equipment to the unit.
2.2 To avoid undue losses of equipment/devices lent to other units.
2.3 To observe proper documentations of all equipment/devices accounted to the unit.
3 POLICIES:
3.1 All medical equipment should be technically evaluated periodically.
3.2 A logbook should be maintained in the unit where all borrowed equipment will be
documented.
Logbook entries should include:
3.2.1 date of borrow
3.2.2 item description
3.2.3 serial/inventory number
3.2.4 name of borrower/ID number/signature
3.2.5 name of returnee/ID number/signature
3.2.6 date or return
3.2.7 remarks
3.3 Equipment lent should be checked of the functioning status before sending and upon
returning.
3.4 All activities involved during the borrowing process should be properly documented.
3.5 There should be proper endorsement of the equipment.
3.6 Borrowing of equipment will depend on the availability of the equipment in the area.
3.7 The borrowing nurse of the equipment will take responsibility for the borrowed item.
3.8 Any item/s borrowed should be properly endorsed to the receiving charge nurse.
3.9 Borrowed equipment should be returned as soon as the procedure is finished and the
purpose for
such borrow is already met.
4 PROCEDURES:
4.1 Borrowing staff calls up the head nurse/charge nurse of the unit for the availability of
the item to
be borrowed.
4.2 Borrowing staff receives the item to be borrowed from the lending unit after having
approval from
the head nurse or the charge nurse.
4.3 Lending staff enters in the borrowers logbook all necessary information needed.
4.4 Borrowing staff takes the borrowed item including all responsibilities incurred for
such borrowing.
58
4.5 Lending staff follows-up the item borrowed if such item is not returned on the
expected schedule.
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
59
Republic of
Yemen 48Modern
48
Hospital
60
Republic of
Yemen 48Modern
48
Hospital
- Hemoglobin
Hb
- Hepatitis B Surface Antigen
HBs Ag
- High Density Lipoprotein
HDL
- Human Lymphocyte Antigen
HLA
- hematocrit
hct
- hour
h.
- Herpes Simplex Virus Type 2
HSV2
- Intake and Output
I&O
- Intracranial Pressure
ICP
- Intensive Care Unit
ICU
- Insulin Dependent Diabetes Mellitus IDDM
- immunoglobulin
Ig
- immunoglobulin A, etc.
Ig A, etc.
- Intramuscular
IM
- Intermittent Positive Pressure Breathing
IPPB
- Intraocular Pressure
IOP
- irregular
irreg.
- Intravenous
IV
- Intravenous Pyelogram
IVP
- Intravenous Urogram
IVU
- Potassium
K
- Kidney, Ureter, Bladder
KUB
- Keep Vein Open
KVO
- Left Bundle Branch Block
LBBB
- Lupus Erythematosus
LE
- Left Lower Lobe
LLL
- Left Lower Quadrant
LLQ
- Left Ventricular Hypertrophy
LVH
- Mean Arterial Pressure
MAP
- Mean Corpuscular Hemoglobin
MCHC
Concentration
Med.
- Medicine
MG
- Myasthenia Gravis
MI
- Myocardial Infarction
MS
- Multiple Sclerosis
MRI
- Magnetic Resonance Imaging
Na
- Sodium
NAD
- No Abnormality Detected
NICCU
- Neonatal Intensive Coronary Care UnitNPO
- Nothing Per Orem.
NSS
- Normal Saline Solution
O2
- Oxygen
OD
- Right Eye
OOB
- Out of Bed
ORIF
- Open Reduction Internal Fixation
OS
- Left Eye
PAC
- Premature Atrial Contraction
PaO2
- Partial Pressure of Oxygen
Para
- Number of deliveries
PAT
- Paroxysmal Atrial Tachycardia
p.c.
- After Meals
PCO2
- Partial Pressure of Carbon Dioxide
PEA
- Pulseless Electrical Activity
61
TB
TIA
Republic of
Yemen 48Modern
48
Hospital
PEEP
- Positive End Expiratory Pressure
per - by way of
PERRLA
- Pupils Equal Round and Reactive to Light and
pHAccommodation
PID - Hydrogen Ion Concentration
PKU- Pelvic Inflammatory Disease
p.m.- Phenylketonuria
PMS- evening
PUO- Premenstrual Syndrome
PPD- Pyrexia of Unknown Origin
PRN- Purified Protein Derivatives
PT - as necessary
Pt - Prothrombin Time / Physio-Therapy
PTT - Patient
PVC- Partial Thromboplastin Time
PND- Premature Ventricular Contraction
q - Paroxysmal Nocturnal Dyspnea
q3h - every
q.d.- every 3 hours
q.h.- everyday
q.i.d.
- every hour
q.o.d.
- four times a day
R/O - every other day
RBBB
- Ruled Out
RBC- Right Bundle Branch Block
RDS- Red Blood Cell
Rh+- Respiratory Distress Syndrome
Rh -- Positive Rh Factor
RHD- Negative Rh Factor
RLL - Rheumatic Heart Disease
RLQ- Right Lower Lobe
RML- Right Lower Quadrant
ROM
- Right Middle Lobe
RUL
- Range Of Motion
RUQ- Right Upper Lobe
Rx - Right Upper Quadrant
s
- Treatment/Prescription
SC - without
SIDS- Subcutaneous
SLE - Sudden Infant Death Syndrome
SOS- Systemic Lupus Erythematosus
sol. - If necessary
SOL - solution
Sp. Gr.
- Space Occupying Lesion
stat - Specific gravity
susp.- immediately
tab. - suspension
TAH- tablet
TAHBSO
- Total Abdominal Hysterectomy
- Total Abdominal Hysterectomy with Bilateral
Salpingo-Oophorectomy
- Tuberculosis
- Transient Ischemic Attack
62
Republic of
Yemen 48Modern
48
Hospital
63
Republic of
Yemen 48Modern
48
Hospital
pint
quart
tablespoon
teaspoon
unit
micrometer
microgram
micro unit
yard
64
pt.
qt.
tbsp.
tsp.
uum
ug.
uU
yrd.
-
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Issued Effective:Replaces:
Title: Prevention of Medication ErrorsDue for Review:Page 1 of 4
CONTENTS: This General Ward policy and procedure serves as guidelines in the practice of
medication
administration in order to avoid commission of error by the nurses in the administration of
medications to
the patient.
1 DEFINITIONS:
1.1 Medication Error any preventable events that may cause or lead to inappropriate
medication
use or patients harm while the medication is in the control of the health care
professional, patient,
or consumer.
1.2 most common and potentially most dangerous nursing error.
1.3 Most Common Types:
1.3.1 Incomplete patient information
1.3.2 Unavailable drug information
1.3.3 Miscommunication of drug orders
1.3.3.1 Poor handwriting
1.3.3.2 Confusion between drug with similar names
1.3.3.3 Misuse of zeroes and decimal points
1.3.3.4 Confusion of metric and other dosing units
1.3.3.5 Inappropriate abbreviations
1.3.4 Lack of appropriate labeling
1.3.5 Environmental factor
1.3.5.1 Poor lighting
1.3.5.2 Heat
1.3.5.3 Noise and interruptions
2
3 PURPOSES:
POLICIES:
2.1Nurses
To ensure
safety
and complete
protection
of patients.
3.1
should
gather
information
and relevant data upon admission.
2.2Drug
To prevent
commission
of medication
3.2
information
references
should be errors.
available in all nursing units.
3.2.1 Updated drug reference handbook
3.2.2 References on pharmacological interaction of different drug properties.
3.3 Nurses should observe 7Rs of medication administration.
3.3.1 Right Patient
3.3.2 Right Drug
3.3.3 Right Dose
3.3.4 Right Route
3.3.5 Right Time
3.3.6 Right Frequency
3.3.7 Right Documentation
3.4 Nurses should use 2 identifiers when administering medications (2 nurses; a doctor or
a nurse;
doctors order sheet and medication sheet; or doctors order sheet and a medication
card).
3.5 Nurses should check with physicians for any medication orders that are unclear.
3.6 Nurses should double-check with each other for any dosage calculation of high-risk
65
medications.
3.7 The following constitute the medication error:
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
67
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Issued Effective:Replaces:
Title: Pain ManagementDue for Review:Page 1 of 3
CONTENTS: This General Ward policy and procedure serves as a guideline in the
management of pain as
experienced by the patient.
1 DEFINITION:
1.1 Pain a subjective experience that may or may not be verbalized. It is an unpleasant
feeling
caused by injury or disease. It can also be described as An unpleasant sensory and
emotional
experience associated with actual or potential tissue damage, or described in terms of
such
damage. It may be caused by psychological trauma or secondary to physical causes.
1.1.1 Acute Pain - includes pain associated with surgery, trauma, medical
emergencies,
childbirth and diagnostic and/or therapeutic procedures. In addition, acute pain
episodes
may be associated with chronic medical conditions such as sickle cell disease,
back pain,
3 POLICIES:
migraine headaches etc.
3.1 A1.1.2
priorChronic
nursingPain
assessment
is done
to every admitted
patient
and documented
- a long term,
continuous,
intermittent
or recurrent
pain or on
Nursing
Notes
discomfort
due,
(Form but
M1016).
not limited to, cancerous disease processes, sickle cell disease, trauma, burns
3.2 When a patient perceives pain, document in the Pain Flow Sheet (Form M3052); refer
requiring
to Pain
extended healing time or any pain disorder.
Score
M3050),
a pain
assessment
tool for scoring.
Fill data
as to: or therapeutic
1.1.3(Form
Procedural
Pain
- pain
and/or discomfort
from invasive
diagnostic
3.2.1 procedures,
Location
such as lumbar puncture, bone marrow aspiration, wound and burn
3.2.2 debridement,
Severity (use patients
description
pain score, needle
if possible)
incision and
drainage&procedures,
aspiration of fluid or aid
from 3.2.3
the Radiation
3.2.4 chest
Duration
or abdomen veni-puncture etc.
3.2.5 Frequency
2 PURPOSES:
3.2.6
Characteristics
(crushing,
burning
use patients own description)
2.1
To provide
guidelines
for proper
pain assessment.
3.2.7
Precipitating
Factors including
activity
&&
pharmacological
use. This is to include
2.2
To provide
safe, consistent
and effective
pain
discomfort management.
over
the counter, Natural & native remedies which the patient may not perceive as
relevant.
3.2.8 Alleviating Factors including pharmacological interventions including over the
counter
drugs.
3.2.9 Allergy status
3.3 Observation of behavioral and physiological responses must be done for infants and
those children
& adults who have cognitive impairment, severe emotional disturbances, dementia,
elderly and
those who have an altered level of consciousness and unable to communicate the
existence and
intensity of their pain.
3.4 All patients in the in-patient areas and emergency
room will be asked about pain
68
observed for
behavioral responses indicating pain during the nurses and clinicians assessments.
(See
Republic of
Yemen 48Modern
Hospital
48
3.5 attached Flow Chart on page 3-2A, which must be followed when assessing pain and
documenting
findings in the patients file.)
3.6 Any patient admitted for pain treatment will have analgesia and pain assessment
management
commenced within 30 minutes.
3.7 Pain intensity, location, pain relief, sedation score, effectiveness and adverse effects
or analgesia
therapy will be recorded by a nurse on the Pain Flow Sheet (Form M3052).
3.8 All patients undergoing invasive procedures will have post-operative
pharmacological analgesia
orders recorded in the Doctors Order Sheet (Form M1043).
3.9 All patients undergoing invasive procedures without general anesthesia will be
evaluated for the
need for pharmacological intervention.
3.10Doctors will be informed when patients are assessed with pain, discomfort or
analgesia side
4 PROCEDURES:
4.1effects.
Assess thoroughly every admitted patient including pain. Within 30 minutes, findings
3.11Effectiveness
of interventions will be reassessed within thirty (30) minutes to one
are
to be
(1)documented
hour of
on Nursing Notes (Form M1016). Assess patient further for pain using a
implementation to be documented on Pain Flow Sheet (Form M3052).
systematic
3.12Reassessment
will continue
every four
(4) hours
until pain score
isand
lesslevel
than of
two (2)
approach with appropriate
assessment
tools
(i.e. appropriate
to age
for
24
hours
understanding, etc.)
then reassessed
every
shift.
4.2and
Document
on Pain Flow
Sheet
(Form M3052) when a patient is identified with pain as
3.13Analgesic
orders
written
before
the pain starts or written in a routine way e.g. q 4
an ongoing
hourly
are
to
pain assessment frequency.
be
considered
empirical
and
topolicy.
be reviewed
in the
actual
pain(Form
relief.M3052).
Therapy
4.2.1
Pain is assessed
per
the
(Document
onlight
PainofFlow
Sheet
must be
4.2.1.1 Pain assessment should commence within 30 minutes. Refer to Pain Score
increased or reduced according to the patients response. Pain relief may require
(Form
flexibility with
M3050) to determine severity of pain.
analgesia.
4.2.1.2 Pain reassessment will continue every four (4) hours.
4.2.1.3 Pain Score less than 2 for 24 hours, should then be reassessed every shift.
4.3 Notify attending physician of the patients pain based on the assessment tool.
4.4 Teach patients and family members the importance of communicating pain/discomfort
and how to
assess and manage pain using appropriate pain assessment tool.
4.5 Administer doctors order on pharmacological interventions according to pain
assessment.
Reassess the effectiveness and document on Pain Flow Sheet (Form M3052) within thirty
(30)
minutes to one (1) hour.
4.5.1 Carry out and administer pharmacological interventions prior to painful
procedures and
evaluate the effectiveness during and after the procedure.
4.6 Determine and apply non-pharmacological interventions based on age, gender, cultural
background, and history.
4.7 Communicate patients response to pain management to the attending physician and
other healthrelated care providers, as necessary.
4.8 Contact and inform attending physician if pharmacological and/or non-pharmacological
interventions are not effective within one hour, i.e. patient is still having moderate or
severe pain.
4.9 Evaluate and document the effectiveness of pain management plans and record any
concern to
69
nursing staff on pharmacological and/or non-pharmacological interventions used,
evaluation data,
and patients response on Pain Flow Sheet (Form M3052) and in the Nursing Notes.
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual:
General Nursing Departmental Manual
Issued Effective:Replaces:
Title: Clients Personal BelongingsDue for Review:Page 1 of 2
CONTENTS: This General Ward policy and procedure deals with the guidelines procedure on
how to
manage clients personal belongings.
1 DEFINITION:
1.1 Personal Belongings - include all clothing and personal items which the patient has in
his/her
possession at the time of admission to Saudi German Hospital.
1.2 Lost Property - any item of personal or monetary value which is lost by the client within
the SGH
facility e.g.: jewelry, ID card, keys, watches, etc.
2 PURPOSE:
2.1 To provide safety and proper handling of patients personal belongings.
3 POLICIES:
3.1 Upon admission to the unit, patient is oriented with the hospital policy on personal
belongings.
3.1.1 Any valuables should not be kept inside the patients room. A safe deposit box is
available
in the Admission and Discharge Office for use.
3.1.2 Patient and family is reminded that any loss of valuables is not the responsibility
of the
hospital management.
3.2 Patients clothing shall be stored in the locker in the patients room, and soiled
clothing shall be
given to the family.
3.3 Patients personal belongings that may be of significance to a police case shall be
handed over to
the police authority, upon request. The receiving police officer, should in turn, sign for
the receipt
of such belongings.
3.4 If a patient dies, his/her personal belongings shall be given to the individual who
comes to collect
his/her body. Any personal belongings of the deceased patient left on the unit/ward will
be kept in
the area until a family member collects them.
3.4.1 The person collecting the left clothing and valuables should sign in the valuables
logbook
acknowledging receipt of the valuables.
RESPONSIBILITIES:
3.4.2 The staff will record in the valuables logbook the itemized contents and the4 name
4.1
Admission/Discharge Officer on Duty
of
the
4.1.1 Upon
Admission:
person
who received the items.
4.1.1.1
Informs
and children,
patients shall
relatives
that valuables
are not
3.5 Toys brought in the
for, patient
or left with
be checked
by the nurse
orallowed
attending
and
should
be
physician to
home.
If safe.
patient
refused
to sent it home.
ensuretaken
that they
are
If the
physician/nurse
decides a toy is not safe, the child will
4.1.1.1.1 He/she must endorse to Admission/Discharge Officer the valuables
not be
against
allowed to keep it with her/him.
itemized
by both The
the patient
3.6 No valuables
of anylists
kindForm
shallM1056
be leftsigned
with children.
parents and
will be instructed to
Admission/Discharge Officer.
remove all
4.1.1.1.2
He/she takes the risk of the valuables
and must sign waiver.
jewelry,
if possible.
70
3.7 Personal property or belongings of patients who absconded should be kept in the
nursing station
and should be released only once bill is settled.
Republic of
Yemen 48Modern
48
Hospital
71
Republic of
Yemen 48Modern
4 PROCEDURES:
Hospital
Issued Effective:Replaces:
48
Republic of
4.1.1 The
Point-of-Care
Testing Committee is chaired by the Clinical Laboratory
and
includes
Hospital
the following people or their designees; OPD Nursing Supervisor, Assistant Nursing Director,
Nursing Educator , QI Representative Nurse , Chief Med. Tech. and Lab. QI Supervisor. Others
are
73
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
reviewing and action in QC results. The laboratory staff regularly reviews the QC data.
External QC
is performed whenever possible.
4.5 Training/Competency
4.5.1 All staff using POCT equipment receives training in the use of the equipment.
4.5.2 The POCT Coordinator will ensure a training program is in place and there is a
system for
documenting when training has been given. The training program should include:
4.5.2.1 Collection, transportation and disposal of specimens
4.5.2.2 Quality control requirements
4.5.2.3 Step by step procedures
4.5.2.4 Recording results
4.5.2.5 Interpretation of results
4.5.2.6 Troubleshooting
4.5.2.7 Maintenance of equipment
4.5.3 Staff may not train each other unless approved by the POCT Coordinator or
designated
representative.
4.5.4
All staffPOCT
using POCT equipment must have up to date competency/audit records.
4.6 Performing
Competency is
4.6.1 Only clinical staffs that have been trained in POCT can perform POCT.
reviewed
at least
forbe
allclearly
POCT. documented. POCT procedures must be
4.6.2
Procedures
for annually
POCT must
authorised bythe
relevant laboratory staff.
4.6.3 All client and quality control results must be recorded. This can be electronically or
on paper. The
record must include:
4.6.3.1 At least 2 unique client identifiers e.g. PIN & name
4.6.3.2 Date and time of test
4.6.3.3 The result
4.6.3.4 The identity of the operator
4.6.4 The transfer of results into the clients clinical record must be traceable and stated
in the POCT
4.7
Troubleshooting/Maintenance/Cleaning of POCT Equipment
procedure.
4.7.1Unexpected
All POCT equipments
must
havemust
a documented
preventative
maintenance
schedule
4.6.5
and extreme
results
be checked
by sending a
sample to the
which is either
laboratory.
done by the using clinical staff or by the SGH maintenance department.
4.7.2 Appropriate back up must be available in case of breakdown.
4.7.3 When a fault is found with POCT equipment it is labelled OUT OF ORDER and must
not be
used.
4.7.4 The POCT Coordinator and other relevant staff must be notified immediately.
4.7.5 Trouble shooting procedures must be documented and include the contact details for
assistance.
4.7.6 Only approved and appropriately qualified and competent SGH or external service
staff must
service POCT equipment.
4.7.7 A service history must be maintained which includes maintenance, faults, corrective
actions
4.8 List and
of POCT Equipments and Testing Locations
repairs by named individuals.
4.8.1 Rapid Point Blood Gas Analyzer (Bayer): Only One machine located in the Open heart
/ 4.7.8
ICUin Procedures for cleaning and decontamination of POCT equipment must be
documented and
the second floor of the Open Heart building.
carried out before any servicing is performed.
75
Republic of
Yemen 48Modern
48
Hospital
4.8.2 Optium Xceed Device (Abbott): 31 devices distributed throughout the hospital as
following (this
list is subject for updating whenever there is a change):
4.8.2.1 8 devices in the inpatient wards: Two in N2S , one in N2N, one in N3S, one in
N4S, and
one in N5S.
4.8.2.2 10 devices in the special units : four in the ER, one in the ICU, one in the NBD ,
one in the
OHU, 1 in the hemodialysis unit, 1 in the delivery room and 1 in the anesthesia.
4.8.2.3 12 devices in the outpatient clinics in the medical tower building : 8 devices in
the Internalprocedures, calibration steps, QC, maintenance and trouble shooting details for
Operational
Medicine Clinics, 1 device in the Ob/Gynecology clinic, 1 device in the Family Medicine
either
Clinic
the Blood Gas analyzer or the Glucometer devices are included under each machine section.
and 2 devices backup with the OPD supervisor.
76
Republic of
Yemen 48Modern
48
Hospital
GENERAL WARD
INTERNAL
POLICIES
AND
PROCEDURES
77
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
3.5 Upon the staffs assumption of his/her duty in his/her assigned unit, he/she will be
assigned to
the preceptor in the unit who will be orienting and mentoring him/her with the
responsibilities in
the unit.
3.6 Competency assessment will be done on the staffs that are not competent against
the list of the
set procedures.
3.7 If the staff is not competent on a certain procedure, he/she is not allowed to
perform such
procedure alone. He/she needs to be guided by any senior or qualified staff in the
performance
of the procedure.
3.7.1 He/she will be subject for close monitoring by the preceptor.
3.7.2 The staff will also be under the close monitoring by the clinical instructor.
3.8 For procedures considered to be low frequency, or seldom occurring procedures
such as code
blue, etc., the following should be done:
3.8.1 Wait for a maximum period of 3 months to have an actual experience, if not;
3.8.2 A simulation or mock procedure will be set-up.
3.9 Unit manager/clinical instructor follows-up the staff in the unit especially on
procedures where
staff got insufficient assessment result.
3.9.1 For any signs of incompetence, it should be reported at once to the Nursing
Education.
The nurse-educator in turn will design a remedial program to help improve
this staff.
3.9.2 Skills assessment must be reviewed periodically as required.
3.10Ward procedures that require competency assessments include:
3.10.1 CPR
3.10.2 Fire/disaster
3.10.3 Infection control
3.10.4 Safety
3.10.5 Blood transfusions
3.10.6 Hazardous materials
3.10.7 Performance appraisal
3.10.8 Use of restraints
3.10.9 Lifting and transferring of patients
3.10.10Monitoring of patient vital signs and impact of deviations
3.10.11Assessment of patients according to scope of service
3.10.12Medication administration
3.10.13IV therapy (insertion, maintenance, discontinuing)
3.10.14Infection control guidelines
3.10.15Patient falls
3.10.16Use of pulse oximetry
3.10.17Nurses role in cardiac/respiratory arrest
RESPONSIBILITIES:
4
3.10.18Nasogastric tubes and gastrostomy tubes and feedings
4.1 Nursing Director:
3.10.19Urinary catheters
4.1.1 Ensures that staffs competency assessment is implemented.
3.10.20Sterile dressings
4.1.2 Sees to it that the staff has undergone skills assessment before being
3.10.21Skin care and the prevention of care of pressure ulcers
assigned in the
3.10.22Nurses role in disaster, fire, and other emergencies
unit.
3.10.23Use of restraints
4.1.3 Assigns the staff in the unit based on his/her competency level.
3.10.24Operation of blood sugar testing equipment
3.10.25How to safely clean up chemical spills
79
Republic of
Yemen 48Modern
Hospital
48
4.2 Nurse-Educator:
4.2.1 Initiates skills assessment verification.
4.2.2 Prepares the staffs competency assessment file and gives it to the staffs
head nurse
who will continue with the competency assessment in the unit.
4.2.3 Reviews staffs competency status for program planning.
4.2.4 Makes recommendations to the department head for staffs unit assignment
based on his
level of competency.
4.2.5 Schedules periodic in-service education and skills training to improve staffs
competency status.
4.3 Clinical Instructor:
4.3.1 Assists the educator in initiating skills assessment verification.
4.3.2 Conducts follow-up to the staff in their unit assignment.
4.3.3 Tabulates individual staffs competency performance.
4.3.4 Informs the unit about the schedule of in-service educational activities.
4.4 Preceptor:
4.4.1 Coaches the staff in the performance of the procedure to be assessed and
makes
necessary recommendations.
4.4.2 Observes staff during the competency assessment process.
4.5 Assessor
4.5.1 Assesses the staffs competence to perform the procedure against the
competency
checklist.
4.5.2 Accomplishes staffs skills assessment form (date of completion, scoring,
etc.), if
applicable.
4.5.3
Evaluates staffs performance and makes referral to the Education
PROCEDURES:
Department
any he/she attends the 2-week-orientation program where competency
5.1 For new staff,
proof
assessment willof staffs incompetence.
Forwards
the completed
competency
assessment
form to the
Education in
be4.5.4
made.
For old staff,
the designated
assessor
will do competency
assessment
Office,
when
their
necessary.
5
respective
unit assignment.
4.5.5
Makes
schedule
of
staffs
attendance
to
the
in-service
education
programs.
5.2 Nurse-educator conducts didactic sessions of all unit-specific and general
4.6 Staff:
departmental
4.6.1 Shows integrity in the performance of any assigned procedure.
procedures.
4.6.2will
Signs
the competency
form after every
skill
evaluation.
5.3 Staff
be made
to perform assessment
a return demonstration
of the
procedure.
4.6.3
Attends
the
in-service
educational
program
when
scheduled.
5.3.1 Assessor should use the official competency assessment form in assessing the
skills.
5.3.2 Put a TICK MARK in the space provided if the staff performs the procedure
correctly. If the staff did not make it right, the assessor should put an X
mark.
5.4 Assessor accomplishes the competency assessment form and has the staff signs it
and forwards
it to the Education Department.
5.5 Low-frequency procedures will be assessed during actual situation or a
mock/simulation
procedure will be conducted.
5.6 Staffs skills assessment may be done in the classroom by the assessor or in the
unit, when
necessary.
5.7 Nurse-educator/clinical instructor/assessor make a summary of the staffs
competency status.
80
5.8 Nurse-educator/clinical instructor/assessor make appropriate recommendation for
the staffs area
of assignment depending on the level of competency.
Republic of
Yemen 48Modern
48
Hospital
81
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Issued Effective:Replaces:
Title: Scope of Service - In-Patient Nursing UnitsDue for Review:Page 1 of 3
CONTENTS: This general wards policy and procedure deals with the scope of service of the
in-patient
nursing units.
1 DEFINITIONS:
1.1 Scope of Service the coverage of services offered by the In-Patients Nursing Units
to cater to
the demands of the patients admitted in the unit.
1.2 Scope of Practice the extent of the duties and responsibilities provided by the
unit personnel
to meet the health care demands of all patients.
2 PURPOSES:
2.1 To have a clear definition of the coverage of services that the unit is offering to all
its clients.
2.2 To specify the duties and responsibilities of all unit personnel in the provision of
patient care.
2.3 ToOF
identify
the extent of service of each member of the health team in the delivery
SCOPE
PRACTICE:
3
of 3.1
patient
In-patient units provide appropriate, comprehensive, individualized, safe, and
care.
quality
patient
2.4
To to
protect
all personnel working in the unit from any legal accountabilities in the
care
the patients.
practice
of
the
3.2 Patients admitted to the unit include patients from all ages and wide range of
profession.
illness
conditions.
3.3 Provides comprehensive patient care to patients admitted in the unit.
3.4 Patient care services include but not limited to:
3.4.1 Nursing care to non-surgical patients.
3.4.1.1 Performs assessment.
3.4.1.2 Develops patients plan of care.
3.4.1.3 Provides health teachings.
3.4.1.4 Develops discharge plan.
3.4.1.5 Delivers dependent and independent nursing interventions to alleviate
patients
illness/es.
3.4.1.5.1 Safe medication preparation and administration.
3.4.1.5.2 Routine nursing cares such as vital signs monitoring, etc.
3.4.1.5.3 Provides patient comfort i.e. bed bath, massage, etc.
3.4.2 Pre and post-operative care
3.4.2.1 Prepares patient for surgery
3.4.2.1.1 Ensures that informed consent is signed and witnessed
appropriately
3.4.2.1.2 Pre-operative preparations are done properly
3.4.2.1.3 Pre-operative checklist is accomplished
3.4.2.1.4 Patient is made ready for the contemplated operations
3.4.2.2 Provides post-operative care to the patient.
3.4.2.2.1 Monitors patients condition post recovery.
3.4.2.2.2 Administers due medications post-operatively.
3.4.2.2.3 Assist physician in performing post-operative procedure such as
82
dressing
change, etc.
Republic of
Yemen 48Modern
48
Hospital
DEPARTMENT
OVERSIGHT:
4.1 Accountability
4.1.1 There is a Head Nurse who assumes the unit responsibility. Head nurses
3.4.2.3
schedule
is Provides post-operative health teachings to the patient in accordance to
the nature 10-hour-duty. After duty hours, the accountability of the unit is passed to the
on-duty and type of operation.
3.5 Every patient
to the unit can expect to have an individualized plan of
charge admitted
nurse.
care. Plan
of
care
4.1.2 There is an assigned unit assessor/s and preceptor/s (who may or may not be
is multidisciplinary
including patient and input when possible.
the
head
3.6 Teachings
willor
be
provided
patients
throughout
their stay
including
nurse
the
charge to
nurse),
whoand
arefamilies
responsible
in unit staffs
competency
but
not
after
limited to
patient and from
family
rights
and
responsibilities, pain management, patient4
endorsement
the
Nurse
Educators.
safety,4.1.3
and Staffing needs and problems are taken cared of by the head nurse of the unit
scheduled procedures.
in
coordination with the Director of Nursing.
4.2 Patient Assignment Scheme
4.2.1 Duty roster of the unit staff is prepared by the head nurse or the charge nurse
(in the
absence of the head nurse).
4.2.2 Comprehensive nursing care or Total Patient Care is utilized in the delivery of
care to
the patients. However, in cases where there is shortage of staff, Functional
Method of
Patient Care Delivery is advocated.
4.2.3 Manner of staff assignment is based on staffs competency level and patient
acuity.
4.2.4 Staffing is made up of full time nursing. In-patient staff meetings are held
monthly.
Internal memoranda are used for updates.
4.3 Practices
4.3.1 Ward Policies and Procedures Manuals are available in all in-patient units for
staffs
reference.
4.3.2 Safety
4.3.2.1 It is the responsibility of the unit manager to monitor visiting hours if
they interfere
with the patients well-being, or with the activities of the unit.
4.3.2.2 All unit staff will be identified with ID badges.
4.3.2.3 All staff has the right to question anyone in the unit regarding their
presence if they
are not properly identified.
4.3.2.4 Each staff member has the responsibility to protect the safety and
confidentiality of
the patient.
4.3.2.5 All patients should have waterproof ID bands.
4.3.2.6 All machines and equipments are having periodic preventive
maintenance by
Biomedical Engineers.
4.3.3 Infection Control
4.3.3.1 Infection control policies and practices should be followed.
4.3.3.2 Patients rooms and equipments are cleaned between each patient use.
4.3.3.3 Universal precautions of handwashing and use of protective barriers are
used to
prevent spread of infection.
4.3.4 Emergency
4.3.4.1 Emergency equipments and supplies can be found in the crash cart
located in the
strategical place inside the nurses83
station.
4.3.5 Emergency Plan
4.3.5.1 In-patient units follow protocols as stated in the Emergency
Preparedness Plan.
Republic of
Yemen 48Modern
48
Hospital
STAFFING:
5
5.1 Nursing Personnel
5.1.1 Head Nurse
5.1.2 Charge Nurse
5.2 Support Service Personnel
5.2.1 Nurse Aides
5.2.2 Porters
5.2.3 Ward Secretary
5.2.4 Ward Receptionist
5.3 Qualifications
5.3.1 Registered Nurses
5.3.1.1 Current license from the country of origin
5.3.1.2 Licensed by the Saudi Arabian Ministry of Health
5.3.1.3 BLS certified
5.3.1.4 Competencies as stated in the General Ward Policy and Procedure
Manual
5.3.2 Support Service Personnel
5.3.2.1 Minimum secondary school education
5.3.2.2 Training on hospital works
5.3.2.3 BLS certified
84
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
the
most
important
procedure
fororpreventing
cross-contamination
1.2 Standards the statement of the levels of service
care related
to specific topic
and
and the
removal
of transient
from outcomes.
the hands by using mechanical friction,
process
needed
to attainmicroorganisms
specific observable
soap
and
2 PURPOSES:
water, washing
with responsibilities
the use antimicrobial
agent.
2.1 To establish
individual
in order
to minimize the transmission of
3.2.2 Consider every person (patient or staff) as potentially infectious and susceptible
3
infectious agents
to
between patients and all other people in SGH facilities.
infection.
2.2
To prevent other people (patients family or health care workers) from being
3.2.3 Use of physical protective barriers gloves, facemasks, goggles, gowns, etc. when
infected
getting by the
patient.
in contact with blood and body fluids.
3.2.4 Environmental Cleaning routine care, cleaning, and disinfections of equipment
and
furnishings in patient care areas.
3.2.5 Use of antiseptic agents for cleaning of the skin, mucous membrane prior to
surgery and
wound dressing.
3.2.6 Safe work practices such as proper sharps disposal procedures; sending of
instruments and
other equipment to CSSD for disinfections and sterilization.
3.2.7 Safe disposal of infectious waste materials.
3.3 Door signs for transmission-based precautions shall be posted at the entrance of the
patients room.
3.4 All suspected infectious cases or potential infections admitted in the unit should be
reported to
the appropriate personnel so that necessary precautions will be implemented.
3.5 All isolation cases or suspected cases should be admitted in the isolation ward or
isolation
precaution shall be instituted. If the attending clinician shall not be persuaded to
observe
isolation precautions, nursing personnel shall contact the infection control officer
assigned to
their area.
3.5.1 When possible, a single room is indicated for the following:
3.5.1.1 Patients with highly transmissible or epidemiologically important
microorganisms
(e.g. MRSA, tuberculosis, chickenpox).
3.5.2 When a single room is not available, infected patients shall be placed with
appropriate
85
roommates (cohorting). Patients infected by the same microorganisms can
usually share
a room.
Republic of
Yemen 48Modern
48
Hospital
3.5.3 An infection control officer may be contacted when a single room is not
available for
cohorting.
3.5.4 For all isolation cases should follow the infection control policy and
precautions for the
patient as well as the staff.
3.5.5 Inform departments involved in the provision of patient care such as the Xray,
Laboratory, Physiotherapy, etc. regarding patients condition so that
necessary
precautionary measures will be taken.
3.5.6 Hand washing should be done according to the infection control guidelines.
3.5.7 All health care workers and visitors should use isolation control materials
such as
gloves, facemasks, and gowns, when getting in contact with the patient.
3.5.8 Equipment and other articles necessary to protect health care workers and
visitors shall
be kept available at the nurses station or near the patients bedside.
3.5.8.1 Reusable equipment and supplies in contact with non-intact skin, blood,
body
fluids or mucous membrane shall be bagged or placed in a punctureresistant
container and labeled, before it is sent to CSSD.
3.5.9 All contaminated items should be disposed in the yellow plastic bags.
SPECIAL CONSIDERATIONS:
4
3.5.10 Disposable fluid-filled containers (suction bottles) shall not be emptied but
4.1 For more comprehensive discussions on standard isolation precautions, refer to
shall be
Infection
disposed as follows:
Control Policy and Procedure Manual (IC 7-1).
3.5.10.1Place the container in a plastic bag, tie the bag close. Double-bag if
necessary.
3.5.10.2Place the bag into the infectious waste container.
86
Republic of
Yemen 48Modern
48
Hospital
GENERAL
NURSING
INTERNAL
POLICIES
AND
PROCEDURES
87
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
89
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
90
Republic of
Yemen 48Modern
48
Hospital
91
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
REFERENCE:
5
Manual:
General Ruth
Nursing
Departmental
Manual
5.1 Fundamentals of Nursing, Human Health
and Function,
F. Craven,
Constance
J.
Hirnle, pp.
Title: Kardex
238.
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure discusses the use of kardex in the unit
as a
guideline in the continuity in the provision of patient care.
1 DEFINITION:
1.1 Kardex - a name for a filing system allowing for a quick reference to the particular
needs of the
patient. It is a flip-over card usually kept in a portable index file that contains pertinent
information about patient and their ongoing plan of care.2 PURPOSES:
2.1 To organize information in a useful manner needed for end of shift endorsement.
2.2 To eliminate the need for continual referral to patients file for routine information.
2.3 To provide opportunity for nursing team to promote continuity of care.
3 POLICIES:
3.1 The kardex should include the following information:
3.1.1 Name, age, sex, nationality, PIN and room number
3.1.2 Date of admission
3.1.3 Chief complaints
3.1.4 Diagnosis, name of attending physician
3.1.5 Allergies
3.1.6 Medications
3.1.7 Type of account
3.1.8 Diet
3.1.9 Ongoing IV fluid, if any
3.1.10 Nursing care plan
3.1.11 Referrals, if any
3.1.12 X-ray and laboratory investigations
3.1.13 Special procedure
3.1.14 Surgery done, if any
3.1.15 Respiratory therapy, such as use of oxygen, mechanical ventilation, or
suctioning
3.1.16 Contraptions (NGT, Foleys Catheter, Colostomy, ICD, etc.)
3.1.17 Special precautions related to patient care
3.2 Pencil should be used in writing on the kardex.
3.3 Kardex should be updated on time.
3.4 All entries in the kardex should be written clearly.
3.5 A nursing care plan should be updated regularly to suit patients needs.
3.6 Kardex should be used as a basis for endorsement.
3.6.1 Kardex is discarded as soon as the patient is discharged.
4 RESPONSIBILITIES:
4.1 Charge nurse will be responsible to update clients data (medicine, laboratory, etc.)
4.2 Clients personal data should be completed.
4.3 Diagnosis, special procedure, operations should be clearly written
4.4 Room number should be updated when client is transferred to other room.
4.5 Kardex should be endorsed properly to the next shift.
92
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
94
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Nursing Care Plan
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure of 48 MODERN HOSPITAL defines the
formulation and implementation of individualized patient care plan.
1 DEFINITION:
1.1 Nursing Care Plan also called patient care plan, is a written guideline on the
intended care to be
administered to the patient based on the assessment findings. It is designed to
ameliorate client
problems. It contains nursing diagnoses, goals, outcome criteria, nursing interventions,
and
evaluation.
1.2 Nursing Interventions any treatment, based upon clinical judgment and knowledge
that a nurse
performs to enhance patient/client outcomes. It is used to monitor health status;
prevent, resolve, or
control a problem; assist with activities of daily living; or promote optimum health and
independence. Interventions are written as specific activities on the plan of care.
1.3 Multidisciplinary Care Plan also called Collaborative (Integrated) Care Plan, is a
patient plan
of care involving all members of the healthcare team.
2 PURPOSES:
2.1 To direct patient care activities related to the person for whom the goals and outcome
criteria were
developed.
2.2 To direct the activities of the nursing staff towards the provision of client care.
2.3 To promote continuity of care.
2.4 To allow for delegation of specific activities.
2.5 To establish coordinated activities of all members of the health team in delivering
patient care.
3 POLICIES:
3.1 An individualized-tailored plan of care should be formulated and developed for every
patient who
stays in the hospital for more than 24 hours.
3.2 Nursing care plan is developed with input from physicians and other health care
disciplines.
4 RESPONSIBILITIES:
3.3 Plan of care is reviewed every shift and when there is an observed significant changes
4.1 Nursing Director:
in the
4.1.1 Ensures that all patients admitted to the facility for more than 24 hours have a
patients condition or when new treatments are added and discontinued.
developed
3.4 All changes and revision in the plan of care should always be documented.
individualized nursing care plan.
3.5 All significant findings are documented in the nursing care plan.
4.1.2 Assesses staff performance in the implementation of the policy and to make
3.6 A standard nursing care plan form should be utilized. Form is kept in the Kardex
necessary
(Attachment
revisions in the policy when needed in collaboration with the TQM Team.
Form M1058). All problems identified, plan of care, and interventions implemented are
4.2 Nurse Supervisor:
written in
4.2.1 Verifies the implementation of the patient care plan in the unit.
the form. Evaluation results of the care are reflected in the documentations in the
4.2.2 Coordinates with the unit managers in the implementation of the policy.
nursing notes.
4.3 Unit Manager:
Black ink is used in writing entries.
95
Republic of
Yemen 48Modern
48
Hospital
96
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Nursing Documentations
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure stresses on the guidelines and practices
in making
documentations in the medical record.
1 DEFINITIONS:
1.1 Nursing Documentations a systematic, clear and concise written accounts of all
patients care
management.
2 PURPOSES:
2.1 Means of communication among health personnel.
2.2 Serves as legal document.
2.3 Serves as a basis in determining prognosis.
2.4 For continuity of care.
2.5 For future reference in education and research.
2.6 For auditing, monitoring, and financial billing.
2.7 For research purposes.
3 CHARACTERISTICS:
3.1 Accurate.
3.1.1 uses precise measurements
3.1.2 follows standard hospital abbreviations
3.1.3 timely and well written
3.1.4 legible handwriting
3.2 Concise sequential and exact accounts of events.
3.3 Consistent and complete.
3.4 Confidential.
3.5 Relevant and clear.
3.6 Systematic and orderly.
4 POLICIES:
4.1 There should be at least one entry every shift (12-hour-shift) written in English
language.
4.2 Only Registered Nurses should do all charting. Any charting done by midwives should
be
countersigned by RNs.
4.3 Ensures correct file by checking patients name, PIN, and room number.
4.4 All entries should be clearly and legibly written in black ink.
4.5 Follows standard hospital abbreviations.
4.6 Never chart or record ahead of time and for anyone else. Follow policy in making
corrections.
4.6.1 Draw a single line across an incorrect entry.
4.6.2 Write error above the incorrect word or entry and enclose with a parenthesis.
4.6.3 Write the correct entry in a paragraph form.
4.6.4 Never use correction fluid in correcting errors in the medical record.
error
Example: (post tyroidectomy)post Thyroidectomy
4.7 Entries should be in chronological order according to the right sequence of time or
occurrence.
4.7.1 To write shift time (0700H-1930H / 1900H-0730H) as heading.
4.7.2 When failed to record on time, write by97indicating late entry and put the correct
time.
4.8 Each entry should be written with a date, time, and signature of the staff with his/her
complete
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
99
Republic of
Yemen 48Modern
Hospital
48
48 MODERN
Applies to: General Ward and Specialty
Units HOSPITAL
CONTENTS:This General Ward policy and procedure discusses about the procedure of nursing
endorsements.
Manual: General Nursing Departmental Manual
1 DEFINITION:
1.1 Nursing Endorsement a method or process used to communicate or disseminate
Title: Nursing Endorsement
information
from outgoing shift to incoming shift regarding patients health problem, plan,
treatment and
desired outcome reflected in the kardex for continuity of patients care. (Kardex
contains all
relevant information concerning the patients current on-going care).
2 PURPOSES:
2.1 To give a vivid information about the patients present health condition and plan of
care.
2.2 To provide as a baseline for comparison and indicate the kind of care to be anticipated
on the next
shift.
2.3 To identify priorities to which incoming staff must attend.
2.4 To give basic identifying information about each patient - name, room number, bed
designation,
current diagnosis, etc.
2.5 To give a summary of each newly admitted patient, including his/her diagnosis, age,
plan of
therapy, and general condition.
2.6 To report patients who have been transferred or discharged.
3 POLICIES:
3.1 Must provide only essential information regarding the patient. It should be accurate,
complete,
concise, current and confidential.
3.2 Should start on time attended by all incoming nurses. Morning shift - 7:00 AM - 7:30
AM and
Night Shift - 7:00 PM - 7:30 PM.
3.3 Endorsement should be given by a charge nurse or a team leader .
3.4 Must be done in nurses room followed by a group rounds. The following must be
observed
during group rounds:
3.4.1 Knock on the door softly and announced your presence before entering.
3.4.2 Ensure patients privacy.
3.4.3 Speak in a low voice to avoid disturbing the patient.
3.5 All clarifications should be made during the time of endorsement.
3.6 Outgoing nurses should not leave the unit until all reports are completed and/or any
question about
patient is answered.
3.7 Kardex must be updated before the endorsement.
3.8 Receiving nurses should take written note of the pertinent and important data
regarding patients
care.
3.9 Endorsement is communicated in a language (English) that is understood by all.
4 PROCEDURES:
4.1 The following must be endorsed to the incoming shift:
4.1.1 Total census:
4.1.2 Number of admission and discharge 100
4.1.3 Number of expired patients
4.1.4 Transferred in/transferred out
4.2 Specific patient information such as:
Republic of
Yemen 48Modern
48
Hospital
4.2.1 Name
4.2.2 Age
4.2.3 Sex
4.2.4 Nationality
4.2.5 Diagnosis
4.2.6 Doctors name
4.2.7 Type of account (cash or charge)
4.2.8 Name of company (for charge cases)
4.2.9 Diet
4.3 Specific procedures to be done.
4.4 Consultation and investigation to be followed up
4.5 Current orders (especially any newly changed orders in medication, IV fluids, diet and
activity
level)
4.6 Changes in medical condition and response to medical therapy
4.7 Needs/problems identified, nursing actions carried out and patients response during
the shift.
SPECIAL
CONSIDERATIONS:
5
5.1 Unprofessional and judgmental comments about the patient should be avoided because
this could
predispose incoming nurses to view and respond to patient negatively.
5.2 Any conflict that happened between nurses during endorsement must be settled
immediately.
101
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Assessing Patients Psychological
Needs
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure of 48 MODERN HOSPITAL describes the
techniques to be used in assessing and identifying patients psychological needs for the
purpose of
developing a comprehensive plan of care during the entire period of patients
hospitalization.
1
DEFINITION:
1.1 Human Needs any physiological or psychological factors necessary for a healthy
existence.
1.2 Psychological Needs deep, intangible human needs that can be possessed by a human
being in
his search for meaningful occurrences in life.
2 PURPOSES:
2.1 To be able to identify patients psychological needs in order to formulate an
appropriate and
effective plan of care.
2.2 To understand the underlying cause of the attitudes and behaviors exhibited by the
patient during
the treatment phase.
3 2.3
POLICIES:
To administer a therapeutic relationship with patient and significant others.
3.1 Staff should utilize therapeutic nurse-patient interactions in assessing patients level
of needs.
3.2 Staff should be alert of non-verbal cues presented by the patient towards illness state
in order to be
an effective care-provider.
3.3 Staff should develop a plan of care focusing on the patients psychological well being in
order to
establish a therapeutic nurse-patient relationship to speed up patients recovery.
4 RESPONSIBILITIES:
4.1 Director of Nursing:
4.1.1 Ensures that policy on the assessment of patients psychological needs in the
formulation
of patient care plan is done by all staff.
4.1.2 Reviews staff performance in the implementation of policy and to make revision of
the
policy when necessary.
4.2 Nurse-Supervisor:
4.2.1 Reviews unit performance in the implementation of the policy.
4.2.2 Coordinates with the head nurses for any case of ineffective patient psychological
needs
assessment and nursing interventions.
4.3 Nurse-Educator:
4.3.1 Conducts orientation on the techniques and strategies to be employed in
assessing patient
psychological needs in relation to the development
of patient care plan.
102
4.3.2 Conducts periodic in-service education on updates concerning patient
psychological needs
assessment.
Republic of
Yemen 48Modern
48
Hospital
103
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Republic of
Yemen 48Modern
48
Hospital
105
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure serves Title:
as guidelines
when
to summon
Calling For
a Physician
for a
physical presence of a physician in the unit for various purposes such as referral of patients
conditions,
evaluation of the health status, and other patient-management related purposes.
1 DEFINITIONS:
1.1 Levels of physicians according to the clinical privileges assigned by the Clinical
Services
Directorate and Clinical Privileging, Credentialing and Promotions Committee:
1.1.1 House Officer assists medical members assigned in the department; an MBBS or
MBBCH (or its equivalent); fresh graduate; MD under board. Has undergone a
minimum
of (1) year rotation.
1.1.2 Resident works under the supervision of a treating supervisor or other
consultant; an
MBBS or MBBCH degree holder; with minimum of one (1) year residency training
after
qualification; published at least one (1) paper.
1.1.3 Specialist works under the supervision of Associate Consultant; an MBBS or
MBBCH
degree holder; has minimum of above one (1) year residency training after
qualifications;
published one (1) paper.
1.1.4 Associate Consultant works under the supervision of a Consultant; an MBBS or
MBBCH degree holder with one (1) year internship; Msc followed by MD or Board,
or
equivalent in the specialty; has a minimum of 3 years as consultant after
qualifications and
has published 3 papers in reputable local/international journal in his/her specialty.
1.1.5 Consultant works under the supervision of a Senior Consultant; an MBBS or
MBBCH
degree holder with one (1) year internship; Msc followed by MD or Board, or
equivalent in
the specialty; has a minimum of 5 years as consultant after qualifications and has
published
5 papers in reputable local/international journal in his/her specialty.
1.1.6 Senior Consultant works under the supervision of a Department Head; an MBBS
or
MBBCH degree holder with one (1) year internship; Msc followed by MD or Board,
or
equivalent in the specialty; has a minimum of 7 years as consultant after
qualifications
3 POLICIES: and
has published
7 papers
inresident
reputable
local/international
journal
inon
his/her
specialty.
3.1 Unit nurses
should inform
the
physicians
first before
calling
the attending
2
PURPOSES:
physician,
2.1
To inform
patients
attending
physician about their admission(s) in the unit.
unless
requested
by the
patient.
Patients
admittingshould
complaints
and
impression.
3.2 2.1.1
Calling
of the physician
include
the
following purposes:
2.1.2To
The
roomabout
number.
3.2.1
inform
the patients admission in the unit.
2.1.3For
Thereferral
results of
of patients
diagnostic
examinations.
3.2.2
condition.
2.2 For evaluation of the patients status and for any deterioration in his present
condition.
106
2.3 To relay results of diagnostic examinations indicated for the patient.
2.4 To perform evaluation of patients condition prior to discharge.
2.5 Upon request of the patient and relatives for the physicians presence in the unit.
Republic of
Yemen 48Modern
48
Hospital
107
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Airway Management
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the procedural guidelines on
the use of
artificial aid or appliance to maintain patency of the airway, in case of an airway obstruction.
1 DEFINITIONS:
1.1 Airway the passage by which the air enters and leaves the lungs from the nose or the
mouth to
the alveoli, or vice versa.
1.2 Obstruction an act of blockage in the passage due to the narrowing of the respiratory
passageways.
1.2.1 Obstruction Can Be Due To:
1.2.1.1 Tongue fallen back in the throat.
1.2.1.2 Chocking by food or foreign body.
1.2.1.3 Trauma due to head or neck injury.
1.2.1.4 Aspiration of vomitus or blood
1.2.1.5 Diphtheria in children
2 PURPOSES:
2.1 To facilitate proper and normal breathing.
2.2 To prevent the risk for aspiration or suffocation.
2.3 To prevent complications that would endanger the lives of an
individual.
3 OBJECTIVES:
3.1 Identify the clinical settings in which airway compromise is likely to occur.
3.2 Recognize the signs and symptoms of acute airway obstruction.
3.3 To know the techniques to establish and maintain a patent airway and confirm the
adequacy of
ventilation and oxygenation.
3.4 Actual or impending airway obstruction should be suspected in all injured patients.
3.5 With all airway maneuvers, the cervical spine must be protected by in line
immobilization.
4 POLICIES:
4.1 Airway clearance should be ensured at all times by means of proper breathing
assessment.
4.2 Airway management should be done as early as possible to prevent complications like
brain death,
life term disability, or death of the client.
4.3 Airway management should be done by a health care provider, a skilled person or a
doctor, to
avoid malpractice and associated complications.
4.4 The health care provider should be able to recognize the possibilities of airway
obstructions in
trauma patients that includes:
4.4.1 Maxillofacial Trauma facial fractures with associated hemorrhage, increased
secretions,
108
and dislodged teeth.
Republic of
Yemen 48Modern
Hospital
48
Neck Trauma causes disruption of the larynx, trachea, and compression of the
soft
tissues.
4.4.2
4.4.3 Laryngeal Trauma
4.5 Should know about the definite airway maintenance and cervical spine protection.
4.6 Always know the location of airway or emergency equipment in the unit.
5 EQUIPMENT NEEDED:
5.1 Protective barriers for healthcare professionals e.g. disposable gloves, masks,
apron, goggles
5.2 Different sizes of oropharyngeal and nasopharyngeal airways
5.3 Ambubag and oxygen masks
5.4 Suction equipment and suction catheters
5.5 Tracheostomy sets and tubes in cases of surgical interventions
6 PROCEDURES:
5.6 Laryngoscope with different sizes of blades
6.1 Assess
the airway.
5.7 Oxygen
delivery equipment
6.1.1
Look for of
symmetrical
rise and fall of chest and adequate chest wall excursion.
5.8 Syringes
different sizes
6.1.2
Listen for if
the
movement of air on both sides of the chest. Rapid respiratory rate
5.9 Ventilator,
needed
indicates
air hunger.
6.1.3 Use of pulse oximeter gives the information regarding the [patients oxygen
saturation and
peripheral perfusion.
6.2 Call assistance for help to reduce the risk for injury especially for trauma cases.
Cervical spine
must be protected by in-line immobilization.
6.3 If the mouth is closed, open it gently by tilting the head backward and lift the chin if
not
contraindicated.
6.3.1 If the tongue is blocking the airway, this position will reposition the tongue and
allow the
air to enter the lungs.
6.4 If still there is no response, again, follow the basic look, listen, and feel. Do the finger
sweep to
remove the obstruction or do suction if there is secretions blocking the airway.
6.5 Insert oropharyngeal or nasopharyngeal airway and check for spontaneous respiration.
6.6 If there is no respiration, initiate artificial respiration by ambubag or with oxygen.
Continue efforts
until the assistance arrive.
6.7 If the client is stable, keep him under observation.
6.8 Check the need for definitive airway by using:
6.8.1 Endotracheal intubation to be done only by experts.
6.8.2 Surgical airway if there is any difficulty or inability to intubate the trachea.
6.8.2.1 Jet insuflation of the airway can provide temporary supplemental
oxygenation
through an insertion of a needle through the cricothyroid membrane or into
the
trachea (by placing a large caliber plastic cannula G10-12 for adult; G-16-18
for
children).
6.8.2.2 Surgical cricothyroidectomy for the insertion of endotracheal or
tracheostomy tube.
6.9 Assessment of breathing.
6.9.1 Quiet breathing normal breathing or just audible
6.9.2 No sound complete obstruction
109
6.9.3 Snoring tongue fallen back in throat
6.9.4 Bubbling/gurgling fluids ( vomitus/blood) in the throat
6.9.5 Wheezing or whistling foreign body in throat or trachea
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Applying an External Catheter
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in the
application of
external catheter.
1 DEFINITION:
1.1 External Catheter a rubber appliance applied in the perineal area to collect urine for
incontinent
patients.
2 PURPOSES:
2.1 To relieve acute or chronic urinary retention and incontinence.
2.2 To prevent discomfort from urine wetting.
2.3 To prevent skin breakdown.
3 EQUIPMENTS/SUPPLIES:
3.1 Leg drainage bag with tubing or urinary drainage bag with tubing
3.2 Condom sheath
3.3 Bath blanket or similar drape
3.4 Disposable gloves
3.5 Basin of warm water and soap
3.6 Washcloth and towel
3.7 Elastic tape or Velcro strap
4 POLICIES:
4.1 Doctors order must be obtained.
4.2 Proper identification and assessment of patients condition prior to procedure.
4.3 Procedure should be performed by a qualified nurse of the same gender.
4.4 Infection control measures should be followed.
5 PREPARATIONS:
5.1 Assess:
5.1.1 The clients voiding pattern
5.1.2 The clients penis for swelling or excoriation that would contraindicate use of
the condom
catheter
5.2 Determine:
5.2.1 If the client has had an external catheter previously, and, if so, any difficulties
with it
5.3 Perform:
5.3.1 Any procedures that are best completed without the catheter in place
5.4 Assemble equipment and supplies.
5.4.1 Assemble the leg drainage bag or urinary drainage bag for attachment to the
condom
6 PROCEDURES:
sheath.
6.1
Explain
to the client
what
youitself
are going
to do, why
it is
necessary, and how he can
5.5
Roll
the condom
outward
onto
to facilitate
easier
application.
cooperate.
5.6 Position the client in either a supine or a sitting position.
6.2 Discuss if using a condom catheter will impact further care or treatments.
6.3 Wash hands and observe other appropriate infection control procedures.
6.4 Provide for client privacy.
6.5 Inspect and clean the penis. Clean the genital area, and dry it thoroughly.
110
Republic of
Yemen 48Modern
48
Hospital
111
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Assessing the Neurological System
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure serves as guidelines in assessing
clients
neurological system.
1 DEFINITION:
1.1 Assessment the method of appraising the clients condition that can aid in the
formulation of
nursing diagnosis and patient care planning.
2 PURPOSES:
2.1 To utilize the four methods of physical assessment and health examination.
2.2 To identify the expected outcomes of health assessments.
2.3 To utilize variations in examination techniques appropriate for clients of different
ages.
3 POLICIES:
3.1 Unit staffs should conduct health assessments to all patients admitted in the unit.
3.2 Four (4) methods of examination should be employed inspection, palpation,
percussion, and
auscultation.
3.3 Assessment results are used as the bases in the identification of nursing problems
and in the
formulation of nursing care plan.
3.4 Staff should perform neurological system assessment to patients suspected to have
neurological
deficits.
4 PREPARATIONS:
4.1 Assemble equipment and supplies:
5 PROCEDURES:
4.1.1 Percussion hammer
5.14.1.2
Explain
to the
client what
youbroken
are going
to do, why
is necessary,
and how he can
Tongue
depressors
(one
diagonally,
for it
testing
pain sensation)
cooperate.
4.1.3 Wisps of cotton, to assess light touch sensation
5.24.1.4
WashTest
hands
andofobserve
appropriate
infection
control
procedures.
tubes
hot andother
cold water,
for skin
temperature
assessment
(optional)
5.3 Provide for client privacy.
5.4 Determine clients history of the following:
5.4.1 Presence of pain in the head, back, or extremities, as well as onset and
aggravating and
alleviating factors
5.4.2 Disorientation to time, place, or person
5.4.3 Speech disorders
5.4.4 Any history of loss of consciousness, fainting, convulsions, trauma, tingling or
numbness,
tremors or tics, limping, paralysis, uncontrolled muscle movements, loss of
memory, or
mood swings
5.4.5 Alterations in smell, vision, taste, touch, or hearing
5.5 Language
5.5.1 If the client displays difficulty speaking:
5.5.2 Point to common objects, and ask the client to name them.
112to match the printed and written words
5.5.3 Ask the client to read some words and
with
pictures.
your
Ask the client to respond to simple verbal and written commands, e.g., point to
Republic
toes or raise
of your left arm.
5.6 Orientation
Yemen
48Modern
48
5.6.1 Determine the clients orientation to time, place, and person by tactful
questioning. Hospital
5.6.1.1 Ask the client the city and state of residence, time of day, date, day of the
week,
duration of illness, and names of family members.
5.6.1.2 More direct questioning may be necessary for some people, e.g., Where
are you
now? What day is it today?
5.7 Memory
5.5.4
5.7.1 Listen for lapses in memory.
5.7.1.1 Ask the client about difficulty with memory. If problems are apparent, three
categories of memory are tested: immediate recall, recent memory, and
remote
memory.
5.7.2 To assess immediate recall:
5.8 Ask the client to repeat a series of three digitse.g., 7-4-3spoken slowly.
5.9 Gradually increase the number of digitse.g., 7-4-3-5, 7-4-3-5-6, and 7-4-35-6-7-2
until the client fails to repeat the series correctly.
5.10 Start again with a series of three digits, but this time asks the client to
repeat them
backward.
5.11 The average person can repeat a series of five to eight digits in sequence,
and four to
six digits in reverse order.
5.8 To assess recent memory:
5.8.1 Ask the client to recall the recent events of the day, such as how he got to the
clinic. This
information must be validated, however.
5.8.2 Ask the client to recall information given early in the interview, e.g., the name
of a
doctor.
5.8.3 Provide the client with three facts to recalle.g., a color, an object, an
address, or a
three-digit numberand ask the client to repeat all three. Later in the interview,
ask the client
to recall all three items.
5.9 To assess remote memory:
5.9.1Ask the client to describe a previous illness or surgery.
5.10 Attention Span and Calculation
5.10.1 Test the ability to concentrate or attention span by asking the client to
recite the
alphabet or to count backward from 100.
5.10.2 Test the ability to calculate by asking the client to subtract 7 or 3
progressively from
100i.e., 100, 93, 86, 79, or 100, 97, 94.
5.11 Level of Consciousness
5.11.1 Apply the Glasgow Coma Scale.
5.12 Cranial Nerves
5.12.1 Test Cranial Nerves.
5.12.1.1 Cranial Nerve IOlfactory
5.12.1.1.1.Ask client to close eyes and identify different mild aromas,
such
as coffee, vanilla.
5.12.1.1.2Cranial Nerve IIOptic
5.12.1.1.2.1 Ask client to read Snellens chart, check visual fields by
confrontation, and conduct an ophthalmoscopic examination.
5.12.1.1.3 Cranial Nerve IIIOculomotor
5.12.1.1.3.1 Assess six ocular
113 movements and pupil reaction.
5.12.1.1.4 Cranial Nerve IVTrochlear
5.12.1.1.4.1 Assess six ocular movements.
5.12.1.1.5 Cranial Nerve VTrigeminal
Republic of
Yemen 48Modern
Hospital
48
elicit blink reflex. To test light sensation, have client close eyes, and
wisp of cotton over clients forehead and paranasal sinuses. To test
sensation, use alternating blunt and sharp ends of a safety pin over
same
area.
5.11.1 Cranial Nerve VIAbducens
5.11.1.1Assess directions of gaze.
5.11.2 Cranial Nerve VIIFacial
5.11.2.1Ask client to smile, raise the eyebrows, frown, puff out his cheeks, close
his eyes
tightly. Ask client to identify various tastes place on tip and sides of tongue
sugar,
saltand identify areas of taste.
5.11.3 Cranial Nerve VIIIAuditory
5.11.3.1Assess clients ability to hear spoken word and vibrations of tuning fork.
5.11.4 Cranial Nerve IXGlossopharyngeal
5.11.4.1Apply tastes on posterior tongue for identification.
5.11.4.2Ask client to move tongue from side to side and up and down.
5.11.5 Cranial Nerve XVagus
5.11.5.1Assessed
with CNusing
IX; assess
clients speech
for
hoarseness.
5.12Reflexes
- Test reflexes
a percussion
hammer,
comparing
one side of the body
5.11.6
Cranial
Nerve
XIAccessory
with the
5.11.6.1Ask
clientthe
to shrug
shoulders
against resistance from your hands and to
other
to evaluate
symmetry
of response.
turn
his
head
5.12.1 Biceps Reflex
to side against
resistance
from
your
hand.
5.12.1.1The
biceps
reflex tests
the
spinal
cord level C-5, C-6.
5.11.6.2
Repeat
for
the
other
side.
5.12.1.1.1 Partially flex the clients arm at the elbow, and rest the forearm over
5.11.7
Cranial Nerve XIIHypoglossal
the
5.11.7.1Ask client
to placing
protrude
hispalm
tongue
at midline,
then move it side to side.
thighs,
the
of the
hand down.
biceps
5.12.1.1.2 Place the thumb of your nondominant hand horizontally over the
tendon.
5.12.1.1.3 Deliver a blow (slight downward thrust) with the percussion hammer
to your
thumb.
5.12.1.1.4 Observe the normal slight flexion of the elbow, and feel the bicepss
contraction through your thumb.
5.12.2 Triceps Reflex
5.12.2.1The triceps reflex tests the spinal cord level C-7, C-8.
5.12.2.1.1 Flex the clients arm at the elbow, and support it in the palm of your
nondominant hand.
5.12.2.1.2 Palpate the triceps tendon about 25 cm (12 in) above the elbow.
5.12.2.1.3 Deliver a blow with the percussion hammer directly to the tendon.
5.12.2.1.4 Observe for the normal slight extension of the elbow.
5.12.3 Brachioradialis Reflex
5.12.3.1The brachioradialis reflex tests the spinal cord level C-3, C-6.
5.12.3.1.1 Rest the clients arm in a relaxed position on your forearm or on the
clients
own leg.
5.12.3.1.2 Deliver a blow with the percussion hammer directly on the radius 25
cm
(12 in) above the wrist or the
114 styloid process, the bony prominence on
the
thumb side of the wrist.
5.12.3.1.3 Observe the normal flexion and supination of the forearm.
5.12.4.1.3 Deliver a blow with the percussion hammer directly to the tendon.
5.12.4.1.4 Observe the normal extension or kicking out of the leg as the
quadriceps
muscle contracts.
5.12.4.1.5 If no response occurs, and you suspect the client is not relaxed, ask
the
client to interlock the fingers and pull.
5.12.5 Achilles Reflex
5.12.5.1The Achilles reflex tests the spinal cord level S-1, S-2.
5.12.5.1.1 With the client in the same position as for the patellar reflex, slightly
dorsiflex the clients ankle by supporting the foot lightly in the hand.
5.12.5.1.2 Deliver a blow with the percussion hammer directly to the Achilles
tendon
just above the heel.
5.12.5.1.3 Observe and feel the normal plantar flexion (downward jerk) of the
foot.
5.12.6 Plantar (Babinskis) Reflex
5.12.6.1The plantar or Babinskis reflex is superficial. It may be absent in adults
without
pathology, or overridden by voluntary control.
5.12.6.1.1 Use a moderately sharp object, such as the handle of the percussion
hammer,
a key, or the dull end of a pin or applicator stick.
5.12.6.1.2 Stroke the lateral border of the sole of the clients foot, starting at
the heel,
continuing to the ball of the foot, and then proceeding across the ball of
the
foot toward the big toe.
5.12.6.1.3 Observe the response. Normally, all five toes bend downward; this
reaction
is negative Babinskis. In an abnormal Babinski response, the toes
spread
outward and the big toe moves upward.
5.13Motor Function
5.13.1 Gross Motor and Balance Tests
5.13.1.1Walking Gait
5.13.1.1.1 Ask the client to walk across the room and back, and assess the
clients gait.
5.13.1.2Rombergs Test
5.13.1.2.1 Ask the client to stand with feet together and arms resting at the
sides, first
with eyes open, then closed.
5.13.1.3Standing On One Foot With Eyes Closed
5.13.1.3.1 Ask the client to close his eyes and stand on one foot, then the other.
5.13.1.3.2 Stand close to the client during this test.
5.13.1.4HeelToe Walking
5.13.1.4.1 Ask the client to walk a straight line, placing the heel of one foot
directly in
front of the toes of the other foot.
5.13.1.5Toe or Heel Walking
5.13.1.5.1 Ask the client to walk several steps on the toes and then on the
heels.
5.13.1.6Fine Motor Tests for the Upper Extremities
5.13.1.6.1 Finger-to-Nose Test
5.13.1.6.1.1Ask the client to abduct and extend the arms at shoulder height
and
rapidly touch the nose alternately with one index finger and then the
115
other.
5.13.1.6.1.2Have the client repeat the test with the eyes closed if the test is
performed easily.
5.13.1.6.2 Alternating Supination and Pronation of Hands on Knees
5.13.1.6.2.1Ask the client to pat both knees with the palms of both hands
and then
with the backs of the hands alternately at an ever-increasing rate.
5.13.1.6.3 Finger to Nose and to the Nurses Finger
Republic
of the client to touch the nose and then your index finger,
5.13.1.6.3.1Ask
held
at a
Yemen
48Modern
48
distance at about 45 cm (18 in), at a rapid and increasing rate.
Hospital
Republic of
Yemen 48Modern
48
Hospital
examining table.
5.13.1.9.3 Ask the client to close his eyes.
5.13.1.9.4 Grasp a middle finger or a big toe firmly between your thumb and
index
while
client
finger, and exert the same pressure on both sides of the finger or toe
moving it.
5.13.1.9.5 Move the finger or toe until it is up, down, or straight out, and ask the
117
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Application of Skin Traction
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the procedure in the
application of skin
traction.
1 DEFINITION:
1.1 Traction - is a treatment modality in which a pulling force is applied to separate parts
of an
injured, diseased and deformed portion of the body or extremity.
1.1.1 Types of Traction
1.1.1.1 Manual - use as a primary form of traction accomplished by an individual
exerting a
temporary, steady pull on anothers extremity or joint.
1.1.1.2 Mechanical - uses gadgets and devices and is further classified depending
on the
nature of attachment and the nature of the pulling force.
1.1.1.2.1 Skin Traction - the traction force is applied over a large area of skin
from
where it is transmitted to the musculoskeletal structures.
1.1.1.2.2 Skeletal - applies force directly to the bone using aseptically inserted
pins,
wire or traction screws.
2 PURPOSES:
2.1 To reduce stable fractures or dislocations prior to casting, splinting or application of
skin traction.
2.2 Restore and maintain alignment of bone ends following fracture.
2.3 Relieve pain and/or muscle spasm.
2.4 Provide immobilization to prevent soft tissue damage.
2.5 Correct, lessen or prevent deformities.
2.6 Reduce and treat subluxations.
2.7 Rest an inflamed, diseased or injured body parts.
2.8 Prevent or correct the development of soft tissue contracture.
2.9 Expand joint spaces prior to surgery
2.10Maintain the desired position post-operatively.
3 CONTRAINDICATIONS:
3.1 Presence of an existing skin condition (e.g. wounds, sores, abrasions).
3.2 Where the skin is thin and friable.
3.3 If there is circulatory impairment or loss of normal skin sensation.
4 EQQUIPMENTS/SUPPLIES:
4.1 Adhesive/non-adhesive skin traction
4.2 Weight/pulley system
4.3 Thomas splint POLICIES:
(optional)
5
4.4 Bed frame with5.1
traction
bars
Counter-traction
must be present for any type of traction to be
4.5 Razor
effective.
4.6 Blue sheet
5.2 Continuous traction should be maintained.
4.7 Traction Rope
4.8 Disposable Gloves
118
Republic of
Yemen 48Modern
48
Hospital
5.3 Prevention of complication for patient on traction is a must. Proper body alignment
and
positioning is maintained.
5.4 Maintain the prescribed direction of pull.
5.5 Nurse must be aware of the physicians order for type of traction, amount of weight
to be used and
length of time to be applied
6
PROCEDURES:
6.1 Skin Traction
6.1.1 Verify doctors order.
6.1.2 Explain and discuss the procedure with the patient.
6.1.3 Provide privacy.
6.1.4 Wash hands, wear gloves. Cleanse the affected site; shave any limb covered by
thick
hairs.
6.1.5 Check for the affected part and ensure that the skin is intact.
6.1.6 Apply tincture of benzoin compound on the affected part to increase the
adhesive quality
of the material used.
6.1.7 Apply the extension strapping and bandage without folds or creases leaving the
patellae
and the knee 10-15 degrees off full flexion.
6.1.8 Leave the ankle joint free and apply latex foam to bony prominences.
6.1.9 Ensure that the affected part is in the correct anatomical position.
6.1.10 Connect traction rope into the pulley and hang the prescribed weight freely.
6.1.11 Remove gloves and wash hands.
6.1.12 Document the following:
6.1.12.1Date and time applied
6.1.12.2Site of the affected part
6.1.12.3 Condition of the affected part prior and after the procedure as to:
6.1.12.3.1 Temperature
6.1.12.3.2 Color
6.1.12.3.3 Degree of sensation and movement
7
6.1.12.4Prescribed weight
6.1.13 Charge the supplies used.
SPECIAL CONSIDERATIONS:
7.1 Care of patient on traction
7.1.1 Provide physical and psychological support.
7.1.2 Prevent or reduce friction by ensuring the following:
7.1.2.1 Weights are hanging freely and not resting on the floor, bed or chair.
7.1.2.2 Traction ropes are unobstructed and move freely through pulleys.
7.1.2.3 Counter-traction is sufficient to prevent shearing forces from damaging the
patients
skin.
119
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Republic of
Yemen 48Modern
48
Hospital
PROCEDURES:
7
7.1 Explain to the client what you are going to do, why it is necessary, and how she can
cooperate.
7.2 Wash hands and observe other appropriate infection control procedures.
7.3 Provide for client privacy.
7.4 Prepare the client.
7.4.1 Assist the client to move to the near side of the bed, within your reach, and
adjust the bed
to a comfortable working height.
7.4.2 Establish which position the client prefers.
7.4.3 Expose the back from the shoulders to the inferior sacral area.
7.5 Massage the back.
7.5.1 Pour a small amount of lotion onto the palms of your hands and hold it for a
minute.
7.5.2 The lotion bottle can also be placed in a bath basin filled with warm water.
7.5.3 Using your palm, begin in the sacral area, using smooth, circular strokes.
7.5.4 Move your hands up the center of the back and then over both scapulae.
7.5.5 Massage in a circular motion over the scapulae.
7.5.6 Move your hands down the sides of the back.
7.5.7 Massage the areas over the right and left iliac crests.
7.6 Apply firm, continuous pressure without breaking contact with the clients skin.
7.6.1 Repeat above for 35 minutes, obtaining more lotion as necessary.
7.6.2 While massaging the back, assess for skin redness and areas of decreased
circulation.
7.7 Pat dry any excess lotion with a towel.
8
7.8 Document that a REFERENCE:
back rub was performed, and the clients response.
8.1 Fundamentals of Nursing concepts, process, and practice
7th Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
121
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
122
Republic of
Yemen 48Modern
Hospital
48
PREPARATIONS:
5
5.1 Assess:
5.1.1 Condition of the skin
5.1.2 Fatigue
5.1.3 Presence of pain and need for adjunctive measures before the
bath
5.1.4 Range of motion of the joints
5.1.5 Any other aspect of health that may affect the clients bathing
process
5.2 Assemble equipment and supplies:
5.3 Determine:
5.3.1 The purpose and type of bath the client needs
5.3.2 Self-care ability of the client
5.3.3 Any movement or positioning precautions specific to the client
5.3.4 Other care the client may be receiving
PROCEDURES:
5.3.5 what
Clients
comfort
level
being
bathed
by someone
else
6.1 Explain to the client
you
are going
towith
do, why
it is
necessary,
and how
she can
6
cooperate.
6.2 Wash hands and observe other appropriate infection control procedures.
6.3 Provide for client privacy.
6.4 Prepare the client and the environment:
6.4.1 Invite a family member or significant other to participate, if desired.
6.4.2 Close windows and doors to ensure the room is a comfortable temperature.
6.4.3 Offer the client a bedpan or urinal, or ask whether the client wishes to use the
toilet or
commode.
6.4.4 Encourage the client to perform as much personal self-care as possible.
6.4.5 During the bath, assess each area of the skin carefully.
6.5 Bed Bath
6.5.1 Prepare the bed and position the client appropriately.
6.5.1.1 Position the bed at a comfortable working height. Lower side rail on the
side close to
you. Keep the other side rail up.
6.5.1.2 Assist the client to move near you.
6.5.1.3 Place bath blanket over top sheet.
6.5.1.4 Remove the top sheet from under the bath blanket by starting at clients
shoulders
and moving linen down towards clients feet.
6.5.1.5 Ask the client to grasp and hold the top of the bath blanket while pulling
linen to the
foot of the bed.
6.5.1.6 Note: If the bed linen is to be reused, place it over the bedside chair. If it is
to be
changed, place it in the linen hamper.
6.5.1.7 Remove clients gown while keeping the client covered with the bath
blanket.
6.5.1.8 Place gown in linen hamper.
6.5.2 Make a bath mitt with the washcloth.
6.5.3 Wash the face.
6.5.3.1 Place towel under clients head.
6.5.3.2 Wash the clients eyes with water only, and dry them well.
6.5.3.3 Use a separate corner of the washcloth for each eye.
6.5.3.4 Wipe from the inner to the outer canthus.
6.5.3.5 Ask whether the client wants soap used on her face.
6.5.3.6 Wash, rinse, and dry the clients face,
123 ears and neck.
6.5.3.7 Remove the towel from under the clients head.
6.5.4 Wash the arms and hands.
6.5.4.1 Place a towel lengthwise under the arm away from you.
6.5.4.2 Wash, rinse, and dry the arm by elevating the clients arm and supporting
the clients
Republic of
wrist and elbow.
Yemen
48Modern
48
6.5.4.3 Apply deodorant or powder if desired.
Hospital
6.5.4.4
Optional: Place a towel on the bed and put a washbasin on it.
6.5.4.5 Place the clients hands in the basin.
6.5.4.6 Assist the client as needed to wash, rinse, and dry her hands, paying
particular
attention to the spaces between her fingers.
6.5.4.7 Repeat for hand and arm nearest you.
6.5.5 Wash the chest and abdomen.
6.5.5.1 Place bath towel lengthwise over chest. Fold bath blanket down to the
clients pubic
area.
6.5.5.2 Lift the bath towel off her chest, and bathe her chest and abdomen with
your mitted
hand, using long, firm strokes.
6.5.5.3 Rinse and dry well.
6.5.5.4 Replace the bath blanket when the areas have been dried.
6.5.6 Wash the legs and feet.
6.5.6.1 Expose the leg farthest from you by folding the bath blanket towards the
other leg,
being careful to keep the perineum covered.
6.5.6.2 Lift leg and place the bath towel lengthwise under the leg.
6.5.6.3 Wash, rinse, and dry the leg, using long, smooth, firm strokes from the
ankle to the
knee to the thigh.
6.5.7 Reverse the coverings and repeat for the other leg.
6.5.7.1 Wash the feet by placing them in the basin of water.
6.5.7.2 Dry each foot.
6.5.7.3 Obtain fresh, warm bathwater now or when necessary.
6.5.8 Wash the back and then the perineum.
6.5.8.1 Assist the client into a prone or sidelying position facing away from you.
6.5.8.2 Place the bath towel lengthwise alongside the back and buttocks while
keeping the
client covered with the bath blanket as much as possible.
6.5.8.3 Wash and dry the clients back, moving from the shoulders to the buttocks,
and upper
thighs, paying attention to the gluteal folds.
6.5.8.4 Perform a back massage now or after completion of bath.
6.5.8.5 Assist the client to the supine position and determine whether the client
can wash the
perineal area independently.
6.5.8.6 If the she cannot do so, drape the client and wash the area.
6.5.9 Assist the client with grooming aids such as powder, lotion, or deodorant.
6.5.9.1 Use powder sparingly.
6.5.9.2 Release as little as possible into the atmosphere.
6.5.9.3 Help the client put on a clean gown or pajamas.
6.5.9.4 Assist the client to care for hair, mouth, and nails.
6.6 For a Tub Bath or Shower
6.6.1 Prepare the client and the tub.
6.6.1.1 Fill the tub about one-third to onehalf full of water at 4346C (110115F).
6.6.1.2 Cover all intravenous catheters or wound dressings with plastic coverings,
and
instruct the client to prevent wetting these areas, if possible.
6.6.1.3 Put a rubber bath mat or towel on the floor of the tub if safety strips are
not on the tub
floor.
6.6.2 Assist the client into the shower or tub.
6.6.2.1 Assist the client taking a standing shower with the initial adjustment of the
water
temperature and water flow pressure,
124 as needed.
6.6.2.2 Explain how the client can signal for help, leave the client for 25 minutes,
and place
an occupied sign on the door.
Republic of
Yemen 48Modern
48
Hospital
6.6.3 Assist the client with washing and getting out of the tub.
6.6.3.1 Wash the clients back, lower legs, and feet, if necessary.
6.6.3.2 Assist the client out of the tub.
6.6.4 Dry the client, and assist with follow-up care.
6.6.4.1 Assist the client back to her room.
6.6.4.2 Clean the tub or shower in accordance with agency practice, discard the
used linen in
the laundry hamper, and place the unoccupied sign on the door.
6.7 Document:
6.7.1 Type of bath given
6.7.2 Skin assessment, such as excoriation, erythema, exudates, rashes, drainage, or
skin
breakdown
6.7.3 Nursing interventions related to skin integrity
6.7.4 Ability of the client to assist or cooperate with bathing
6.7.5 Client response to bathing
6.7.6 Educational needs regarding hygiene
6.7.7 Information or teaching shared with the client or their family
6.8 Variation: Bathing Using a Hydraulic Bathtub Chair
6.8.1 Bring the client to the tub room in a wheelchair or shower chair.
6.8.1.1 Fill the tub and check the water temperature with a bath thermometer.
6.8.1.2 Lower the hydraulic chair lift to its lowest point, outside the tub.
6.8.1.3 Transfer the client to the chair lift and secure the seat belt.
6.8.1.4 Raise the chair lift above the tub.
6.8.1.5 Support the clients legs as the chair is moved over the tub.
6.8.1.6 Position the clients legs down into the water and slowly lower the chair lift
into the
tub.
6.8.1.7 Assist bathing the client, if appropriate.
6.8.1.8 Reverse the procedure when taking the client out of the tub.
6.8.1.9 Dry the REFERENCE:
client and transport her to her room.
7
7.1 Fundamentals of Nursing concepts, process, and practice
7th Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
125
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Bed Making
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the procedure in bed making.
1 DEFINITION:
1.1 Bedmaking - is a procedure of changing bed linens either:
1.1.1 Unoccupied bed one which is prepared to be ready to receive patient.
1.1.1.1 Open Bed - a bed which is made either for a new patient or anambulatory
patient.
1.1.1.2 Closed Bed - a bed which will remain empty until the admission of a patient.
1.1.2 Occupied Bed one which is made with patient on it.
1.1.3 Post-op Bed one which is prepared for post-operative patient.
2 PURPOSES:
2.1 To provide comfort.
2.2 To promote rest and sleep.
2.3 To adapt to the needs of the patient and be ready for any emergency or critical
condition.
2.4 To promote cleanliness and prevent bedsore.
2.5 To establish an effective nurse-patient relationship.
3 EQUIPMENTS/SUPPLIES:
3.1 Clean linens:
3.1.1 Bottom sheet
3.1.2 Top sheet
3.1.3 Draw sheet
3.2 Blanket/comforter
3.3 Tuckables
3.4 Pillow with pillowcase
3.5 Trolley with hamper bags (for soiled linen)
3.6 Masks, gloves, disposable apron, as needed
4 POLICIES:
4.1 Ensure safety by:
4.1.1 Observing fall precautions
4.1.2 Follow infection control measures for infectious cases.
4.2 Bed making should be done once a day or as required.
4.3 Soiled linens should not be left on the floor. It should be placed inside the hamper bag.
4.4 Do not allow uniform in contact with soiled linen.
4.5 Bed should be made without wrinkles.
4.6 Observe /maintain body mechanics.
4.7 As soon as patient is discharged, bed linens should be stripped off immediately.
Housekeeping is
informed to clean the room to prepare for incoming admission.
PREPARATIONS:
5
5.1 Assess:
5.1.1 Note specific orders or precautions for moving and positioning the client.
5.1.2 Determine presence of incontinence or excessive drainage from other sources
indicating
the need for protective waterproof pad.
126
Republic of
Yemen 48Modern
Hospital
48
5.1.3 Assess
6.7.1 Unoccupied
bed:skin condition and need for special mattress, footboard, or heel
protectors.
6.7.1.1
Place the fresh linen on the clients chair or overbed table; do not use
5.2clients
Assemble equipment and supplies.
another
bed.
PROCEDURES:
6
6.7.1.2
Assess
and
assist
theyou
client
of bed.
6.1
Explain
to the
client
what
areout
going
to do, why it is necessary, and how she
6.7.1.3
Make sure that this is an appropriate and convenient time for the client to
can
cooperate.
be
out
of
6.2 Wash hands before and after the procedure.
bed.
6.3 Assemble
equipment and other items needed.
6.7.2
Assist
clientand
to aexplain
comfortable
chair
6.4 Providethe
privacy
the procedure.
6.7.3
Strip
the
bed.
6.5 Lower bed height within your reach.
6.7.3.1
bed
for anyunless
items contra-indicated.
belonging to the client, and detach the call
6.6
Keep Check
the bed
in linens
flat position,
bell
or
any
6.7 Follow bed making procedures according to type:
drainage tubes from the bed linen.
6.7.3.2 Loosen all bedding systematically, starting at the head of the bed on the
far side and
moving around the bed up to the head of the bed on the near side.
6.7.3.3 Remove the pillowcases, if soiled, and place the pillows on the bedside
chair near the
foot of the bed.
6.7.3.4 Fold reusable linens, such as the bedspread and top sheet on the bed, into
fourths.
6.7.3.5 First, fold the linen in half by bringing the top edge even with the bottom
edge, and
then grasp it at the center of the middle fold and bottom edges.
6.7.3.6 Remove the waterproof pad and discard it, if soiled.
6.7.3.7 Roll all soiled linen inside the bottom sheet, hold it away from your
uniform, and
place it directly in the linen hamper.
6.7.3.8 Grasp the mattress securely, using the lugs, if present, and move the
mattress up to
the head of the bed.
6.7.4 Apply the bottom sheet and drawsheet.
6.7.4.1 Place the folded bottom sheet with its center fold on the center of the
bed.
6.7.4.2 Make sure the sheet is hem-side down for a smooth foundation.
6.7.4.3 Spread the sheet out over the mattress, and allow a sufficient amount of
sheet at the
top to tuck under the mattress.
6.7.4.4 Miter the sheet at the top corner on the near side and tuck the sheet
under the mattress,
working from the head of the bed to the foot.
6.7.4.5 If a waterproof drawsheet is used, place it over the bottom sheet so that
the center fold
is at the center line of the bed and the top and bottom edges extend from
the middle of
the clients back to the area of the mid-thigh or knee.
6.7.4.6 Fanfold the uppermost half of the folded drawsheet at the center or far
edge of the
bed, and tuck in the near edge.
6.7.4.7 Lay the cloth drawsheet over the waterproof sheet in the same manner.
6.7.4.8 Optional: Before moving to the other side of the bed, place the top linens
on the bed
hem-side up, unfold them, tuck them in, and miter the bottom corners.
6.7.5 Move to the other side and secure the bottom
linens.
127
6.7.5.1 Tuck in the bottom sheet under the head of the mattress, pull the sheet
firmly, and
miter the corner of the sheet.
6.7.5.2 Pull the remainder of the sheet firmly so that there are no wrinkles.
6.7.5.3 Complete this same process for the drawsheet(s).
6.7.6 Apply or complete the top sheet, blanket, and spread.
6.7.6.1 Place the top sheet, hem-side up, on the bed so that its center fold is at the
Republic of
center of
the bed
and the top edge is even with the top edge of the mattress.
Yemen
48Modern
48
6.7.6.2 Unfold the sheet over the bed.
Hospital
6.7.6.3 Move to the other side of the bed, and secure the top bedding in the
same
manner.
6.7.7 Put clean pillowcases on the pillows as required.
6.7.7.1 Grasp the closed end of the pillowcase at the center with one hand.
6.7.7.2 Gather up the sides of the pillowcase, and place them over the hand
grasping the case.
Then grasp the center of one short side of the pillow through the pillowcase.
6.7.7.3 With the free hand, pull the pillowcase over the pillow.
6.7.7.4 Adjust the pillowcase so that the pillow fits into the corners of the case and
the seams
are straight.
6.7.7.5 Place the pillows appropriately at the head of the bed.
6.7.8 Provide for client comfort and safety.
6.7.8.1 Attach the signal cord so that the client can conveniently use it.
6.7.8.2 If the bed is currently being used by a client, either fold back the top covers
at one
side or fanfold them down to the center of the bed.
6.7.8.3 Place the bedside table and the overbed table so that they are available to
the client.
6.7.8.4 Leave the bed in the high position if the client is returning by stretcher, or
place in the
low position if the client is returning to bed after being up.
6.7.9 Document and report pertinent data.
6.8 Occupied bed:
6.8.1 Remove the top bedding.
6.8.1.1 Remove any equipment attached to the bed linen, such as a call bell.
6.8.1.2 Loosen all the top linen at the foot of the bed, and remove the spread and
the blanket.
6.8.1.3 Leave the top sheet over the client, or replace it with a bath blanket:
6.8.1.4 Spread the bath blanket over the top sheet.
6.8.1.5 Ask the client to hold the top edge of the blanket.
6.8.1.6 Reaching under the blanket from the side, grasp the top edge of the sheet
and draw it
down to the foot of the bed, leaving the blanket in place.
6.8.1.7 Remove the sheet from the bed and place it in the soiled linen hamper.
6.8.2 Change the bottom sheet and drawsheet.
6.8.2.1 Assist the client to turn on the side facing away from the side where the
clean linen is.
6.8.2.2 Raise the side rail nearest the client.
6.8.2.3 If there is no side rail, have another nurse support the client at the edge of
the bed.
6.8.2.4 Loosen the foundation of the linen on the side of the bed near the linen
supply.
6.8.2.5 Fanfold the drawsheet and the bottom sheet at the center of the bed, as
close to the
client as possible.
6.8.2.6 Place the new bottom sheet on the bed, and vertically fanfold the half to be
used on
the far side of the bed as close to the client as possible.
6.8.2.7 Tuck the sheet under the near half of the bed, and miter the corner if a
contour sheet is
not being used.
6.8.2.8 Place the clean drawsheet on the bed with the center fold at the center of
the bed.
6.8.2.9 Fanfold the uppermost half vertically at the center of the bed, and tuck the
near side
edge under the side of the mattress.
128 you onto the clean side of the bed.
6.8.2.10 Assist the client to roll over toward
6.8.2.11 Have the client roll over the fanfolded linen at the center of the bed.
6.8.2.12 Move the pillows to the clean side for the clients use.
6.8.2.13Raise the side rail before leaving the side of the bed.
6.8.2.14 Move to the other side of the bed, and lower the side rail.
Republic of
Yemen 48Modern
48
Hospital
129
Republic of
Yemen 48Modern
48
Hospital
8
REFERENCE:
8.1 Fundamentals of Nursing concepts, process, and practice
7th Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
130
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
131
The babys face should face the breast, with nose opposite the nipples.
The babys body should be closed to the mother.
If the baby is newborn, the mother should support the babys bottom and not just
the head
Republic of
or shoulder.
Yemen
48Modern
48 out:
5.5 Teach mother how to support her breast. The following should be stressed
Hospital
5.5.1 She
should rest her finger on chest wall under her breast so that her first
finger
will form a
support at the base of the breast.
5.5.2 She can use her thumb to press the top of her breast slightly. This can improve
5.4.2
the shape of
5.4.3
the breast so that it is easier for the baby to attach well.
5.4.4
5.5.3 She should not hold the part of her breast near to the nipple.
5.6 Position the baby to the breast and show the mother how to help the baby to attach:
5.6.1 Touch her babys lips with her nipple.
5.6.2 Wait until her babys mouth is opening wide.
5.6.3 Move her baby quickly onto her breast, aiming his lower lip to the nipple.
5.6.4 Instruct the mother to offer her whole breast to the baby not just the nipple. She
should not
touch the nipple or areola with her finger or to try push the nipple into the babys
mouth.
5.7 Observe how the mother responds (if she feels any pain) and ask her how her babys
suckling feels.
5.8 Look for signs of good attachment:
5.8.1 The babys whole body is facing his mother and close to her.
5.8.2 The babys face is close up to the breast.
5.8.3 The baby chin is touching the breast.
5.8.4 The babys mouth is wide open.
5.8.5 The babys lower lip is curled outwards.
5.8.6 There is more areola showing above the babys upper lip and less areaola
showing below
the lower lip.
5.8.7 You can see the baby taking slow, deep sucks.
5.8.8 The mother does not feel nipple pain.
5.8.9 You may be able to hear the baby swallowing.
5.8.10 The baby is relaxed and happy and satisfied at the end of the feed.
5.9 If attachment is not good, try to attach the baby again.
5.10During feeding the mother should:
5.10.1 Let the baby finish the first breast to make sure that he gets the hindmilk
(hindmilk is the
milk that is produced later in a feed). Offer the second breast and let the baby
take if he/she
wants to, but do not force him.
5.10.2 Start feeding from the right breast at one feeding and the left breast of the
next feeding. So
both breast have the same amount of stimulation and both continue to produce
milk.
5.10.3 Let the baby sucks as long as he/she wants.
5.10.4 If the baby does not want to take one side, the mother can try to hold the baby
in different
position. (e.g. under her arm). This may make the other breast seem more like
the favorite
breast to the baby.
5.11Have the mother breastfeed frequently and on a demand schedule.
5.12Have the mother break the infants suction by placing her finger in the corner of
babys mouth.
5.13Have the mother air dry nipples for 15-20minutes after each feeding.
5.14Have the mother burp the baby at the end or midway though the feeding.
5.14.1 Held the baby upright against the chest and gently pat the back.
5.14.2 Let the baby sit on the mothers lap making him/her bend forwards and to the
left to bring
the air bubble under the cardiac orifice of the stomach.
5.15After feeding is completed health teaching should be given:
5.15.1 Avoid taking medications and drugs
without doctors order.
132
5.15.2 Eat a well balanced diet with extra vitamins, calcium and protein.
5.15.3 Encourage to increase fluid intake daily.
5.15.4 Have adequate rest and to avoid tension, fatigue and stressful environment.
Republic of
Yemen 48Modern
48
Hospital
6
SPECIAL CONSIDERATIONS:
6.1 Do not wash nipples with soap as it removes natural oil from the skin of the nipple
and areola. The
skin become dry and more easily damaged and fissured (cracked).
6.2 The following are several common breast conditions which cause difficulties in
breastfeeding.
6.2.1 Flat or inverted nipples, and long or big nipples
6.2.2 Engorgement
6.2.3 Blocked duct and mastitis
6.2.4 Sore nipple and nipple fissure
6.3 Explain to mother that she may feel uterine cramping during breastfeeding. (Nursing
stimulates
release of oxytocin causing uterine muscle contraction). Administer pain reliever per
doctors
order.
6.4 A normal baby is born with a store of water which keeps him well hydrated until the
milk comes
in. Baby does not need drinks water or glucose water because they interfere with
breastfeeding.
6.5 The baby should be breast feed at night as long as possible.
6.6 In situation where breastfeeding is difficult, it is necessary to express the milk.
Breast milk under
room temperature can be use within 8 hours, and if refrigerated, it can last for 48
hours.
6.7 Make sure that the mother is psychologically and physically prepared before
initiating
breastfeeding.
6.8 All mothers should be taught how to express breast milk properly either manually or
by breast
pump.
6.9 Proper attachment during breastfeeding should be shown to all mothers. Advantages
of
breastfeeding and advantages of bottle feeding should be stressed out.
6.10All mothers should be informed to exclusively breast feed their babies for the first 46 months.
6.11All babies should be given supplementary food along with breastfeeding after the
age of 6 months.
133
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Blood Extraction
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the procedure of
DEFINITION:
blood. - a procedure of obtaining a sample of blood through venipuncture
1.1extracting
Blood Extraction
for
diagnostic tests through aseptic technique.
1
1.2 Venipuncture - a technique in which a vein is punctured through the skin by a sharp
rigid stylet
such as butterfly needle, cannula or by a needle attached to a syringe.
PURPOSES:
2.1 As a source of valuable information to screen patients for disease.
2
2.2 To evaluate the progress of therapy.
2.3 To monitor the well-being of the patient.
2.4 As a tool to establish or workout a diagnosis.
CONTRAINDICATIONS:
3.1 Do not take blood sample from extremities that contain arteriovenous shunts/graft
3 or
loop shunts.
3.2 Site with signs of infection, infiltration or thrombosis.
3.3 On upper extremity from the same side where mastectomy or axillary dissection was
4
performed.
EQUIPMENTS/SUPPLIES:
4.1 Disposable gloves
4.2 Alcohol swabs
4.3 Sterile 2 x 2 gauze
4.4 Rubber tourniquet
4.5 Band aid or adhesive tape
4.6 Appropriate blood collection tube with label containing clients name and PIN.
4.7 Completed laboratory requisition form
4.8 Butterfly needle
4.9 IV cannula
4.10Needle g 23
4.11Syringe (depending on the amount of blood to be collected)
4.12Small sharp container
5
4.13Goggles/face shield
POLICIES:
5.1 Before doing any blood extraction, staff doing the extraction (phlebotomist or
qualified nurse) uses
two (2) identifiers to verify patients identity (patients name and PIN, etc.) especially
prior to
blood drawing.
5.2 Observe the routine schedule for blood extraction usually every 3 hours from 6am12mn;
phlebotomist performs this.
5.3 For urgent or stat extraction, the nurse is the one who extracts blood and send
sample to laboratory
immediately with request through computer specifying Urgent.
5.4 For STAT lab test results will be delivered immediately through phone or computer
monitor.
134
5.5 Observe/Follow standard infection control policy.
5.6 Any specimen sent to laboratory must be properly labeled containing patients name
and PIN.
Republic of
Yemen 48Modern
Hospital
48
PROCEDURES:
7.1 Verify physicians
order. POLICIES:
INFECTION
CONTROL RELATED
6
7.2 Anyone
Prepare who
the needed
equipments.
6.1
performs
tasks involving contacts with blood, blood-related procedures
7.3 Wash
should
be hands and wear gloves.
7.4vaccinated
Identify the
client:Hepatitis B.
against
Ask his/her
name.blood and blood product exposures should be reported to the
6.27.4.1
All incidents
involving
7.4.2 Check ID band
Nurse
7.5Supervisor
Explain the
procedure
to the client.
and
to the Infection
Control Team utilizing an incident reporting scheme.7
7.6 Assist the client in a comfortable position.
7.7 Provide privacy.
7.8 Select the site for extraction. The ideal site is a straight prominent vein that feels
firm and slightly
rebounds when palpated.
7.9 Apply the tourniquet 4-6 inches above the venipuncture site. Most often the
antecubital fossa site
is used. The tourniquet should be applied wherein it can be removed by pulling the
end with a
single motion.
7.10Check for the distal pulse, if no pulse tourniquet is applied neither too tight or too
loose.
7.11Have client open and close fist several times to distend the vein, leaving fist
clenched prior to
venipuncture.
7.12Disinfect site with alcohol swab using a circular motion at the site and extending the
motion 2
inches beyond the site. Allow the alcohol to dry.
7.13Maintain tourniquet only for 1-2 minutes.
7.14Wear goggles or face shield.
7.15Prepare to obtain blood sample. Technique varies depending on the following:
7.15.1 Syringe Method :
7.15.1.1Hold syringe needle at 15-30o angle from the skin with bevel up. Slowly
insert the
needle.
7.15.1.2Gently pull back the syringe plunger and look for blood return.
7.15.1.3Obtain desired amount of blood into the syringe.
7.15.2 Butterfly Needle Method :
7.15.2.1Connect the syringe to the butterfly needle tubing.
7.15.2.2Grasp the wings of the butterfly needle and insert at 20-30 o angle with
bevel up.
7.15.2.3Check for return flow and aspirate desired amount of blood into the
syringe.
7.15.3 Cannula Method :
7.15.3.1Refer to IV Cannula Insertion.
7.15.3.2After removing the needle, aspirate the desired amount.
7.16When collection is completed, remove the tourniquet.
7.17Quickly remove the needle from the vein while applying pressure to the site with 2 x
2 sterile
gauze.
7.18After extraction transfer the blood to appropriate tube and properly label tube
immediately.
7.19After the site clots, apply band-aid.
7.20Dispose the needle into the sharp disposal container.
7.21Remove gloves. Wash hands.
7.22Send sample to laboratory immediately after charging along with properly filled-up
laboratory
135
request.
7.23Charge all supplies used.
7.24Chart in the nursing note the procedure done and amount of blood extracted.
Republic of
Yemen 48Modern
48
Hospital
136
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Blood Transfusion
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the procedure of blood
transfusion.
1 DEFINITION: All intravenous administration of a component of blood or whole blood. This
can be
categorized into 3 types.
1.1 Homologous Transfusion - standard transfusion which random donors are used for
transfusion
to other individuals.
1.2 Autologous Transfusion - blood products donated by the patient for his own use.
1.3 Direct Transfusion - blood products donated by an individual for transfusion to a
specified
recipient.
2 PURPOSES:
2.1 To increase blood volume after surgery, trauma/hemorrhage.
2.2 To increase the number of RBC in patient with severe chronic anemia.
2.3 To provide platelets for those with low platelet counts due to treatment and
chemotherapy.
2.4 To provide clotting factors in plasma for patients with hemophilia or DIC (Disseminated
Intravascular Coagulopathy).
2.5 To replace plasma proteins such as albumin.
2.6 To provide antibodies (IMMUNOTRANSFUSION) to those who are sick and having
lowered
immunity by giving blood or plasma taken from person who have just recovered from
the same
disease.
2.7 To replace the blood with hemolytic agents with fresh blood (exchange blood
transfusion) as in
case of erythroblastosis fetalis in hemolytic anemia etc.
2.8 To combat infection in patients with leukopenia.
2.9 To improve the leukocyte count of blood in agranulocytosis.
2.10Patient with cardiovascular failure, to increase blood volume and RBC while avoiding
cardiovascular overload.
3 EQUIPMENTS/SUPPLIES:
3.1 Blood administration set, IV set
3.2 Blood / Blood components
3.3 NSS 500cc
3.4 Antiseptic solution, tourniquet
3.5 Disposable gloves, blue pads, alcohol swabs
3.6 IV pole, small sharp container
3.7 IV 3000 transparent dressing, cannula g. 16, 18, 20, 22
3.8 Pressure pump (if needed)
3.9 Infusion pump (optional)
3.10Armboard (if needed)
POLICIES:
137
Republic of
4.1 No blood should be transfused without proper typing, cross matching and screening.
48Modern
4.2 PriorYemen
to blood drawing
for blood typing and cross matching, 1 phlebotomist48
and
1 nurse or 2
nurses should
verify patients identity.
Hospital
4.3 The doctor should countercheck and sign in the cross matching report Form M2028
4.4 Obtain doctors order and client or family member consent, and explain about the needs for
blood
transfusion.
138
Republic of
Yemen 48Modern
Hospital
48
4.5 Blood received from blood bank should be started within 30 minutes which is at
room temperature,
if not, return to blood bank with the filled up form blood returned to blood bank
information sheet
M2043.
4.6 Two (2) nurses or 1 nurse and 1 physician should verify the patients identity prior to
the
administration of blood.
4.7 Administration time should not exceed 4 hours because of the increase risk of
bacterial
proliferation.
4.8 Vital signs should be taken and monitored every 5 minutes for the first 15 minutes
then every 15
minutes for 30 minutes then hourly until the transfusion is finished.
4.9 Identification label from the blood bag should not be removed until the transfusion is
completed.
4.10Blood components should not be mixed/primed with any solutions other than Normal
Saline.
4.11Used blood bag with the tubing should be saved for a period of 24 hours after
transfusion.
4.12If the patient is to receive more than 1 unit of blood, a new transfusion set should
be used per
transfusion.
5
PREPARATIONS:
4.13Follow
infection
control
measures.
5.1 Assess:
4.13.1
Perform hand-washing
techniques before initiating blood transfusion.
5.1.1 Manifestations
of hypervolemia
4.13.2
All
blood
units
for
transfusion
should be screened appropriately to reduce the
5.1.2 Status of infusion site
risk5.1.3
of Any unusual symptoms
infectious
5.1.4 transmitting
Vital signs for
baseline diseases.
data
All blood products should be assumed to be infectious and should be handled
5.24.13.3
Determine:
with
gloves.
5.2.1
That a signed consent form was obtained
4.14For
reaction
identified,
immediately
discontinue
5.2.2 any
Anytransfusion
known allergies
or previous
adverse
reactions
to blood the transfusion.
Inform
5.2.3the
Assemble equipment and supplies:
physician
5.3attending
Prepare the
client. and fill-up an incident report.
5.3.1 Instruct the client to report promptly any sudden chills, nausea, itching, rash,
dyspnea,
back pain, or other unusual symptoms.
5.3.2 If the client has an intravenous solution infusing, check whether the needle and
solution
PROCEDURES:
6
are
appropriate
to administer
blood.
6.1 Check
the
doctors order
and obtain
client or family members consent for blood
transfusion.
6.2 Identify correct patient by calling the patient full name and checking the ID band.
6.3 Assess the patients condition, vital signs as baseline and any history of previous
blood transfusion
reaction.
6.4 Explain to the patient/relatives the procedure, approximate duration and desired
outcome of the
transfusion.
6.5 Wash hands, put on gloves.
6.6 Prepare infusion site, select a large vein.
6.7 If cannula is not present, prepare the site for venipuncture, insert cannula and start
NSS @ KVO
rate.
6.8 Remove gloves and wash hands.
6.9 Obtain correct blood component for the client
139 from blood bank and check for the
following:
6.9.1 Check the physicians order with the requisition.
6.9.2 Check the requisition form and the blood bag label with a laboratory technician.
6.9.3 Observe
Republic
the blood
of for abnormal color, RBC clumping, gas bubbles, and
extraneous
Yemen
48Modern
48
material.
Hospital
6.9.4 Return
outdated or abnormal blood to the blood bank.
6.10With another nurse, compare the laboratory blood record with:
6.10.1 The clients name and PIN
6.10.2 The number on the blood bag label
6.10.3 The ABO group and Rh type on the blood bag label
6.10.4 If any of the information does not match exactly, notify the charge nurse and
the blood
bank.
6.10.5 Do not administer blood until discrepancies are corrected or clarified.
6.10.6 Sign the appropriate form with the other nurse
6.11Call the doctor to countercheck the blood and have him sign in the cross matching
report Form
M2028.
6.12Assess the patients physical condition.
6.13Verify the clients identity.
6.13.1 Ask the clients full name.
6.13.2 Check the clients ID band.
6.14Set up the infusion equipment.
6.14.1 Ensure that the blood filter inside the drip chamber is suitable for whole blood
or the
blood components to be transfused.
6.14.2 Attach the blood tubing to the blood filter, if necessary.
6.14.3 Put on gloves.
6.14.4 Close all the clamps on the Y-set: the main flow rate clamp and both Y-line
clamps.
6.14.5 Using a twisting motion, insert the piercing pin (spike) into a container of 0.9
percent
saline solution.
6.14.6 Hang the container on the IV pole about 1 m (36 in) above the planned
venipuncture site.
6.15Prime the tubing.
6.15.1 Open the upper clamp on the normal saline tubing, and squeeze the drip
chamber until it
covers the filter and one-third of the drip chamber above the filter.
6.15.2 Tap the filter chamber to expel any residual air in the filter.
6.15.3 Remove the adapter cover at the tip of the blood administration set.
6.15.4 Open the main flow rate clamp, and rime the tubing with saline.
6.15.5 Close both clamps.
6.16Prepare the blood bag.
6.16.1 Invert the blood bag gently several times to mix the cells with the plasma.
6.16.2 Expose the port on the blood bag by pulling back the tabs.
6.16.3 Insert the remaining Y-set spike into the blood bag.
6.16.4 Suspend the blood bag.
6.16.5 Close the upper clamp below the IV saline solution on the Y-set.
6.16.6 Open the clamp on the blood arm of the Y-set, and prime the tubing.
6.17Establish the blood transfusion.
6.17.1 The blood will run into the saline filled drip chamber. If necessary, squeeze the
drip
chamber to reestablish the liquid level with drip chamber one-third full.
6.17.2 Readjust the flow rate with the main clamp.
6.18Observe the client closely for the first 510 minutes.
6.18.1 Run the blood slowly for the first 15 minutes at 20 drops per minute.
6.18.2 Note adverse reactions, such as chilling, nausea, vomiting, skin rash, or
tachycardia.
6.18.3 Remind the client to call a nurse immediately if any unusual symptoms are felt
during the
transfusion.
6.18.4 If any of these reactions occur, report140
these to the nurse in charge, and take
appropriate
nursing action.
6.19Document relevant data. Record:
6.19.6 Site
of the venipuncture
6.19.7 Size of the needle
6.19.8 Drip rate
6.20Observe for any transfusion reactions as follows.
6.20.1 Circulatory Overload
6.20.1.1dyspnea, cyanosis, sudden anxiety orthopnea, cough, tachypnea,
increased central
venous pressure, crackles at the base of the lungs and neck vein distention.
6.20.2 Septic Reaction
6.20.2.1Chills, fever vomiting, diarrhea, marked decreased in blood pressure and
shock.
6.20.3 Anaphylactic (life threatening reaction)
6.20.3.1Urticaria, nausea and vomiting, chest pain, anxiety, wheezing,
hypotension and
cardiac arrest.
6.20.4 Hemolytic Reaction the most dangerous type of transfusion reaction occurs
when the
donor is incompatible with that of the recipient.
6.20.4.1Acute Hemolytic
6.20.4.1.1 Fever, chills, hypotension, nausea and vomiting, flushing,
tachycardia,
tachypnea, anxiety, hemoglobinemia, hemoglobinuria, coagulation
disorder
and renal failure.
6.20.4.2Delayed Hemolytic
6.20.4.2.1 Continued anemia, hemoglubinuria
6.20.4.3Febrile Nonhemolytic
6.20.4.3.1 Fever (>1oC), flushing, chills, headache, anxiety, muscle pain.
6.20.5 Graft-versus-host-disease - Normal donor lymphocytes reproduce in a recipient
who is
immunocompromised (e.g. patients receiving high dose of chemotheraphy).
6.20.5.1Fever, skin rash, diarrhea, infection, liver dysfunction, manifested by
jaundice, bone
marrow depression.
6.21Monitor the client.
6.21.1 Fifteen minutes after initiating the transfusion, check the vital signs of the
client.
6.21.2 If there are no signs of a reaction, establish the required flow rate.
6.21.3 Do not transfuse a unit of blood for longer than 4 hours.
6.22 Assess the client, including vital signs, every 30 minutes or more often, depending
on the health
status, until 1 hour post-transfusion.
6.22.1 If the client has a reaction and the blood is discontinued, send the blood bag
to the
laboratory for investigation of the blood.
6.22.2 If there is transfusion reaction:
6.22.2.1Stop transfusion immediately by keep IV line open with a saline solution in
case IV
medication should be needed rapidly.
6.22.2.2Notify the physician.
6.22.2.3Monitor vital signs every 15 minutes.
6.22.2.4Send blood samples and collect urine sample for testing per doctors
order.
6.22.2.5Return blood bag and tubing to blood bank with Blood Returned Blood
Bank
Information Sheet (Form M2043) properly filled-up.
6.22.2.6Administer medication per doctors order.
6.22.2.7Fill-up the incident report for intensive
investigation.
141
6.23After transfusion, flush with NSS 20-250 ml.
6.24Terminate the transfusion.
6.24.1 Don clean gloves.
Republic of
Yemen 48Modern
Hospital
48
6.24.2 If no infusion is to follow, clamp the blood tubing and remove the needle.
6.24.3 If another transfusion is to follow, clamp the blood tubing and open the saline
infusion
arm.
6.24.4 If the primary IV is to be continued, flush the maintenance line with saline
solution.
6.24.5 Disconnect the blood tubing system and reestablish the intravenous infusion
using new
tubing.
6.24.6 Save the used blood bag for 24 hours.
6.24.7 Adjust the drip to the desired rate.
6.24.8 Needles should be placed in a labeled, puncture-resistant container designed
for such
disposal. Blood bags and administration sets should be bagged and labeled
before being
sent for decontamination and processing.
6.24.9 Monitor vital signs again.
6.24.10After care of equipment.
6.24.11Wash hands and remove gloves.
6.25Document the following:
6.25.1 Completion of the transfusion
6.25.2 Amount of blood absorbed
6.25.3 The blood unit number
6.25.4 Vital signs
6.25.5 If the primary intravenous infusion was continued, record connecting it.
6.25.6CONSIDERATIONS:
Also record the transfusion on the IV flow sheet and Intake and Output record.
SPECIAL
7
6.26Charge the procedure and supplies used.
7.1 Make sure platelets/fresh frozen plasma are administered immediately when
obtained, and follow
doctors order for the rate and maximum duration.
7.2 Nurses must be aware of the appropriate measures to be done in case of any
untoward reaction
occur. After transfusion, it should be flushed with 20-250 ml of NSS.
7.3 Metric volume measured set is the one being used as blood transfusion set in
Newborn.
7.4 For newborn cases that need fresh frozen plasma transfusion, it is being delivered
via perfusion
pump and regulated per doctors order.
7.5 Contraindications:
7.5.1 Platelet Transfusion:
7.5.1.1 Disseminated intravascular disorder.
7.5.1.2 Idiopathic thrombocytopenic purpura disorders causing rapid platelet
destruction.
7.5.2 Albumin Transfusion:
8
7.5.2.1 Severe anemia because of risk of cellular dehydration. (Should be
administered
cautiously in cardiac and pulmonary disease because of the risk of congestive
heart
failure from circulatory overload)
7.5.3 Gamma Globulin Transfusion:
7.5.3.1 Known hypersensitivity to it or an anti immunoglobulin antibody (IgA).
REFERENCE:
8.1 Fundamentals of Nursing concepts, process, and practice 7 th Edition
Barbara Kozier, Glenora Erb, Audrey Berman,
142 Shirlee Snyder
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Care of the Unconscious Client
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure discusses the procedures on how to
provide care to
the unconscious client.
1 DEFINITION:
1.1 Unconsciousness is a condition in which a patient is unresponsive to and unaware of
environmental stimuli.
1.2 Classification
1.2.1 Coma - is a clinical state of unconsciousness in which the patient is unaware of
self or
environment for prolonged periods. (days to months or even years.)
1.2.2 Akinetic Mutism - is a state of unresponsiveness to the environment in which
patient
makes no movement or sounds but sometimes open the eyes.
1.2.3 Persistent Vegetative State - is a condition in which the patient is described as
wakeful
but devoid of conscious content, without cognitive or affective mental function.
1.3 Causes
1.3.1 Neurologic - (Evaluated by Glasgow Coma Scale)
1.3.1.1 Head injury
1.3.1.2 Stroke
1.3.2 Toxicologic
1.3.2.1 Drug overdose
1.3.2.2 Alcohol Intoxication
1.3.3 Metabolic
1.3.3.1 Hepatic failure
1.3.3.2 Renal Failure
1.3.3.3 Diabetic Ketoacidosis
2 PURPOSES:
2.1 To maintain clear airway.
2.2 To protect from injury.
2.3 To maintain fluid and electrolyte balance.
2.4 To achieve intact oral mucous membrane.
2.5 To maintain normal skin integrity.
2.6 To prevent corneal irritation.
2.7 To attain normal body temperature.
2.8 To promote urinary elimination.
2.9 To promote normal bowel function.
EQUIPMENTS/SUPPLIES:
3
2.10To prevent complications of prolong bedridden like pneumonia, DVT and pulmonary
3.1 Oxygen with complete administering
embolism
device
by appropriate physiotherapy.
3.2 Suction apparatus
3.3 Suction catheter of different size
3.4 Disposable gloves/sterile gloves
3.5 Mask
3.6 Gauze 10 x 10 / Gauze 4 x 4
143
Republic of
Yemen 48Modern
Hospital
48
PROCEDURES:
5
5.1 Maintenance of clear airway.
5.1.1 Place the patient in lateral positions or semi-sitting position to prevent tongue
from
obstructing the airway.
5.1.2 Keep the airway free of secretions with efficient suctioning as needed.
5.1.2.1 Apply airway if necessary.
5.1.2.2 Prepare for insertion of cuffed endotracheal tube.
5.1.2.3 Give oxygen as prescribed.
5.1.3 Check pulse rate and blood pressure to evaluate circulatory
adequacy/inadequacy.
5.1.4 Maintain circulation by keeping blood pressure at normal level and treat lifethreatening
cardiac dysrrhythmias.
5.2 Protection from injury
5.2.1 Provide safety measures such as keeping the siderails always up.
5.2.2 Identify potential sources of injury (example: tight dressings, environmental
irritants,
damp bedding or dressing, tubes and drains) and do necessary measures.
5.3 Maintenance of fluid and electrolyte balance:
5.3.1 Assess mucous membranes and skin turgor for hydration status.
5.3.2 Administer and monitor IV fluids carefully.
5.3.3 Give parenteral and enteral feeding as ordered.
5.4 Achieving intact oral mucous membrane:
5.4.1 Remove dentures if present. Inspect patients mouth for dryness, inflammation
and
presence of crusting.
5.4.2 Do oral care every 2 hours with betadine mouthwash.
5.4.3 Apply vaseline lip emollient to prevent from dryness and cracking.
5.5 Maintenance of Skin Integrity
5.5.1 Keep the patient skin clean, dry and free of pressures. Give complete bed bath
twice daily.
144
5.5.2 Trim the patients nails carefully to prevent excoriation.
5.5.3 Turn the patient side to side on a schedule basis to relieve pressure areas.
5.5.4 Apply air mattress, and prevent wrinkles in the bed linens.
Republic of
Yemen 48Modern
Hospital
48
5.5.5 Passive limb exercise 3 times daily and AVI (Arteriovenous Impulses)
stimulation every 8
hours for 1 hour by physiotherapist.
5.6 Maintenance of Corneal Integrity
5.6.1 Assess the eyes daily for corneal irritation or ulceration.
5.6.2 Irrigate eyes with saline to remove discharge and debris. Instill opthalmic
ointment on
both eyes to prevent glazing or corneal ulceration. Cover with eye pads if
necessary.
5.7 Maintenance of Normal Body Temperature
5.7.1 Check body temperature every 4 hours and record.
5.7.2 Look for possible sites of infection if patient has fever. Apply cooling measures
such as
giving cold sponge, cold IV fluids, cold enema, cold NGT feeding, keeping IV
tubing
cold, reducing room temperature, removing excess linens, applying ice packs.
5.7.3 For hypothermic patients, apply warming blanket and other linens.
5.8 Promotion of Urinary Elimination
5.8.1 Palpate the bladder at intervals to detect urinary retention and an over
distended bladder.
5.8.2 Monitor for fever and urine amount, color and turbidity. Inspect the urethral
orifice for
suppurative discharges.
5.8.3 Change foley catheter every 7-10 days. Inject 3ml H 2O + one drop paraffin oil in
the valve
and aspirate it back once daily in the morning during catheter care.
5.8.4 Inform if oliguria, polyuria and anuria is observed. Maintain strict intake and
output
record.
5.8.5 If patient has condom catheter, check the penis regularly for skin irritation and
bruises. Do
not apply condom catheter too tightly and should be changed daily.
5.9 Promotion of Normal Bowel Elimination
5.9.1 Auscultate for bowel sounds. Palpate lower abdomen for distention. Measure
abdominal
girth.
5.9.2 Observe for constipation (from immobility and lack of dietary fiber).
5.9.2.1 Perform a rectal examination.
5.9.2.2 Stool softener maybe prescribed and to be given with tube feeding.
5.9.2.3 Glycerine suppository maybe prescribed to stimulate bowel emptying.
5.9.3 Monitor for diarrhea (from infection, antibiotics, hyperosmolar fluids, and fecal
impaction).
5.9.3.1 Perform a rectal examination if fecal impaction is suspected.
5.9.3.2 Do meticulous skin care if patient has fecal incontinence.
5.10Prevention
of Complication
SPECIAL CONSIDERATIONS:
6
5.10.1
Monitor
for signsto
and
symptoms
of potential complications such as pneumonia,
6.1 Help family members
cope
with crisis.
aspiration,
6.1.1 Verbalize fears and concerns.
respiratory
thrombosis,
embolism
andand
bedsore.
6.1.2
Encouragedistress,
them to contractures,
provide sensory
stimulation
by talking
touching
5.10.2
Closely monitor vital signs and respiratory function.
their
patient.
5.10.3 Blood sampling to be done daily as per doctors order. If infection is
suspected, send
sample for culture.
5.10.4 Monitor CVP every 4-6 hours, as ordered.
145
5.10.5 Chest physiotherapy.
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
146
Republic of
Yemen 48Modern
Hospital
48
Neurovascular status of the injured area, which includes skin color, skin
temperature,
capillary refill, pulses, movement and sensation.
6.6.1
6.6.2 Skin that will be soon inaccessible under the cast. Note any bruising, abrasions,
incisions
or skin conditions that might contribute to discomfort, infection, and drainage
or skin
breakdown after the cast is applied.
6.6.3 Patient ability to communicate during the procedure.
6.7 Place patient in proper position, expose the part to be casted.
6.8 Protect the bed and patient from water and casting residue. Apply blue sheets.
6.9 Wash hands, wear gloves and apron.
6.10Assist the doctor in applying the cast.
6.11After the procedure, elevate cast site with pillow. For plaster cast, leave the cast
uncovered while
it is drying.
6.12Reassess neurovascular status.
6.13Clean the bed and remove casting materials.
6.14Dispose all supplies used.
6.15Prepare patient for X-ray as ordered.
6.16Remove apron, gloves and wash hands.
6.17Document the following:
6.17.1 Type of cast and site where it was applied.
6.17.2 Time and date of application.
6.17.3 Specific aids used after casting such as crutches or slings.
6.17.4 Neurovascular status before and after casting.
6.17.5
Tolerance to procedure, and any pain medication, if given.
Special
Considerations:
7
6.17.6
Health
given.
7.1 A window
orteachings
opening may
be done in the cast to relieve pressure or to monitor the
6.18Charge
skin
at that the procedure and all supplies used.
location under the cast.
7.2 The time required for the cast to become rigid varies with the material used.
7.3 There should be no movement of the extremity while the cast is being applied and
set.
7.4 Instruct the patient to report immediately if there is:
7.4.1 Numbness and tingling of the casted extremity.
7.4.2 Excessive edema of the extremity above or below the cast.
7.4.3 Decreased movement of the casted extremity.
7.4.4 Paleness or blueness of the casted extremity.
7.4.5 Increased pain or burning under the cast.
7.4.6 Foul odor from the cast.
7.4.7 Change in temperature of the extremity from warm to cold.
7.4.8 Chest pain or shortness of breath.
7.4.9 Nausea, vomiting or abdominal pain when the patient is in a body spica cast.
7.5 The following health teaching should be given to patient:
7.5.1 Inspect the skin around the edges daily. If rough edges occur, place adhesive
tape over
the edge.
7.5.2 Notify the physician:
7.5.2.1 If the cast is rubbing and irritating the skin. Do not cut the cast.
7.5.2.2 If the cast cracks or breaks.
7.5.3 Do not put anything down the cast to scratch an itchy area. Articles dropped
into a cast
can cause infection and loss of skin.
7.5.4 Avoid getting the cast wet. If the physician
147 permits, a plastic bag or cast cover
can be
taped over the extremity so a shower can be taken.
7.5.5 Elevate the casted extremity when sitting or lying.
Republic of
Yemen 48Modern
48
Hospital
7.5.6
If in a body cast, turn every few hours to prevent respiratory congestion
and skin
pressure
areas.
7.5.7 Exercise joints not in the cast to maintain strength and mobility.
7.5.8 Exercise casted extremity as directed by physician.
7.5.9 Eat a balanced diet with emphasis on fiber to prevent constipation.
7.5.10 Drink extra water to prevent constipation.
7.6 Observe for complications of improper cast application
7.6.1 Palsy, paresthesia, ischemia
7.6.2 Ischemic myositis
7.6.3 Pressure necrosis
7.6.4 Misalignment or non-union of fracture bones.
148
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
149
Republic of
Yemen 48Modern
48
Hospital
150
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Cleaning a Sutured Wound and Applying a Sterile
Dressing
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in doing
wound
dressing.
1 DEFINITION:
1.1 Sutured Wound wound that has been surgically sutured.
1.2 Wound Dressing - a procedure done under aseptic technique where a material is
applied to the
surface of a wound to provide and maintain an environment in which healing can take
place at
maximum rate.
1.3 Types of Dressing:
1.3.1 Dry-to-dry dressing used primarily for wound closing by primary intention.
1.3.2 Wet-to-dry dressing used for untidy or infected wounds that must be debrided
and
closed by secondary intention.
1.3.3 Wet-to-wet dressing used on clean open wound or on granulating surfaces.
2 PURPOSES:
2.1 To prevent, eliminate, and control infection.
2.2 To absorb drainage or secretion.
2.3 To provide physical, psychological and aesthetic comfort.
2.4 To protect the wound from further injury.
2.5 To protect the skin surrounding the wound.
2.6 To maintain moist wound and environment.
2.7 To remove necrotic tissue.
2.8 To promote hemostasis as in pressure dressings.
3 INDICATIONS:
3.1 Surgical incision.
3.2 Insertion of central line or other invasive procedure.
4
EQUIPMENTS/SUPPLIES:
3.3 Wounds with drain.
4.1 Bath blanket (if necessary)
4.2 Moisture-proof bag
4.3 Mask (optional)
4.4 Acetone or another solution (if necessary to loosen adhesive)
4.4.1 Disposable gloves
4.4.2 Sterile gloves
4.5 Sterile dressing set; if none is available, gather the following sterile items:
4.5.1 Drape or towel
4.5.2 Gauze squares
4.5.3 Container for the cleaning solution
4.5.4 Two pairs of forceps
4.5.5 Gauze dressings and surgipads
4.5.6 Applicators or tongue blades, to apply ointments
4.5.7 Additional supplies required for the particular dressing
4.5.8 Tape, tie tapes, or binder
4.5.9 Hydrocolloid dressing at least 34 cm (1.5 in) larger than wound on all
four sides
151
Republic of
Yemen 48Modern
48
Hospital
Skin barrier or skin prep
(optional)
Wound barrier dressing
Scissors
Paper tape
4.5.10
4.5.11
4.5.12
4.5.13
5
POLICIES:
5.1 Hospital Infection Control Policy is observed.
5.2 Privacy should be maintained.
5.3 Dressing should be done by the doctor assisted by a nurse.
5.4 Wound culture, if needed, should be taken prior to dressing.
5.5 Dressing trolley should be checked for completeness of items at the start of each
shift.
5.6 Solutions, ointment and spray should be labeled as to date of opening.
5.7 During wound dressing, the upper level of trolley should be kept free and the
surface should be
disinfected before and after.
5.8 Counting/Checking of dressing instruments before and after used.
5.9 All items must be charged.
6
PREPARATIONS:
6.1 Assess:
6.1.1 Client allergies to wound cleaning agents
6.1.2 The appearance and size of the wound
6.1.3 The amount and character of exudates
6.1.4 Client complaints of discomfort
6.1.5 The time of the last pain medication
6.1.6 Signs of systemic infection
6.2 Determine:
6.2.1 Any specific orders about the wound or dressing
6.3 Assemble equipment and supplies.
6.4 Prepare the client and assemble the equipment.
6.4.1 Acquire assistance for changing a dressing on a restless or confused adult.
6.4.2 Assist the client to a comfortable position in which the wound can be readily
exposed.
Expose only the wound area.
6.4.3 Make a cuff on the moisture-proof bag for disposal of the soiled dressings, and
place the
bag within reach.
6.4.4 It can be taped to the bedclothes or bedside table.
6.4.5 Put on a facemask, if required.
7
PROCEDURES:
7.1 Explain to the client what you are going to do, why it is necessary, and how she can
cooperate.
7.2 Wash hands and observe other appropriate infection control procedures.
7.3 Provide for client privacy.
7.4 Remove binders and tape.
7.4.1 Remove binders, if used, and place them aside. Untie tie tapes, if used.
7.4.2 If adhesive tape was used, remove it by holding down the skin and pulling the
tape
gently but firmly toward the wound.
7.4.3 Use a solvent to loosen tape, if required.
7.5 Remove and dispose of soiled dressings appropriately.
7.5.1 Put on clean disposable gloves, and remove the outer abdominal dressing or
surgipad.
7.5.2 Lift the outer dressing so that the underside is away from the clients face.
7.5.3 Place the soiled dressing in the moisture-proof bag without touching the
152
outside of the
bag.
7.5.4 Remove the under dressings, taking care not to dislodge any drains.
Republic of
If the gauze sticks to the drain, support the drain with one hand and remove the
Yemen
48Modern
48
gauze
Hospital
with
the other.
7.5.6 Assess the location, type, and odor of wound drainage, and the number of
gauzes
saturated or the diameter of drainage collected on the dressings.
7.5.7 Discard the soiled dressings in the bag as before.
7.5.5
7.5.8 Remove gloves, dispose of them in the moisture-proof bag, and wash hands.
7.6 Set up the sterile supplies.
7.6.1 Open the sterile dressing set, using surgical aseptic technique.
7.6.2 Place the sterile drape beside the wound.
7.6.3 Open the sterile cleaning solution, and pour it over the gauze sponges in the
plastic
container.
7.6.4 Put on sterile gloves.
7.7 Clean the wound, if indicated.
7.7.1 Clean the wound, using your gloved hands or forceps and gauze swabs
moistened with
cleaning solution.
7.7.2 If using forceps, keep the forceps tips lower than the handles at all times.
7.7.3 Use the cleaning methods described, or one recommended by agency protocol.
7.7.4 Use a separate swab for each stroke, and discard each swab after use.
7.7.5 If a drain is present, clean it next, taking care to avoid reaching across the
cleaned
incision.
7.7.6 Clean the skin around the drain site by swabbing in half or full circles from
around the
drain site outward, using separate swabs for each wipe.
7.7.7 Support and hold the drain erect while cleaning around it.
7.7.8 Clean as many times as necessary to remove the drainage.
7.7.9 Dry the surrounding skin with dry gauze swabs, as required.
7.7.10 Do not dry the incision or wound itself. Moisture facilitates wound healing.
7.8 Apply dressings to the drain site and the incision.
7.8.1 Place a precut 4 x 4 gauze snugly around the drain, or open a 4 x 4 gauze to
4 x 8,
fold it lengthwise to 2 x 8, and place the 2 x 8 gauze around the drain so
that the ends
overlap.
7.8.2 Apply the sterile dressings one at a time over the drain and the incision.
7.8.3 Place the bulk of the dressings over the drain area and below the drain,
depending on the
clients usual position.
7.8.4 Apply the final surgipad, remove gloves, and dispose of them.
7.8.5 Secure the dressing with tape or ties.
7.9 Applying a Hydrocolloid Dressing
7.9.1 Thoroughly clean the skin area around the wound.
7.9.1.1 Wash hands and put on clean gloves.
7.9.1.2 Clean the skin well but gently with normal saline or a mild cleansing
agent. Always
rinse the adjacent skin well before applying a dressing.
7.9.1.3 Clip the hair about 5 cm (2 in) around the wound area, if indicated
7.9.1.4 Leave the residue that is difficult to remove on the skin.
7.9.1.5 Remove gloves, and dispose of them in the moisture-proof bag.
7.9.2 Clean the wound, if indicated. Put on clean or sterile gloves.
7.9.2.1 Clean the wound with the prescribed solution.
7.9.2.2 Dry the surrounding skin with dry gauze.
7.9.3 Assess the wound.
7.9.3.1 Apply the dressing. Follow the manufacturers instructions.
7.9.3.2 Hold the dressing in place for about one minute with your hand.
7.9.3.3 Remove and dispose of the gloves.
153 Optional: Apply tape to window
frame the
edges of the dressing.
7.9.4 Assess and change the dressing as indicated.
Republic of
Yemen 48Modern
48
Hospital
7.9.4.1 Inspect the dressing at least daily for leakage, dislodgement, odor, and
wrinkling.
7.9.4.2 Change the dressing if any of these signs are present.
7.9.5 Document:
7.9.5.1 Dressing change
7.9.6 Clients response
7.10Applying a Transparent Wound Barrier
7.10.1 Clean the wound, if indicated.
7.10.1.1 Put on clean or sterile gloves in accordance with agency practice.
7.10.1.2 Clean the wound with the prescribed solution.
7.10.1.3Dry the surrounding skin with dry gauze.
7.10.1.4Assess the wound.
7.10.2 Apply the wound barrier.
7.10.2.1Review the instructions on the barrier package. Remove part of the paper
backing
on the dressing.
7.10.2.2Apply the dressing at one edge of the wound site, allowing at least 2.5 cm
(1 in) of
coverage of the skin surrounding the wound.
7.10.2.3Gently lay or press the barrier over the wound. Keep it free of wrinkles,
but avoid
stretching it too tightly.
7.10.2.4Remove and dispose of gloves appropriately.
7.10.3 Reinforce the dressing only if absolutely needed.
7.10.3.1Apply paper or other porous tape to window frame the edges of the
dressing.
7.10.4 Assess the wound at least daily.
7.10.4.1Determine the extent of serous fluid accumulation under the dressing;
wound
healing, and the need to repair the dressing.
7.10.4.2If the dressing
is leaking, remove it and apply another dressing.
8
REFERENCE:
7.10.5 Document: 8.1 Fundamentals of Nursing concepts, process, and practice 7 th
7.10.5.1Dressing
change
Edition
7.10.5.2Wound status
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
7.10.5.3Clients response
154
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
155
Republic of
Yemen 48Modern
48
Hospital
5.4 Ensure patients safety by observing possible complications. Call bell should be
within reach.
5.5 Method of application varies according to patients age and condition, type of
devices to be used
and area involved.
PROCEDURES:
6
6.1 Check for the doctors order.
6.2 Prepare the items/supplies to be used.
6.3 Wash hands before and after the procedure.
6.4 Explain the procedure to the patient.
6.5 Take vital signs as baseline to assess the condition of patient.
6.6 Determine method of application to be used, and place underpad under the area.
6.7 Expose the area to be treated. Provide privacy and make sure that room is warm.
6.8 Start cold application and take note of the time it started.
6.9 Observe patients condition. Discontinue if any untoward reaction is observed and
notify the
treating doctor immediately.
6.10Aftercare of equipment and supplies.
6.11Record the procedure as to date, time and duration; type of device; and site of
application.
6.12Charge the procedure and supplies used.
7
SPECIAL CONSIDERATIONS:
7.1 When applying cold to an open wound or to a lesion that may open during
treatment, use sterile
technique.
7.2 Maintain sterile technique during eye treatment.
7.3 Warn the patient against placing ice directly on skin, because extreme cold can
cause burns.
7.4 Extreme external cooling with ice water baths is usually contra-indicated because
this measure
does not treat the cause of the fever.
7.5 Sponging should not be performed until 30 minutes after the administration of an
antipyretic so
that the hypothalamic temperature set point will be lowered, otherwise, the body will
resist the
cooling attempt and shivering can occur.
156
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
Hospital
48
6.17.1.4Center the faceplate over the stoma and skin barrier, then press and hold
the
faceplate against the clients skin for a few minutes, to secure the seal.
6.17.1.5Press the adhesive around the circumference of the adhesive disc.
6.17.1.6 Tape the faceplate to the clients abdomen using four or eight 7.5-cm (3in) strips of
hypoallergenic tape.
6.17.1.7 Place the strips around the faceplate in a picture-framing manner, one
strip down
each side, one across the top, and one across the bottom.
6.17.1.8 The additional four strips can be placed diagonally over the other tapes
to secure the
seal.
6.17.1.9 Stretch the opening on the back of the pouch, and position it over the
base of the
faceplate. Ease it over the faceplate flange.
6.17.1.10 Place the lock ring between the pouch and the faceplate flange, to seal
the pouch
against the faceplate.
6.17.1.11 Close the base of the pouch with the appropriate clamp.
6.17.1.12 Attach the pouch belt, and fasten it around the clients waist (optional).
6.17.2 Dispose of equipment, or clean reusable equipment.
6.17.2.1 Discard a disposable bag in a plastic bag before placing in the waste
container.
6.17.2.2 If feces are liquid, measure the volume. Note the feces character,
consistency, and
color before emptying the feces into a toilet or hopper.
6.17.2.3 Wash reusable bags with cool water and mild soap, rinse, and dry.
6.17.2.4 Wash a soiled belt with warm water and mild soap, rinse, and dry.
6.17.2.5 Remove and discard gloves.
6.17.3 Variation: Applying the Skin Barrier and Appliance as One Unit
6.17.3.1Prepare the skin barrier by measuring the size of the stoma, tracing a
circle on the
backing of the skin barrier, and cutting out the traced stoma pattern to make
an
opening in the skin barrier.
6.17.3.1.1 Prepare the appliance by cutting an opening 0.30.4 cm (1/81/6 in)
larger
than the stoma size (if not already present) and peeling off the backing
from
the adhesive seal.
6.17.3.1.2 Center the opening of the pouch over the skin barrier.
6.17.3.1.3 Remove the skin barrier backing to expose the sticky adhesive side.
6.17.3.1.4 Center the skin barrier and appliance over the stoma, and press it
onto the
SPECIAL CONSIDERATIONS:
clients skin.
7
6.18
7.1 The
Document
colostomy
the bag
procedure
is emptied
in the
orclients
changed
record.
when Report
it is one-fourth
and record:
to one-third full so
that
6.18.1
the weight
Pertinent assessments and interventions
6.18.2
of its contents
Any increase
does in
not
stoma
causesize
the pouch to separate from the adhesive disk and spill
the6.18.3
contents.
Change in color indicative of circulatory impairment
7.26.18.4
Irrigation
Presence
of colostomy
of skin irritation
is initiated
or when
erosion
bowel function has resumed usually 5 th-6th
day6.18.5
post- Discoloration of the stoma
6.18.6
operatively.
Appearance
The main
of the
purpose
peristomal
of colostomy
skin
irrigation is to empty the colon of gas,
mucus,
6.18.7
and
Amount and type of drainage
160
6.18.8
feces so
Clients
that the
experience
patient can
with
gothe
about
ostomy
with social and business activities without fear
of fecal
6.18.9 Skills learned by the client
6.18.10Client
drainage.
reaction to the procedure
Republic of
Yemen 48Modern
48
Hospital
7.3 For some patients, colostomy bags are not always necessary. As soon as the patient
has learned a
routine for evacuation, bags may be dispensed with a simple dressing of disposable
tissue, held in
place by an elastic belt.
7.4 Promote the patients acceptance of the colostomy by building up self-esteem.
Encourage the
family to assist the patient during period of adjustment.
7.5 Health Teaching:
7.5.1 Instruct the patient to assess the stoma and surrounding skin frequently.
7.5.2 Explain that the pouch should be changed when 1/4 - 1/3 full. Teach the patient
how to
perform self-care of colostomy.
7.6 Diet Management
7.6.1 Avoid overeating and eating irregularly. Chew the food well.
7.6.2 Encourage to eat a well balanced diet to avoid diarrhea and constipation.
7.6.3 Explain to the patient to avoid foods known to cause odors such as onions,
cabbage, eggs,
fish and beans. Fecal odors are lessened with youghurt, juice and milk.
7.6.4 Most gas is due to swallowed air (often takes in while chewing a gum), highly
spiced
foods, and carbonated beverages, including beer. Gas forming foods such as
beans,
cabbage, onions,
radishes, cucumbers and highly seasoned foods must be 8
REFERENCE:
avoided.
8.1 Fundamentals of Nursing concepts, process, and practice
7.6.5 Participation
any type of sport or activity is possible.
7thin
Edition
7.7 Approximately 10-12%
of males
with
colostomy
of sexual
function
Barbara
Kozier,
Glenora
Erb, suffer
Audreyimpairment
Berman, Shirlee
Snyder
and
potency. In women, a colostomy does not preclude successful pregnancy. Close
medical care is
required.
161
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Condom Catheter Application
Republic of
Yemen 48Modern
48
Hospital
5.15Make sure tubing lay over the patients leg and not under. Secure the drainage bag
to the side of
the bed below the level of patients bladder.
5.16Cover patient, place in comfortable position.
5.17Dispose used supplies, remove gloves and wash hands.
5.18Measure patients urinary output and record every 4 hours.
5.19Change the condom catheter once a day to clean the area and assess the skin for
any signs of
impaired skin integrity.
5.19.1 In removing condom catheter, remove the adhesive strip first then gently roll
out the
condom catheter and pull it out.
5.20Record the date and time of application and removal, skin condition, and patients
response.
6
SPECIAL
CONSIDERATIONS:
5.21Aftercare
of
equipment.
6.1 Inspect the condom catheter for twist which can result in displacement of catheter.
5.22Charge
the procedure
and supplies
used.
6.2
If the patient
gets an erection,
assure
him that it is usual when applying a condom
catheter. Your
calm reassurance and matter-of-fact attitude will help decrease the patients
embarrassment and
provide guidance to his coping response.
163
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
165
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
167
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
7
PROCEDURES:
7.1 Explain to the client what you are going to do, why it is necessary, and how he can
cooperate.
7.2 Wash hands and observe other appropriate infection control procedures.
7.3 Provide for client privacy.
7.4 Prepare the equipment and the client.
7.4.1 Fill the washbasin with warm water at about 4043C (105110F).
7.4.2 Assist the ambulatory client to a sitting position in a chair, or the bed client to a
supine or
semi-Fowlers position.
7.4.3 Place a pillow under the bed clients knees.
7.4.4 Place the washbasin on the moisture resistant pad at the foot of the bed for a
bed client, or
on the floor in front of the chair for an ambulatory client.
7.4.5 For a bed client, pad the rim of the washbasin with a towel.
7.5 Wash the foot and soak it.
7.5.1 Place one of the clients feet in the basin and wash it with soap.
7.5.2 Rinse the foot well to remove soap.
7.5.3 Rub callused areas of the foot with the washcloth.
7.5.4 If the nails are brittle or thick, and require trimming, replace the water and
allow the foot
to soak for 1020 minutes.
7.5.5 Clean the nails as required with an orange stick.
7.5.6 Remove the foot from the basin and place it on the towel.
7.5.7 Repeat for second foot.
7.6 Dry the foot thoroughly and apply lotion or foot powder.
7.6.1 Blot the foot gently with the towel to dry it thoroughly, particularly between the
toes.
7.6.2 Apply lotion or lanolin cream.
7.6.3 Apply foot powder, if applicable.
7.6.4 Repeat for second foot.
7.7 If agency policy permits, trim the nails of the first foot while the second foot is
soaking.
7.8 Give health-teachings on the following:
7.8.1 Active and passive exercises.
7.8.2 To wear properly fitted shoes and clean socks daily.
7.8.3 To consult a podiatrist for treatment of corns and calluses.
7.8.4 If feet are cold, wear socks or slippers and to use extra blanket. (Avoid using
heating pad
or hot water bottle.)
7.8.5 Regularly check the feet for infection or complications.
7.8.6 Wearing tight fitting garments and elastic garters, walking barefoot, sitting
with knees
REFERENCE:
8
crossed should 8.1
be avoided.
Fundamentals of Nursing concepts, process, and practice
7.8.7 Check worn shoes
frequently for rough spots in the lining.
7th Edition
7.9 Aftercare of equipment.Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
7.10Document the procedure, observations, and health-teachings given.
7.11Charge the procedure and supplies used, in the Inpatient Charging Form.
169
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
Hospital
48
PREPARATIONS:
6
6.1 Assess:
6.1.1 When the client last had a bowel movement, and the amount, color, and
consistency of the
feces
6.1.2 Presence of abdominal distention
6.1.3 Whether the client has sphincter control
6.1.4 Whether the client can use a toilet or commode or must remain in bed and use a
bedpan
6.2 Determine:
6.2.1 Whether a physicians order is required
6.2.2 The presence of kidney or cardiac disease that contraindicates the use of a
hypotonic
solution
6.3 Assemble equipment and supplies:
6.3.1 Disposable linen-saver pad
6.3.2 Bath blanket
6.3.3 Bedpan or commode
6.3.4 Clean gloves
6.3.5 Water-soluble lubricant if tubing not prelubricated
6.3.6 Paper towel
6.3.7 Large-volume enema
6.3.7.1 Solution container, with tubing f correct size and tubing clamp
PROCEDURES:
6.3.7.2 Correct solution, amount, and temperature
7.1 Explain
client what you are going to do, why it is necessary, and how he can
6.3.7.3to
IVthe
pole
cooperate.
6.3.8 Small-volume enema
7.2 Wash
hands
and observe
other appropriate
infection
control
procedures.
6.3.8.1
Prepackaged
container
of enema solution
with
lubricated
tip
7.3 Provide
for
client
privacy.
6.3.8.2 Lubricate about 5 cm (2 in) of the rectal tube.
7as
7.4 Assist
the
adult
client
to a left
lateral
position,
withtubing
the right
leg
as acutely
6.3.8.3
Run
some
solution
through
the
connecting
of a
large
volumeflexed
enema
possible
and
set
and the
the linen-saver
pad to
under
the
buttocks.
rectal tube,
expel
any
air in the tubing; then close the clamp.
7.5 Insert the rectal tube.
7.5.1 For clients in the left lateral position, lift the upper buttock.
7.5.2 Insert the tube smoothly and slowly into the rectum, directing it toward the
umbilicus.
7.5.3 Insert the tube 710 cm (34 in).
7.5.4 If resistance is encountered at the internal sphincter, ask the client to take a
deep breath,
then run a small amount of solution through the tube.
7.5.5 Never force tube or solution entry. If instilling a small amount of solution does
not permit
the tube to be advanced, or the solution to freely flow, withdraw the tube.
7.5.6 Check for any stool that may have blocked the tube during insertion. If present,
flush it
and retry the procedure. You may also perform a digital rectal examination, to
determine if
there is an impaction or other mechanical blockage.
7.5.7 If resistance persists, end the procedure and report the resistance to the
physician and
nurse in charge.
7.6 Slowly administer the enema solution.
7.6.1 Raise the solution container, and open the clamp to allow fluid flow. Or:
7.6.2 Compress a pliable container by hand. 171
7.6.3 During most low enemas, hold or hang the solution container no higher than 30
cm (12
in) above the rectum.
Republic of
Yemen 48Modern
48
Hospital
During a high enema, hang the solution container about 45 cm (18 in).
7.6.4
Administer the fluid slowly. If the client complains of fullness or pain,7.6.5
use the
clamp to
stop the flow for 30 seconds, and then restart the flow at a slower rate.
7.6.6 If you are using a plastic commercial container, roll it up as the fluid is instilled.
7.6.7 After all the solution has been instilled, or when the client cannot hold any more
and feels
the desire to defecate, close the clamp, and remove the rectal tube from the
anus.
7.6.8 Place the rectal tube in a disposable towel as you withdraw it.
7.7 Encourage the client to retain the enema.
7.7.1 Ask the client to remain lying down.
7.7.2 Request that the client retain the solution for the appropriate amount of time
for
example, 510 minutes for a cleansing enema, or at least 30 minutes for a
retention enema.
7.8 Assist the client to defecate.
7.8.1 Variation:
Assist the Administering
client to a sitting
position
bedpan, commode,
or toilet.
7.8.4
an Enema
toon
anthe
Incontinent
Client
7.8.2
Ask
the
client
who
is
using
the
toilet
not
to
flush
it.
The
nurse
needs
observe
7.8.4.1 After the rectal tube is inserted, have the client assume a supinetoposition
the
feces.
on a bedpan.
7.8.3
If a specimen
is required,
ask theslightly,
client toto
use
bedpanifornecessary,
commode.
7.8.4.2
The head of
of feces
the bed
can be elevated
30 adegrees
for easier
breathing, and use pillows to support t clients had and back.
7.8.5 Variation: Administering a Return-Flow Enema
7.8.5.1 For a return-flow enema, the solution is instilled into the clients rectum
and sigmoid
colon.
7.8.5.2 Then the solution container is lowered so that the fluid flows back out
through the
rectal tube into the container, pulling the flatus with it.
7.8.5.3 The inflow outflow process is repeated five or six times, and the solution is
replaced
several times during the procedure, if it becomes thick with feces.
7.9 Document the procedure.
7.9.1 Document
the type of solution; length of time solution was retained; the
SPECIAL
CONSIDERATIONS:
8
amount,
color,
8.1 Patient
with salt-retention disorders such as congestive heart failure, may absorb
and consistency
of the returns; and the relief of flatus and abdominal distention
sodium from
the
in the
saline enema solution. It should be administered with caution and electrolyte status
client record.
should be
monitored.
8.2 Schedule retention enema before meals, since a full stomach may stimulate
peristalsis and make
retention difficult.
8.3 Dont give enema to a patient who is in sitting position unless absolutely necessary.
9
REFERENCE:
9.1 Fundamentals of Nursing concepts, process, and practice
7th Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
172
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Electrocardiography
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in performing
electrocardiography.
1 DEFINITION:
1.1 Electrocardiography - a non-invasive procedure that is used to ascertain information
about the
electrophysiology of the heart.
2 PURPOSES:
2.1 Useful tool in the diagnosis of those conditions that may cause aberrations in the
electrical activity
of the heart:
2.1.1 MI and other types of coronary artery disease such as angina.
2.1.2 Cardiac rhythm changes or cardiac dysrhythmias.
2.1.3 Electrolyte disturbances especially in calcium and potassium levels.
2.1.4 Drug effects.
2.2 A part of elective investigations prior to various interventions such as surgery and
anti-cancer
therapy.
3 CONTRAINDICATION:
3.1 Uncooperative patient.
4 EQUIPMENTS/SUPPLIES:
4.1 ECG machine with cables, leads and graph paper.
4.2 Chest electrodes (rubber)
4.3 Alcohol swab
4.4 ECG conducting gel
4.5 Tissue paper
4.6 Plastic clamp for limb leads
4.7 Razor
5 POLICIES:
5.1 Observe Hospital Infection Control Policy.
5.2 Under ordinary circumstances, obtain doctors order. If patient complains of chest
pain ECG is
done immediately.
6
PROCEDURES:
5.3 As part of pre-operative investigation, ECG result should be ready prior to pre6.1 Check doctors order.
anesthesia
6.2 Identify correct patient.
evaluation.
6.3 Explain the procedure.
6.4 Provide privacy.
6.5 Wash hands and wear gloves.
6.6 Remove patients jewelries such as watch, rings and bracelets to minimize or
prevent artifacts in
the recordings.
6.7 Place the patient in supine position. Drape properly.
6.8 Clean the limbs and the site where electrodes will be applied to ensure good
placement and lessen
electrical artifacts.
173 apply the electrodes as follows:
6.9 Apply electrodes gel on the placement site and
Republic of
Yemen 48Modern
48
Hospital
174
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Eye Dressing
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure serves as a guideline in performing eye
dressing.
1 DEFINITION:
1.1 Eye Patch - is a method of covering or protecting the affected eyes by applying an
eyepad or
gauze.
1.2 Eye Shield - is a hard plastic non-metallic material cover to support an eye patch in
place or
protect eye from further injury.
1.3 Pressure Dressing - is a method of using an eye cover (eye patch and eye shield) with
intent of
applying pressure on the affected eye for medical reason.
2 PURPOSES:
2.1 To keep eyes at rest (eye patch).
2.2 To prevent patient from touching his/her eye (patch, shield, & pressure dressing).
2.3 To absorb tears and secretions (patch, pressure dressing).
2.4 To protect eyes from light, dust, and further injury.
2.5 To control or lessen edema.
2.6 To prevent blinking that promotes healing.
3 CONTRAINDICATIONS:
3.1 Eye patch is contraindicated, if there is infection.
3.2 Pressure dressing is contraindicated to glaucoma.
4 EQUIPMENTS/SUPPLIES:
4.1 Eye patch:
4.1.1 Eye medication, as ordered
4.1.2 Eye patch (sterile)
4.1.3 Hypoallergenic tape
4.2 Eye shield and Eye dressing:
4.2.1 Eye shield (plastic)
4.2.2 Sterile eye patch
4.2.3 Transparent tape
4.3 Sterile gloves
5 POLICIES:
5.1 Follow infection control measures.
5.2 Protect patient from accident and further injury.
5.3 Orient patient to his surroundings.
5.4 Effective verbal communication is a must.
PROCEDURES:
6.1 Identify correct patient and explain the procedure.
6.2 Arrange supplies and provide privacy.
6.3 Wash hands and wear gloves.
6.4 Place patient in sitting or lying position.
6.5 Instruct patient to close both eyes.
6.6 Perform procedure as follows:
175
Republic of
Hospital
176
48
Republic of
Yemen 48Modern
48
Hospital
177
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
178
Republic of
Yemen 48Modern
48
Hospital
179
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
180
Republic of
Yemen 48Modern
48
Hospital
181
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
Hospital
48
6
POLICIES:
6.1 Obtain physicians order.
6.2 Proper identification of the patient prior to procedure.
6.3 Generally carried out by the doctor and assisted by the nurse except in special area
like ICU, ER
where a registered nurse may carry out the procedure after initial assessment.
6.4 Airway must be secured by intubation prior to procedure, if patient is comatose.
6.5 Ensure patients safety.
6.6 Follow infection control policy.
7
PROCEDURES:
7.1 Explain the procedure to the patient whenever possible.
7.2 Provide privacy, wash hands, wear gloves, gown, and face shield.
7.3 Gather all equipment.
7.3.1 If unconscious, prepare the necessary equipment for intubation at bedside.
7.4 Take vitals signs as baseline, attached to cardiac monitor.
7.5 Remove any dentures, inspect for loose teeth.
7.6 Remove debris or suction vomitus from the buccal cavity.
7.7 Administer medication as prescribed.
7.8 Insert NGT. Refer to Nasogastric Tube Insertion procedure.
7.9 Assist the doctor during the procedure.
7.9.1 Maintain a record of Intake and Output.
7.9.2 Anticipate the needs.
7.9.3 Procedure is done by the doctor until return flow is clear.
7.10Observe the outflow for the color, fragment, and amount.
7.11Suction the buccal cavity throughout the procedure to prevent aspiration.
7.12For ingested poison or drugs, save the specimen for laboratory analysis.
7.12.1 Dilute activated charcoal tablet with saline solution to be administered for
ingested poison
(for absorption of remaining toxic substance).
7.13Observe for complications like:
7.13.1 bradyarrythmias
7.13.2 temperature drop for patient receiving ice saline lavage (gastric bleeding)
7.13.3 aspiration pneumonitis
7.13.4 stomach perforation
7.14Follow procedure for removal of nasogastric tube.
7.15Aftercare of equipment.
7.16Remove gloves, gown, and face shield. Wash hands.
7.17Documentation of the following:
7.17.1 date and time of lavage
7.17.2 size and type of tube inserted
7.17.3 volume and type of irrigating solution used
7.17.4 volume, color, and consistency of gastric contents drained
7.17.5 vital signs and level of consciousness
7.17.6 drugs instilled through the tube or medication given
7.17.7 duration of the procedure
7.17.8 tolerance and other observations made
7.17.9 outcome of the procedure
7.18Charge
the procedure and supplies used in the Inpatient Charging Form.
SPECIAL CONSIDERATIONS:
8
8.1 Continuous blood pressure and cardiac monitoring should be done as vagal
stimulation from the
tube or gastric distention may cause bradycardia, and many ingested substances
affect the blood
pressure and heart rate (if indicated per doctors order).
8.2 To secure small child, place mummy board183
and protective pad under head.
Republic of
Yemen 48Modern
48
Hospital
8.3 Careful assessment is needed. Specific amount and type of poison ingested must be
taken into
consideration prior to performing the procedure.
184
Republic of
Yemen 48Modern
Hospital
48
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Gastorostomy/Jejunostomy Feeding
Republic of
Yemen 48Modern
Hospital
48
Abdominal pads
5.8.5
Abdominal binder or Montgomery 5.8.6
straps
POLICIES:
6
6.1 Administer feeding solution at room temperature.
6.2 Obtain doctors order.
6.3 Only commercially prepared feeding should be used.
6.4 Keep intake and output record.
6.5 Follow infection control measures.
7
PREPARATIONS:
7.1 Assess:
7.1.1 For any clinical signs of malnutrition or dehydration
7.1.2 For allergies to any food in the feeding
7.1.3 For the presence of bowel sounds
7.1.4 For any problems that suggest lack of tolerance of previous feedings
7.2 Determine:
7.2.1 Type, amount, and frequency of feedings
7.2.2 Tolerance of previous feedings
7.3 Assemble equipment and supplies:
7.3.1 Correct amount of feeding solution
7.3.2 Graduated container, to hold the feeding
7.3.3 Large bulb syringe
7.3.4 Graduated container with 60 Ml of water, to flush the tubing
7.3.5 Graduated container, to measure residual formula
7.3.6 For a tube sutured in place:
7.3.6.1 4 x 4 gauze squares, to cover the end of the tube
7.3.6.2 Elastic band
7.3.7 For tube insertion:
7.3.7.1 Clean disposable gloves
7.3.7.2 Moisture-proof bag
7.3.7.3 Water-soluble lubricant
7.3.7.4 18 Fr whistle-tip catheter, or other feeding tube
7.3.7.5 Tubing clamp
7.3.8 For cleaning the peristomal skin and dressing the stoma:
7.3.8.1 Mild soap and water
7.3.8.2 Petrolatum, zinc oxide ointment, or other skin protectant
7.3.8.3 Precut 4 x 4 gauze squares
7.3.8.4 Uncut 4 x 4 gauze squares
7.3.8.5 Abdominal pads
7.3.8.6 Abdominal binder or Montgomery straps
7.3.9 Assist the client to a Fowlers position in bed, or a sitting position in a chair.
7.3.9.1 If a sitting position is contraindicated, a slightly elevated right side-lying
position is
acceptable.
PROCEDURES:
8
8.1 Explain to the client what you are going to do, why it is necessary, and how she can
cooperate.
8.2 Wash hands and observe other appropriate infection control procedures.
8.3 Provide for client privacy.
8.4 Assess tube placement. Attach the syringe to the open end of the tube, and aspirate
alimentary
secretions. Check the pH.
8.4.1 Allow 1 hour to elapse before testing the pH, if the client has received a
medication.
8.4.2 Use a pH meter rather than pH paper, 186
if the client is receiving a continuous
feeding or if
food coloring has been added to the formula.
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
9.2 Evaluate patients tolerance from tube feeding by checking amount of aspirated
residual every 4
hours, because gastric and intestinal contents can cause injury and necrosis at stoma
site.
10 REFERENCE:
10.1Fundamentals of Nursing concepts, process, and practice 7th
Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
188
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Title: Glucotest
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure serves as a guideline in performing
glucotest.
1 DEFINITION:
1.1 Glucotest - a method or procedure to obtain a blood sample for random blood sugar
using a
glucometer machine.
2 PURPOSES:
2.1 To detect or monitor elevated blood glucose level in-patient with diabetes.
2.2 To obtain quick result of serum glucose level.
2.3 To specify the suitable and effective treatment.
3 EQUIPMENTS/SUPPLIES:
3.1 A tray containing:
3.1.1 Glucometer
3.1.2 Glucostrip
3.1.3 Penlet sampler
3.1.4 Sterile lancet
3.1.5 Small sharp disposable container
3.1.6 Disposable gloves
3.1.7 Alcohol swabs
3.1.8 Small band aid
3.1.9 Sterile gauze 2 x 2
4 POLICY:
4.1 Follow standard infection control policy.
PROCEDURES:
5
5.1 Verify physicians order.
5.2 Identify correct client.
5.3 Prepare all equipment.
5.4 Set-up the lancet device.
5.4.1 Snap off the clear cap on the lancing device (as if breaking a cracker in half).
5.4.2 Insert a new lancet firmly into the lancet-holder.
5.4.3 Replace the cap until it snaps or clicks into place. Be careful not to touch the
exposed
needle on the lancet.
5.4.4 Look in the window of the lancing device and turn the setting dial to set the
depth level.
Start at 3.
5.4.5 Cock device, by pushing in until clicking sound is heard. You may have already
cocked
the device when you inserted the lancet. Set lancing device aside, proceed to
the next
step.
5.5 Prepare for puncture site.
5.5.1 To bring fresh blood to the surface of the test site, rub the site vigorously for a
few
seconds, until you feel it getting warm.
5.6 Prepare glucometer device.
189 on.
5.6.1 Insert the test strip. The meter will turn
5.6.2 Wait until you see the APPLY SAMPLE message on the meter display screen
BEFORE
Republic of
Yemen 48Modern
48
Hospital
lancing your test site. Set Meter aside proceeds to the next step.
5.7 Fill the Test Strip with Blood
5.7.1 Bring the test strip to the blood sample at a slight angle.
5.7.2 Gently touch only one edge of the test strip to the blood sample on your test
site. The
strip acts like a sponge and pulls the blood into the edge of the test strip.
5.7.3 Do not lift the strip up until you hear the beep or see arrows moving clockwise
on your
meter screen. This means you have enough blood and the meter is reading your
glucose.
5.7.4 The test result is complete when you hear one beep. Your blood glucose test
result is
shown on the display screen.
5.7.5 Inform client his/her blood sugar reading and relay to physician and document
in the file.
5.7.6 Dispose the used lancet in the sharp container. Do after care of the
equipments used.
SPECIAL
6
5.7.7 CONSIDERATIONS:
Remove gloves and wash hands.
6.1
DO
NOT
press
the
test
strip
against
the
test
site.
5.8 Charge the procedure and the supplies used.
6.2 DO NOT scrape the blood.
6.3 DO NOT use the flat side of the test strip.
6.4 The range of the glucometer device is 0-500 mg/dl. Above this range the meter
reads HI.
6.5 Test results below 50 mg/dl indicate low blood glucose. Test results greater than
240 mg/dl
indicate high blood glucose. If the obtained results is below 60 mg/dl or above 240
mg/dl and no
symptoms match the test result, recheck blood sugar. If there are symptoms that
match said result
or if same results were repeatedly obtained, notify the physician.
6.6 Do not use test strips that have passed the expiration date on the package since
they may cause
false results.
6.7 For the above mentioned conditions, RBS is taken in the following interval according
to doctors
order:
6.7.1 Every hour
6.7.2 Every 3 hours
6.7.3 Every 6 hours
6.7.4 Every 12 hours
6.7.5 Every 24 hours
6.8 Test strips automatically pull the sample into the strip.
6.9 Confirmation beep helps eliminate wasted test strips and short sampling.
6.10With clean, dry hands you may gently touch the test strip anywhere.
6.11Target areas are easily identified for clear, hassle-free sample application.
6.12Test strip code is included inside the box.
6.13For clients on hemodialysis, test is done before and after dialysis through the
arterial port of the
extracorporeal circuit.
190
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
Hospital
48
7 PROCEDURES:
7.1 Explain to the
client
what wetting
you are the
going
to will
do, make
why ititisdifficult
necessary,
and how can
6.2.3
Whether
hair
to comb
cooperate.
6.2.4 Whether a physicians order is needed before a shampoo can
7.2 Wash hands
and observe other appropriate infection control procedures.
be given
7.3 Provide for client privacy.
6.2.5 The type of shampoo to be used
7.4 Position and
prepare
the client
appropriately.
6.2.6
The best
time of
day for the shampoo
7.4.1 Assist the client who can sit to move to a chair. If health permits, assist a client
6.3 Assemble equipment and supplies
confined
to a bed to a sitting position by raising the head of the bed. Otherwise, assist the
client to
alternate side-lying positions, and do one side of the head at a time.
7.4.2 If the client remains in bed, place a clean towel over the pillow and the clients
shoulders.
7.4.3 Place it over the sitting clients shoulders.
7.5 Remove any pins or ribbons in the hair.
7.6 Remove any mats or tangles gradually.
7.6.1 Mats can usually be pulled apart with fingers or worked out with repeated
brushings.
7.6.2 If the hair is very tangled, rub alcohol or an oil, such as mineral oil, on the
strands, to
help loosen the tangles.
7.6.3 Comb out tangles in a small section of hair toward the ends.
7.6.4 Stabilize the hair with one hand, and comb towards the ends of the hair with the
other
hand.
7.7 Brush and comb the hair.
7.7.1 For short hair, brush and comb one side at a time. Divide long hair into two
sections by
parting it down the middle from the front to the back.
7.7.2 If he hair is very thick, divide each section into front and back subsections, or
into
several layers.
7.7.3 Arrange the hair as neatly and attractively as possible, according to the
individuals
desires.
7.8 Document assessments and special nursing interventions.
7.9 Hair Shampoo
7.9.1 Arrange the equipment.
7.9.2 Put the plastic sheet or pad on the bed under the head.
7.9.3 Remove the pillow from under the clients head, and place it under the
shoulders, unless
there is some underlying condition.
7.9.4 Tuck a bath towel around the clients shoulders.
7.9.5 Place the shampoo basin under the head, putting a folded washcloth or pad
where the
clients neck rests on the edge of the basin.
7.9.6 If the client is on a stretcher, the neck can rest on the edge of the sink, with the
washcloth
as padding.
7.9.7 Fanfold the top bedding down to the waist, and cover the upper part of the
client with the
bath blanket.
7.9.8 Place the receiving receptacle on a table or chair at the bedside.
7.9.9 Put the spout of the shampoo basin over the receptacle.
7.10Protect the clients eyes and ears.
7.10.1 Place a damp washcloth over the clients
eyes.
192
7.10.2 Place cotton balls in the clients ears, if indicated.
7.11Shampoo the hair.
7.11.1 Wet the hair thoroughly with the water.
Republic of
Yemen 48Modern
48
Hospital
7.11.2 Apply shampoo to the scalp. Make a good lather with the shampoo while
massaging the
scalp with the pads of your fingertips.
7.11.3 Rinse the hair briefly, and apply shampoo again.
7.11.4 Make a good lather and massage the scalp as before.
7.11.5 Rinse the hair thoroughly this time to remove all the shampoo.
7.11.6 Squeeze as much water as possible out of the hair with your hands.
7.12Dry the hair thoroughly.
7.12.1 Rub the clients hair with a heavy towel.
7.12.2 Dry the hair with the dryer. Set the temperature at warm.
7.12.3 Continually move the dryer to prevent burning the clients scalp.
7.13Ensure client comfort.
7.13.1 Assist the person confined to bed to a comfortable position.
7.13.2 Arrange the hair using a clean brush and comb.
7.14Document the shampoo and any assessments.
8 REFERENCE:
8.1 Fundamentals of Nursing concepts, process, and practice 7 th
Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
193
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Handling of Narcotics and Controlled Drugs
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure serves as a guideline in handling
narcotics and
controlled drugs.
1 DEFINITION:
1.1 Narcotic - is a drug derived from opium or opium-like compounds, with potent
analgesic effects
associated with significant alteration of mood and behavior with potential for
dependence and
tolerance following repeated administration such as Pethidine, Morphine, Fentanyl.
1.2 Controlled drugs are potentially addictive or habit-forming wherein their
manufacture, sale, or
supply is prohibited except in accordance with regulations made under the law.
1.2.1 Example given : Dormicum, Valium, Nubain, Fortal, Tramal, Duragesic and other
drugs ( Xanax, Lexotanil, Ativan, Revotril ) presently calssified by the Saudi
Arabian
Ministry of Health.
1.2.2 These drugs can either be in :
1.2.2.1 Injectable form for IV or IM, intra-spinal, subcutaneous use.
1.2.2.2 Tablet or liquid for oral use and rectal preparation.
2 PURPOSES:
2.1 To prevent misuse and abuse of narcotic and controlled drugs.
POLICIES:
2.2All
To nursing
regulatestations
system must
of issuance
and own
replenishment.
4.1
have their
stock to meet the existing needs of the
2.3 To follow
individual
unit.the standard requirements of MOH in handling narcotics and controlled drugs.
3 EQUIPMENTS/SUPPLIES:
Quantity in stock is documented in the Narcotic/Controlled book.
3.1Narcotic/controlled
Narcotic safety vault
4.2
drugs should not be moved from one unit to another without proper
4
3.2 Logbook
authorization
of Narcotic
designated
narcotic/controlled
drug nurse (assigned by Nursing Director) and
3.3
prescription
(Form M5043)
designated
3.4 Controlled prescription (Form M5043A)
responsible
Pharmacist.
3.5
Information
for Controlled Drugs (Form M1071)
4.3 The storage cabinet is safe, secure, made of steel and with double locks.
4.4 The head nurse (or charge nurse/team leader during HN absence) has full control and
authority of all
stocks of narcotic/controlled drugs kept in her unit.
4.4.1 Only the unit head or charge nurse/team leader on duty should handle
Narcotic/controlled
drug vault key.
4.4.2 The unit Head nurse regulates replacement of the used drugs (as per pharmacy
schedule)
and prepares all prescriptions and empty ampoules ready for collection from
the
Pharmacy.
4.5 All ampoules should be kept safe and fully accounted for (tallying contents inside
the vault
against the logbook record).
194
4.5.1 At the end of each shift, outgoing Charge Nurse must endorse to incoming
Charge
Nurse:
Republic of
Yemen 48Modern
48
Hospital
5.3 Prepare the desired amount of medicine and discard the remaining quantity in the
presence of
head nurse or charge nurse/team leader.
5.4 Hand over the empty ampoules to the head nurse or charge nurse/team leader.
5.5 Have the head nurse or charge nurse/team leader witness the administration of
drug.
5.6 Follow procedures of medication administration.
5.7 Document the following in the nurses notes and medication sheet:
5.7.1 Name of the drug and dose.
5.7.2 Date and time given.
5.7.3 Any adverse reaction observed.
5.7.4 Refusal, if any.
5.8 Charge narcotic/controlled drug used in the Inpatient Charging Form.
5.9 Head nurse (or charge nurse in her absence) shall fill up the form:
5.9.1 Re-check all information for completeness and accuracy of data written in
Form M1071.
5.9.2 Transfer the data from Form M1071 to the Prescription Form M5043 or Form
M5043A.
5.9.3 Use only same pen and ink color, preferably black.
5.9.4 Write neatly and legibly, if possible in block letters.
5.9.5 Get the signature and stamp of the
Prescribing Doctor within 24 hours. 6
REFERENCES:
6.1 Medication Administration, p. 520-521
Craven and Hirnle Fundamentals of Nursing
Human Health and Function, Fourth Edition
196
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
cooperate
4.1.2 Wash hands and observe appropriate infection control procedures.
4.1.3 Provide for client privacy.
4.2 Assessing the Hair
4.2.1 Assemble equipment and supplies:
4.2.2 Clean gloves
4.3 Assessing the Skull and Face
4.3.1 Explain to the client what you are going to do, why it is necessary, and how he
can
cooperate.
4.3.2 Wash hands and observe other appropriate infection control procedures.
4.3.3 Provide for client privacy.
4.3.4 Determine clients history of the following:
4.3.5 Any past problems with lumps or bumps, itching, scaling, or dandruff
4.3.6 Any history of loss of consciousness, dizziness, seizures, headache, facial pain,
or injury
4.3.7 When and how any lumps occurred
4.3.8 Length of time any other problem existed
4.3.9 Any known cause of problem
4.3.10 Associated symptoms, treatment, and recurrences
4.4 Assessing the Eye Structure and Visual Acuity
4.4.1 Assemble equipment and supplies:
4.4.2 Cotton tip applicator
4.4.3 Examination gloves
4.4.4 Millimeter ruler
197
4.4.5 Penlight
Republic of
Yemen 48Modern
48
Hospital
198
Republic of
Yemen 48Modern
Hospital
48
4.14.2 Stethoscope
4.14.3 Skin marker/pencil
4.14.4 Centimeter ruler
4.14.5 Determine clients history of the following:
4.14.6 Family history of illness, including cancer
4.14.7 Allergies
4.14.8 Tuberculosis
4.14.9 Smoking and occupational hazards
4.14.10Any medications being taken
4.14.11Current problems such as swellings, coughs, wheezing, pain
4.15Assessing the Female Genitals and Inguinal Area
4.15.1 Assemble equipment and supplies:
4.15.2 Examination gloves
4.15.3 Drape
4.15.4 Supplemental lighting, if needed
4.16Assessing the Male Genitals and Inguinal Area
4.16.1 Assemble equipment and supplies:
4.16.2 Examination gloves
4.17Assessing the Rectum and Anus
4.17.1 Assemble equipment and supplies:
4.17.2 Examination gloves
4.17.3 Water-soluble lubricant
4.18Assessing the Musculoskeletal System
4.18.1 Assemble equipment and supplies:
4.18.2 Goniometer
4.19Assessing the Peripheral Vascular System
4.19.1 Determine clients history of the following:
4.19.2 Past history of heart disorders, varicosities, arterial disease, and
hypertension
4.19.3 Lifestyle patterns, specifically exercise patterns, activity patterns,
and tolerance
4.19.4 Smoking habits and use of alcohol
5 PROCEDURES:
5.1 Assessing Appearance and Mental Status
5.1.1 Observe body build, height, and weight in relation to the clients age, lifestyle,
and
health.
5.1.2 Observe the clients posture and gait, standing, sitting, and walking.
5.1.3 Observe the clients overall hygiene and grooming. Relate these to the persons
activities
prior to the assessment.
5.1.4 Note body and breath odor in relation to activity level.
5.1.5 Observe for signs of distress in posture or facial expression.
5.1.6 Note obvious signs of health or illness.
5.1.7 Assess the clients attitude.
5.1.8 Note the clients affect/mood; assess the appropriateness of the clients
responses.
5.1.9 Listen for quantity, quality, and organization of speech.
5.1.10 Listen for relevance and organization of thoughts.
5.1.11 Document findings in the client record.
5.2 Assessing The Hair
5.2.1 Explain to the client what you are going to do, why it is necessary, and how he
can
cooperate.
5.2.2 Wash hands and observe other appropriate infection control procedures.
199
5.2.3 Provide for client privacy.
5.2.4 Determine clients history of the following:
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen
48Modern
48
Approach from behind and beside the client, and lightly touch the cornea
with a
Hospital
corner of
the gauze.
5.7.6 Inspect the anterior chamber for transparency and depth. Use the same
oblique lighting
used when testing the cornea.
5.7.7 Inspect the pupils for color, shape, and symmetry of size.
5.7.5
5.7.8 Assess each pupils direct and consensual reaction to light.
5.7.9 Assess each pupils reaction to accommodation.
5.8 Assessing the Ears and Hearing
5.8.1 Explain to the client what you are going to do, why it is necessary, and how he
can
cooperate.
5.8.2 Wash hands and observe other appropriate infection control procedures.
5.8.3 Provide for client privacy.
5.8.4 Determine clients history of the following:
5.8.5 Family history of hearing problems or loss
5.8.6 Presence of any ear problems
5.8.7 Medication history, especially if there are complaints of ringing in ears
5.8.8 Any hearing difficulty: its onset, factors contributing to it, and how it interferes
with
activities of daily living
5.8.9 Use of a corrective hearing device: when and from whom it was obtained
5.8.10 Position the client comfortably, seated if possible
5.9 Auricles
5.9.1 Inspect the auricles for color, symmetry of size, and position.
5.9.2 Palpate the auricles for texture, elasticity, and areas of tenderness.
5.9.3 External Ear Canal and Tympanic Membrane
5.9.4 Using an otoscope, inspect the external ear canal for cerumen, skin lesions,
pus, and
blood.
5.9.5 Inspect the tympanic membrane for color and gloss.
5.10Gross Hearing Acuity Tests
5.10.1 Assess clients response to normal voice tones. If client has difficulty hearing
the normal
voice, proceed with the following tests.
5.11Perform the watch tick test.
5.11.1 Have the client occlude one ear. Out of the clients sight, place a ticking
watch 23 cm
(12 in) from the unoccluded ear.
5.11.2 Ask what the client can hear. Repeat with the other ear.
5.12Assessing the Mouth and Oropharynx
5.12.1 Determine clients history of the following:
5.12.2 Routine pattern of dental care
5.12.3 Last visit to dentist
5.12.4 Length of time ulcers or other lesions have been present
5.12.5 Any denture discomfort
5.12.6 Any medications client is receiving
5.12.7 Position the client comfortably, seated if possible.
5.13Lips and Buccal Mucosa
5.13.1 Inspect the outer lips for symmetry of contour, color, and texture.
5.13.2 Ask client to purse the lips as if to whistle.
5.13.3 Inspect and palpate the inner lips and buccal mucosa for color, moisture,
texture, and the
presence of lesions.
5.14Teeth and Gums
5.14.1 Inspect the teeth and gums while examining the inner lips and buccal
mucosa.
5.14.2 Inspect the dentures.
201
5.14.3 Ask client to remove complete or partial dentures. Inspect their condition,
noting in
particular broken or worn areas.
Republic of
Yemen 48Modern
48
Hospital
5.15Tongue/Floor
of the Mouth
5.15.1 Inspect the surface of the tongue for position, color, and texture.
5.15.2 Ask the client to protrude the tongue.
5.15.3 Inspect tongue movement.
5.15.4 Ask the client to roll the tongue upward and move it from side to side.
5.15.5 Inspect the base of the tongue, the mouth floor, and the frenulum.
5.15.6 Ask the client to place the tip of his tongue against the roof of the mouth.
5.15.7 Palpate the tongue and floor of the mouth for any nodules, lumps, or
excoriated areas.
5.15.8 Use a piece of gauze to grasp the tip of the tongue and, with the index finger
of your
other hand, palpate the back of the tongue, its borders, and its base.
5.16Salivary Glands
5.16.1 Inspect salivary duct openings for any swelling or redness.
5.17Palates and Uvula
5.17.1 Inspect the hard and soft palate for color, shape, texture, and the presence of
bony
prominences.
5.17.2 Ask the client to open his mouth wide and tilt his head backward.
5.17.3 Then, depress tongue with a tongue blade as necessary, and use a penlight for
appropriate
visualization.
5.17.4 Inspect the uvula for position and mobility while examining the palates.
5.17.5 To observe the uvula, ask the client to say ah so that the soft palate rises.
5.18Oropharynx and Tonsils
5.18.1 Inspect the oropharynx for color and texture.
5.18.2 Inspect one side at a time to avoid eliciting the gag reflex. To expose one side
of the
oropharynx, press a tongue blade against the tongue on the same side about
halfway back
while the client tilts his head back and opens the mouth wide. Use a penlight for
illumination, if needed.
5.18.3 Inspect the tonsils for color, discharge, and size.
5.18.4 Elicit the gag reflex by pressing the posterior tongue with a tongue depressor.
5.18.5 Document findings in the client record.
5.19Assessing the Nose and Sinuses
5.19.1 Determine clients history of the following:
5.19.2 Allergies
5.19.3 Difficulty breathing through the nose
5.19.4 Sinus infections
5.19.5 Injuries to nose or face
5.19.6 Nosebleeds
5.19.7 Any medications taken
5.19.8 Any changes in sense of smell
5.20Nose
5.20.1 Inspect the external nose for any deviations in shape, size, or color and
flaring, or
discharge from the nares.
5.20.2 Lightly palpate the external nose to determine any areas of tenderness,
masses, and
displacements of bone and cartilage.
5.20.3 Determine patency of both nasal cavities.
5.20.4 Ask the client to close the mouth, exert pressure on one naris, and breathe
through the
opposite naris.
5.20.5 Repeat the procedure to assess patency of the opposite naris.
5.20.6 Inspect the nasal cavities using a flashlight or a nasal speculum.
5.20.7 Observe for the presence of redness,
202swelling, growths, and discharge.
5.20.8 Inspect the nasal septum between the nasal chambers.
5.21Facial Sinuses
5.21.1 Palpate the maxillary and frontal sinuses for tenderness.
Republic of
5.22.1 Neck
Muscles
5.22.2 Inspect the neck muscles (sternocleidomastoid and trapezius) for abnormal
swellings or
masses.
5.22.3 Ask the client to hold her head erect.
5.23Observe head movement.
5.23.1 Ask client to:
5.23.2 Move her chin to the chest (determines function of the sternocleidomastoid
muscle).
5.23.3 Move her head back so that the chin points upward (determines function of
the trapezius
muscle).
5.23.4 Move her head so that the ear is moved toward the shoulder on each side
(determines
function of the sternocleidomastoid muscle).
5.23.5 Turn her head to the right and to the left (determines function of the
sternocleidomastoid
muscle).
5.23.6 Assess muscle strength.
5.23.7 Ask the client to:
5.23.8 Turn her head to one side against the resistance of your hand.
5.23.9 Repeat with the other side.
5.23.10 Shrug her shoulders against the resistance of your hands.
5.24Lymph Nodes
5.24.1 Palpate the entire neck for enlarged lymph nodes.
5.25Trachea
5.25.1 Palpate the trachea for lateral deviation.
5.25.2 Place your fingertip or thumb on the trachea in the suprasternal notch, and
then move
your finger laterally to the left and the right in spaces bordered by the clavicle,
the
anterior aspect of the sternocleidomastoid muscle, and the trachea.
5.26Thyroid Gland
5.26.1 Inspect the thyroid gland.
5.26.2 Stand in front of the client.
5.26.3 Observe the lower half of the neck overlying the thyroid gland for symmetry
and visible
masses.
5.26.4 Ask the client to hyperextend her head and swallow. If necessary, offer a glass
of water
to make it easier for the client to swallow.
5.26.5 Palpate the thyroid gland for smoothness.
5.26.6 Note any areas of enlargement, masses, or nodules.
5.26.7 If enlargement of the gland is suspected:
5.26.8 Auscultate over the thyroid area for a bruit.
5.26.9 Use the bell-shaped diaphragm of the stethoscope.
5.26.10Document findings in the client record.
5.27Assessing the Breast and Axillae
5.27.1 Determine clients history of the following:
5.27.1.1Breast self-examination; technique used and when performed in relation
to the
menstrual cycle
5.27.1.2Breast masses, and what was done about them
5.27.1.3Any pain or tenderness in the breasts and relation to the womans
menstrual cycle
5.27.1.4Any discharge from the nipple
5.27.1.5Medication history
5.27.1.6Estrogen replacement therapy 203
5.27.1.7Alcohol consumption
5.27.1.8High-fat diet
5.27.1.9Obesity
5.27.1.10Use
Republic
of oral
ofcontraceptive
5.27.1.11Menarche before age 12
Yemen 48Modern
48
5.27.1.12Menopause after age 55
Hospital
5.27.1.13Pregnancy
after age 30
5.27.2 Inspect the breasts for size, symmetry, and contour or shape while the client
is in a sitting
position.
5.27.3 Inspect the skin of the breast for localized discolorations or
hyperpigmentation, retraction
or dimpling, localized hypervascular areas, swelling, or edema.
5.27.4 Emphasize any retraction by having the client:
5.27.5 Raise the arms above the head
5.27.6 Push the hands together, with elbows flexed
5.27.7 Press the hands down on the hips
5.27.8 Inspect the areola area for size, shape, symmetry, color, surface
characteristics, and any
masses or lesions.
5.27.9 Inspect the nipples for size, shape, position, color, discharge, and lesions.
5.27.10Palpate the axillary, subclavicular, and supraclavicular lymph nodes.
5.27.11The client is seated with the arms abducted and supported on the nurses
forearm.
5.27.12Use the flat surfaces of all fingertips to palpate the four areas of the axilla:
5.27.12.1The edge of the greater pectoral muscle along the anterior axillary line
5.27.12.2The thoracic wall in the midaxillary area
5.27.12.3The upper part of the humerus
5.27.13The anterior edge of the latissimus dorsi muscle along the posterior axillary
line
5.27.14Palpate the breast for masses, tenderness, and any discharge from the
nipples.
5.27.15Palpate the areola and the nipples for masses.
5.27.16Compress each nipple to determine the presence of any discharge.
5.27.17If discharge is present, milk the breast along its radius to identify the
dischargeproducing lobe.
5.27.18Assess any discharge for amount, color, consistency, and odor.
5.27.19 Note any tenderness on palpation.
5.27.20Teach the client the technique of breast self-examination.
5.27.21Document findings in the client record.
5.28Assessing the Abdomen
5.28.1 Determine clients history of the following:
5.28.1.1Incidence of abdominal pain: its location, onset, sequence, and
chronology; its
quality (description); its frequency; associated symptoms
5.28.1.2Bowel habits
5.28.1.3Incidence of constipation or diarrhea
5.28.1.4Change in appetite
5.28.1.5Food intolerances
5.28.1.6Foods ingested in last 24 hours
5.28.1.7Specific signs and symptoms
5.28.1.8Previous problems and treatment
5.28.2 Assist the client to a supine position, with the arms placed comfortably at the
sides.
5.28.3 Place small pillows beneath the knees and the head to reduce tension in the
abdominal
muscles.
5.28.4 Expose only the clients abdomen from chest line to the pubic area to avoid
chilling and
shivering, which can tense the abdominal muscles.
5.28.5 Inspection of the Abdomen
5.28.6 Inspect the abdomen for skin integrity.
5.28.7 Inspect the abdomen for contour and 204
symmetry.
5.28.8 Observe the abdominal contour while standing at the clients side when the
client is
supine.
Republic of
Yemen 48Modern
48
5.28.9 AskHospital
the client to take a deep breath and to hold it.
5.28.10Assess the symmetry of contour while standing at the foot of the bed.
5.28.11 If distention is present, measure the abdominal girth by placing a tape
around the
abdomen at the level of the umbilicus.
5.28.12Observe abdominal movements associated with respiration, peristalsis, or
aortic
pulsations.
5.28.13Observe the vascular pattern.
5.28.14Auscultation of the Abdomen
5.28.15Auscultate the abdomen for bowel sounds, vascular sounds, and peritoneal
friction rubs.
5.28.16Percussion of the Abdomen
5.28.17Percuss several areas in each of the four quadrants to determine presence of
tympany and
dullness.
5.28.18Use a systematic pattern: Begin in the lower left quadrant, then proceed to
the lower right
quadrant, the upper right quadrant, and the upper left quadrant.
5.28.19Percussion of the Liver
5.28.19.1Percuss the liver to determine its size.
5.28.20Palpation of the Abdomen
5.28.20.1Perform light palpation first to detect areas of tenderness and/or muscle
guarding.
5.28.20.2Systematically explore all four quadrants.
5.28.20.3Perform deep palpation over all four quadrants.
5.28.21Palpation of the Liver
5.28.21.1Palpate the liver to detect enlargement and tenderness.
5.28.22Palpation of the Bladder
5.28.22.1Palpate the area above the pubic symphysis if the clients history
indicates possible
urinary retention.
5.28.23Document findings in the client record.
5.29Assessing the Nails
5.29.1 Assessment
5.29.2 Inspect fingernail plate shape to determine its curvature and angle.
5.29.3 Inspect fingernail and toenail texture.
5.29.4 Inspect fingernail and toenail bed color.
5.29.5 Inspect tissues surrounding nails.
5.29.6 Perform blanch test of capillary refill.
5.30Assessing the Skin
5.30.1 Determine clients history of the following:
5.30.1.1Pain or itching
5.30.1.2Presence and spread of any lesions, bruises, abrasions, or pigmented
spots
5.30.1.3Previous experience with skin problems
5.30.1.4Associated clinical signs
5.30.1.5History of problems in other family members
5.30.1.6Related systemic conditions
5.30.1.7Use of medications, lotions, home remedies
5.30.1.8Excessively dry or moist feel to the skin
5.30.1.9Tendency to bruise easily
5.30.1.10Any association of the problem to season of year
5.30.2 Inspect skin color.
5.30.3Inspect uniformity of skin color.
5.30.4 Assess edema, if present
5.30.5 Inspect, palpate, and describe skin lesions. Apply gloves if lesions are open or
draining.
205
5.30.6 Observe and palpate skin moisture.
5.30.7 Palpate skin temperature.
5.30.8 Compare the two feet and the two hands, using the backs of your fingers.
levels, high
blood pressure, stroke, obesity, congenital heart disease, arterial disease,
hypertension, and rheumatic fever
5.31.1.2Clients past history of rheumatic fever, heart murmur, heart attack,
varicosities, or
heart failure
5.31.1.3Present symptoms indicative of heart disease
5.31.1.4Presence of diseases that affect heart
5.31.1.5Lifestyle habits that are risk factors for cardiac disease
5.31.2 Simultaneously inspect and palpate the precordium for the presence of
abnormal
pulsations, lifts, or heaves.
5.31.3 Inspect and palpate the aortic and pulmonic areas, observing them at an angle
and to the
side, to note the presence or absence of pulsations.
5.31.4 Inspect and palpate the tricuspid area for pulsations and heaves or lifts.
5.31.5 Inspect and palpate the apical area for pulsation, noting its specific location (it
may be
displaced laterally or lower) and diameter.
5.31.6 If displaced laterally, record the distance between the apex and the MCL in
centimeters.
5.31.7 Inspect and palpate the epigastric area at the base of the sternum for
abdominal aortic
pulsations.
5.31.8 Auscultate the heart in all four anatomic sites: aortic, pulmonic, ricuspid, and
apical
(mitral).
5.31.9 Carotid Arteries
5.31.9.1Palpate the carotid artery.
5.31.9.2Use extreme caution.
5.31.9.3Auscultate the carotid artery.
5.31.10Jugular Veins
5.31.10.1Inspect the jugular veins for distention.
5.31.10.2The client is placed in a semi- Fowlers position, with the head supported
on a
small pillow.
5.31.10.3If jugular distention is present, assess the jugular venous pressure (JVP).
5.31.10.4Locate the highest visible point of distention of the internal jugular vein.
5.31.10.5 Measure the vertical height of this point in centimeters from the sternal
angle.
5.31.10.6 Repeat the steps above on the other side.
5.31.10.7Document findings in the client record.
5.32Assessing the Thorax and Lungs
5.32.1 Posterior Thorax
5.32.1.1Inspect the shape and symmetry of the thorax from posterior and lateral
views.
5.32.1.2Inspect the spinal alignment for deformities.
5.32.1.3Have the client stand. From a lateral position, observe the three normal
curvatures:
cervical, thoracic, and lumbar.
5.32.1.4 To assess for lateral deviation of spine (scoliosis), observe the standing
client from
the rear. Have the client bend forward at the waist and observe from behind.
5.32.1.5Palpate the posterior thorax.
5.32.1.6For clients who have no respiratory complaints, rapidly assess the
temperature and
integrity of all chest skin.
206 complaints, palpate all chest areas for
5.32.1.7For clients who do have respiratory
bulges,
tenderness, or abnormal movements.
5.32.1.8Avoid deep palpation for painful areas, especially if a fractured rib is
suspected.
5.33.1.7Number of pregnancies
5.33.1.8Number of live births
5.33.1.9Labor
Republicorof
delivery complications
5.33.1.10Urgency and frequency of urination at night
Yemen
48Modern
48
5.33.1.11Blood in urine
Hospital urination
5.33.1.12Painful
5.33.1.13Incontinence
5.33.1.14History of sexually transmitted disease, past and present
5.33.1.15Position the client supine with feet elevated on the stirrups of an
examination
table.
5.33.1.16Alternately, assist the client into the dorsal recumbent position with
knees flexed
and thighs externally rotated.
5.33.2 Inspect the distribution, amount, and characteristics of pubic hair.
5.33.3 Inspect the skin of the pubic area for parasites, inflammation, swelling, and
lesions.
5.33.4 To assess pubic skin adequately, separate the labia majora and labia minora.
5.33.5 Inspect the clitoris, urethral orifice, and vaginal orifice when separating the
labia minora.
5.33.6 Palpate the inguinal lymph nodes.
5.33.7 Document findings in the client record.
5.34Assessing the Male Genitals and Inguinal Area
5.34.1 Determine clients history of the following:
5.34.1.1Usual voiding patterns and any changes, bladder control, urinary
incontinence,
frequency, or urgency
5.34.1.2Abdominal pain
5.34.1.3Any symptoms of sexually transmitted disease
5.34.1.4Any swellings that could indicate presence of hernia
5.34.1.5Family history of nephritis, malignancy of the prostate, or malignancy of
the
kidney.
5.34.2 Pubic Hair
5.34.2.1Inspect the distribution, amount, and characteristics of pubic hair.
5.34.3 Penis
5.34.3.1Inspect the penile shaft and glans penis for lesions, nodules, swellings,
and
inflammation.
5.34.3.2Inspect the urethral meatus for swelling, inflammation, and discharge.
5.34.3.3Compress or ask the client to compress the glans slightly to open the
urethral
meatus to inspect it for discharge.
5.34.3.4 If the client has reported a discharge, instruct the client to strip the penis
from the
base to the urethra.
5.34.3.5Palpate the penis for tenderness, thickening, and nodules.
5.34.3.6Use your thumb and first two fingers.
5.34.4 Scrotum
5.34.4.1Inspect the scrotum for appearance, general size, and symmetry.
5.34.4.2To facilitate inspection of the scrotum during a physical examination, ask
the client
to hold the penis out of the way.
5.34.4.3Inspect all skin surfaces by spreading the rugated surface skin and lifting
the
scrotum as needed to observe posterior surfaces.
5.34.4.4Palpate the scrotum to assess status of underlying testes, epididymis,
and spermatic
cord. Palpate both testes simultaneously for comparative purposes.
5.34.5 Inguinal Area
5.34.5.1Inspect both inguinal areas for bulges while the client is standing, if
possible.
5.34.5.2First, have the client remain at 208
rest.
5.34.5.3Next, have the client hold his breath and strain or bear down, as though
having a
bowel movement.
or
5.34.5.4Palpate
Republic hernias.
of
5.34.5.5Document findings in the client record.
Yemen 48Modern
48
5.34.6 Assessing the Rectum and Anus
Hospital
5.34.6.1Determine
clients history of the following:
5.34.6.2History of bright blood in stools, tarry black stools, diarrhea, constipation,
abdominal pain, excessive gas, hemorrhoids, or rectal pain
5.34.6.3Family history of colorectal cancer
5.34.6.4When last stool specimen for occult blood was performed, and the results
5.34.6.5For males, if not obtained during the genitourinary examination, any signs
symptoms of prostate
5.34.7 Position the client.
5.34.8 In adults, a left lateral or Sims position with the upper leg acutely flexed is
required for
the examination.
5.34.9 For females: a dorsal recumbent position with hips externally rotated and
knees flexed or
a lithotomy position may be used.
5.34.10For males: a standing position while the client bends over the examining
table may also
be used.
5.34.11Inspect the anus and surrounding tissue for color, integrity, and skin lesions
5.34.12Then, ask the client to bear down as though defecating.
5.34.13Describe the location of all abnormal findings in terms of a clock, with the12
oclock
position toward the pubic symphysis.
5.34.14Palpate the rectum for anal sphincter tonicity, nodules, masses, and
tenderness.
5.34.15On withdrawing the finger from the rectum and anus, observe it for feces.
5.34.16Document findings in the client record.
5.35Assessing the Musculoskeletal System
5.35.1 Determine clients history of the following:
5.35.1.1History or presence of muscle pain: onset, location, character, associated
phenomena, and aggravating and alleviating factors
5.35.1.2Any limitations to movement or inability to perform activities of daily
living
5.35.1.3Previous sports injuries
5.35.1.4Any loss of function without pain
5.35.2 Muscles
5.35.2.1Inspect the muscles for size.
5.35.2.2Compare each muscle on one side of the body to the same muscle on the
other side.
5.35.2.3For any apparent discrepancies, measure the muscles with a tape.
5.35.2.4Inspect the muscles and tendons for contractures.
5.35.2.5Inspect the muscles for fasciculations and tremors.
5.35.2.6Inspect any tremors of the hands and arms by having the client hold the
arms out in
front of the body.
5.35.2.7Palpate muscles at rest to determine muscle tonicity.
5.35.2.8Palpate muscles while the client is active and passive for flaccidity,
spasticity, and
smoothness of movement.
5.35.2.9Test muscle strength. Compare the right side with left side.
5.35.3 Bones
5.35.3.1Inspect the skeleton for normal structure and deformities.
5.35.3.2Palpate the bones to locate any areas of edema or tenderness.
5.35.4 Joints
5.35.4.1Inspect the joint for swelling.
5.35.4.2Palpate each joint for tenderness, smoothness of movement, swelling,
crepitation,
and presence of nodule
209
5.35.4.3Assess joint range of motion.
5.35.4.4Ask the client to move selected body parts. If available, use a goniometer
to
Republic of
Yemen 48Modern
48
Hospital
210
Republic of
Yemen 48Modern
Hospital
48
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
Perfusor tubing 5.2.3
Disposable gloves5.2.4
5.2.5
Blue pads
Alcohol pad
5.2.6
5.2.7
Syringe with needle
NSS 500cc
5.2.8
5.2.9
IV Tray
6
POLICIES:
6.1 Obtain doctors order.
6.2 Observe 7 rights of medication administration.
6.3 Follow strict aseptic technique.
6.4 Have a senior nurse double check the prepared dose.
PROCEDURES:
6.5
the site of injection for subcutaneous administration.
7.1 Rotate
Subcutaneous:
6.6 7.1.1
Prior Check
to administration,
clotting
profilesthe
should
be obtained
doctors order
and identify
correct
patient. to detect bleeding
tendencies
and
7.1.2 Assess patients condition. Check vital signs and coagulation profile as
Protamine Sulphate should be available as antidote.
baseline.
7.1.3 Wash hands. Verify medication label (including expiry date) with doctors
7
order and
medication record.
7.1.4 Withdraw the prescribed dose from multi-dose vial after double-checked by a
senior
nurse.
7.1.5 Change needle preferably gauge 25 or according to the amount of underlying
tissues.
7.1.6 Place in the injection tray the prepared medicine, alcohol pad, band aid, and
small sharp
container and bring to patients bedside.
7.1.7 Identify the correct patient by calling his/her name and checking the ID band.
7.1.8 Provide privacy and explain the procedure.
7.1.9 Select and assess the site of injection.
7.1.9.1 Common site is the fatty area anterior to either iliac crest.
7.1.9.2 Other sites:
7.1.9.2.1 Outer posterior aspect of upper arm.
7.1.9.2.2 Abdomen from below the coastal margin to the iliac crest.
7.1.9.2.3 Anterior aspect of the thigh.
7.1.9.2.4 Scapular areas of the upper back.
7.1.9.2.5 Upper ventral or dorsal gluteal area.
7.1.10 Position to expose the site of injection.
7.1.11 Cleanse the area gently with alcohol pad. Do not rub.
7.1.12 Form a fat roll by gently grasping skin at the selected site without pinching
the tissue.
7.1.13 Hold the shaft of the syringe in dart fashion and insert needle directly to the
skin at 4590o angle depending on the amount of tissue grasped (thin tissue 45 o, fatty
tissue 90o).
7.1.14 Move right hand into position to direct plunger without aspirating.
7.1.15 Firmly push plunger down as far as it will go.
7.1.16 After injection, withdraw the needle gently at the same angle at which it
entered
releasing skin roll upon withdrawal of needle.
7.1.17 Press an alcohol pad to the site for 6-10 seconds. Do not rub or massage the
area and
instruct patient not to do the same.
7.1.18 Place patient in comfortable position.
212
7.1.19 Dispose syringe and needle in the sharp container.
7.1.20 Wash hands.
7.1.21 Observe patient for abnormality and notify the treating doctor, if any.
Republic of
Yemen 48Modern
48
Hospital
213
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
215
Republic of
Yemen 48Modern
4 POLICIES:
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: High Risk Medications
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines and
precautionary
measures in the administration of medications that are considered high-risk or
dangerous.
1 DEFINITIONS:
1.1 High-Risk Medications
1.1.1 According to the Drug drugs with low therapeutic index and limited range of
safety;
borderline effect as therapeutic or toxic.
1.1.2 According to the Situation drugs administered during critical or high-risk
situations.
1.1.2.1 cardiac arrest
1.1.2.2 respiratory failure
1.1.2.3 convulsions
1.1.2.4 bronchial asthma
1.1.2.5 hypotension
1.1.2.6 bradycardia
1.1.2.7 hypertensive encephalopathy
1.1.2.8 hypoxia
1.1.2.9 acute coronary syndrome
2 PURPOSES:
2.1 To observe precautionary and safety measures in the administration of drugs
considered high
risks.
2.2 To ensure that the action of the drug does not cause harmful side effects.
3 EQUIPMENTS/SUPPLIES:
3.1 infusion pumps
3.2 syringe pumps
3.3 infusomat
3.4 perfusor syringe
3.5 perfusor tubing
3.6 extension set
3.7 cardiac monitor
3.8 syringes
3.9 needles
3.10alcohol swab
3.11peripheral cannula
3.12central cannula
3.13oximeter
3.14capnograph
3.15pressure gauge for arterial and CVP cannulae
4.1 All medications identified as high risks or dangerous via hospital policy should not be
administered by nurses alone.
216
Republic of
4.1.2
If nurses 48Modern
necessitate to administer the medication, he/she should be 48
under
the strict
Hospital
217
Republic of
supervision of the physician; or
Yemen
48Modern
48
4.1.3 For competent nurses, prior to administration, two (2) nurses, to prevent
commissionHospital
of
errors, should check and double-check with each other for dosage calculation of
the
medication; and both nurses sign.
4.1.4 Infusion pumps or perfusor syringe should be used when administering IV
high-risk
medications to ensure that it is regulated and delivered to the patient
accurately.
4.1.5 All high-risk medications should be labeled.
4.2 Basic safety precautions in medication preparation and administration according to
the hospital
policy should be observed at all times.
4.2.1 Medication storage areas should be locked at all times except when nurses are
preparing
medications.
4.2.2 Medication preparation area should be well lit, clean, and located preferably in
a closed
area to avoid distraction.
4.3 Patients vital signs should be monitored frequently to observe for any adverse
effects of the
drug.
4.3.1 heart rate
4.3.2 respiration
4.3.3 temperature
4.3.4 oxygen saturation
4.3.5 blood pressure, either invasive or non-invasive
4.4 For any manifestation of adverse reaction of the drug, refer to the physician
immediately.
4.5 Medications classified as high risk according to the drug, include the following:
4.5.1 cardiac drugs (examples and has to take precautions)
4.5.1.1 inotropics
4.5.1.1.1 obtain baseline data ( heart rate and rhythm, blood pressure, and
electrolytes)
4.5.1.1.2 take apical-radial pulse for 1 minute
4.5.1.1.2.1 for sudden increase or decrease in pulse rate, pulse deficit,
irregular
beats, and regularization of previously irregular rhythm, check
blood
pressure and obtain a 12-lead ECG.
4.5.1.1.3 monitor for digoxin level 8 hours after the last dose
4.5.1.2 antiarrythmics
4.5.1.2.1 connect patient to the cardiac monitor.
4.5.1.3 antianginals
4.5.1.3.1 avoid mixing with other drugs
4.5.1.3.2 check apical pulse rate before administration
4.5.1.3.2.1 withhold for pulse rate slower than 60beats/minute
4.5.1.3.3 monitor for blood pressure frequently
4.5.1.4 antihypertensives/vasodilators
4.5.1.4.1 frequent monitoring of blood pressure
4.5.2 central nervous system drugs
4.5.2.1 anticonvulsants
4.5.2.1.1 should not be administered for pregnant women
4.5.2.1.2 monitor periodic liver, renal, and hematopoietic functions
4.5.3 respiratory tract drugs as examples
4.5.3.1 bronchodilators
4.5.3.1.1 never administer without dilution
4.5.3.1.1.1 discard unused diluted solution after 24 hours
4.5.3.1.2 do not mix with other drugs
218
4.5.3.1.3 monitor responses to the drug by maintaining the oxygen saturation
4.5.3.2 oxygen therapy
4.5.3.2.1 check oxygen saturation level with the use of an oximeter
Republic of
5 PROCEDURES:
Yemen
48Modern
5.1 Verify
doctors
orders.
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
220
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Hot Compress
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the procedure in hot
compress
application.
1 DEFINITION:
1.1 Hot compress - a procedure/measure of applying external heat to keep body surface
or area of
the body warm rendering therapeutic effect. This dilates blood vessels and increases
the blood
supply.
2 PURPOSES:
2.1 To decrease pain and muscle tone.
2.2 To promote healing and suppuration.
2.3 To relieve deep congestion.
2.4 To soften the exudates.
2.5 To provide warmth and stimulate peristalis.
3 CONTRAINDICATIONS:
3.1 Impaired kidney, heart and lung functions
3.2 Acutely inflamed areas i.e. appendicitis and tooth abscess
3.3 Paralysis, weak and debilitated patients
3.4 Open wounds as bleeding may take place
3.5 Edema, headache, high temperature
3.6 Metabolic disorders i.e. diabetis, arteriosclerosis due to increased hazards of tissue
damage
3.7 Very young and old patients because of risk of tissue burn.
4 EQUIPMENTS/SUPPLIES:
4.1 Hot water bag with cover
4.2 Towel (optional)
4.3 Hot water
4.4 Thermometer
4.5 Sphygmomanometer and Stethoscope
5 POLICIES:
5.1 Obtain doctors order.
5.2 Ensure hot water bag is tightly covered without leak.
PROCEDURES:
6
5.3
Neverthe
apply
hot water
bag and
directly
to the
6.1
Check
physicians
order
purpose
of skin.
the treatment.
5.4
Application
should
not exceed
6.2
Wash
hands and
provide
privacy.more than 20-30 minutes.
6.3 Assemble the equipment near bedside.
6.4 Explain the procedure.
6.5 Obtain the baseline vital signs.
6.6 Check the skin for lotion/ointment. Remove, if present.
6.7 Instruct the patient not to lie on the bag.
6.8 Fill the bag only two third (2/3) full, expel air from the bag. Secure the cap, and
turn upside
down to check any leak.
6.9 Cover the bag with protective towel and apply on the affected area.
221
Republic of
Yemen 48Modern
48
Hospital
6.10Assess tolerance. Examine the area at time intervals. Discontinue if skin turns red.
6.11Aftercare of hot water bag. Empty bag, wash with soap. Rinse well and hang to
dry. Keep in
proper place.
6.12Document date and time, site applied and patients reaction.
6.13Charge the supplies used.
222
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Wards Policies and Procedures
Title: Infection Control Guidelines
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
4.1.5 Enforce strict visiting hours for isolation cases with proper precautions for
visitors.
4.2 Unit Staff:
4.2.1 Adheres to infection control policies and procedures for the safe practice for
the staff as
well as the patient.
4.2.2 Observes aseptic technique for all ward procedures.
4.2.2.1 Complies with the nursing service policy on the cleaning and storage of
equipment.
4.2.3 Submits for an annual screening for HBV, HCV, and HIV.
4.2.3.1 Staff records should be maintained in the staff file.
4.2.3.2 Vaccination of the health care workers according to Infection Control APP
IC-9.
4.2.4 Any needle stick injuries should be reported immediately for their
management and the
need for post-exposure prophylaxis.
4.2.5 Proper instructions should be given to the patient or relatives about the selfcollected
specimen (e. g. urine collection).
4.3 Patient:
4.3.1 Adheres to infection control policies and procedures in the unit.
4.3.2 Follow proper instructions in the collection of specimen.
225
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Instillation of Ear Drops
Republic of
Yemen 48Modern
48
Hospital
227
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Instillation of Eye Drops/Ointment
Republic of
Yemen 48Modern
48
Hospital
229
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Republic of
Yemen 48Modern
48
Hospital
231
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Insulin Therapy
232
Republic of
Yemen 48Modern
48
Hospital
233
Republic of
Yemen 48Modern
Hospital
48
Instruct patient to bring hard candies and pack of sugar with him/her
always.
6.1.5
Patient and relatives must be aware of the signs and symptoms of insulin
6.1.6
reaction and the
proper intervention.
6.2 Wear identification bracelet or necklace. Carry more detailed information about
insulin in the
wallet.
6.3 Preparation of insulin.
6.3.1 Avoid injection of cold insulin. It can lead to lipodystrophy, reduced rate of
absorption
and local reactions.
6.3.2 Examine vial before preparing dose. Do not use solutions if discolored or
presence of
precipitates is noted.
6.3.3 Insulin should not be mixed unless prescribed by physician. In general, regular
insulin is
drawn up into syringe first to avoid contaminating the bottle with the second
insulin.
6.3.4 Insulin is generally administered 15-30 minutes before a meal so that peak
action will
coincide with postprandial hyperglycemia.
6.3.5 Allow approximately 1 inch. between injection sites and avoid reuse of a site
for 6-8
weeks if possible. Maintain an injection record or chart to assure systematic
site rotation.
6.4 Hypoglycemic reaction is an emergency situation, since prolonged hypoglycemia
can cause
irreversible brain damage. Monitor early signs and symptoms:
6.4.1 sweating
6.4.2 tremor
6.4.3 pallor
6.4.4 tachycardia
6.4.5 palpitation
6.4.6 nervousness
6.4.7 headache & confusion
6.5 Exercise and delayed meals decrease the need for insulin, whereas illness and
emotional stress
increase the need for insulin.
6.6 If patient is engaged in active sports, it is suggested that injection of insulin be
made into the
abdomen rather than into a muscle that will be heavily taxed, since this may speed
up insulin
absorption.
6.7 Presence of acetone without sugar usually signifies insufficient carbohydrate intake.
Acetone
with sugar may indicate onset of ketoacidosis. Notify physician promptly.
6.8 Hypoglycemic reaction is sometimes the first indication of pregnancy in the diabetic
woman.
Patient should report promptly to physician.
6.9 The nurse should know when hypoglycemia is most likely to occur with the type of
insulin that is
being used.
6.10Exercise on a regular basis should be encouraged to diabetic patients because this
234
promotes the
utilization of carbohydrates and enhance the action of insulin.
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Intravenous Cannula Insertion
235
difficult to
visualize and stabilize.
5.5.3.1.1 Gauge 22 - 16 cannula can be used.
5.5.3.1.2 Excellent for a confused patient because her clothing may cover it
and keep
her from noticing it.
5.5.3.2 The accessory cephalic veins - branching off the cephalic vein are located
on the top
of the forearm.
5.5.3.2.1 Gauge 22 - 18 cannula can be used.
5.5.3.3 Medial veins of the forearm - originate in the palm of the hand, extend
along the
underside of the arm, and empty into the basilic vein or median cubital vein.
5.5.3.3.1 Gauge 24 - 20 cannula can be used.
5.5.3.4 Median veins - cephalic, cubital and basilic-lie in the antecubital fossa
generally
used to draw blood and to place a midline or peripherally inserted central
catheter.
5.5.3.5 Basilic vein - lies along the medial (little finger) side of the arm.
5.5.3.6 Cephalic Vein - lying along the lateral (thumb) side of the arm, is large and
easy to
access. An excellent choice for infusing chemically irritating solutions.
5.5.3.7 Metacarpal and Dorsal Veins - on top of the hand are good sites to begin
IV therapy
easily visualized.
5.6 Apply tourniquet 4-6 inches above the chosen site, ensure that distal pulse is still
palpable.
5.7 Prepare the site by cleaning with alcohol swab.
5.8 Position the cannula 45 degrees angle to the skin of puncture site and insert
directly to the
selected vein.
5.9 Upon visualization of back flow, lower the cannula almost parallel to the skin and
advance it
slightly to ensure the cannula tip is in the lumen of the vein. While immobilizing the
vein,
advance the cannula completely.
5.10Place a protective pad or sponge under the catheter hub to catch any blood when
stylet is remove.
5.11Release the tourniquet, apply digital pressure beyond the cannula tip, stabilize the
hub.
5.12Remove stylet and flush the cannula with distilled water and NSS, apply
transparent dressing to
visualize insertion site. Label IV dressing the date and time of insertion.
5.13Administer IV meds as ordered or attached the IV line and start infusion at slow
rate.
5.14Use armboard, if necessary, to stabilize the limb.
5.15Dispose all supplies used, remove gloves and wash hands. Dispose all sharps in
sharps container
and contaminated materials in yellow bag.
5.16Check the site frequently for infiltration, phlebitis, bruising, pain and redness. If
observed,
remove cannula immediately and reinsert.
5.17Document the following:
5.17.1 Date and time of insertion
5.17.2 Site of insertion
5.17.3 Size or gauge of cannula
5.17.4 Medications given or IV fluid infused
236
5.17.5 Any observations made
5.17.6 Interventions made in case complication arise
5.18Variation: Inserting a Butterfly (Winged-Tip) Needle
5.18.1 Hold the needle, pointed in the direction of the blood flow, at a 30- degree
angle, with the
SPECIAL CONSIDERATIONS:
6.1 A vein that is suitable for venipuncture should feel round, firm, elastic and engorged
- not hard,
bumpy or flat.
Republic
of and thumb maybe easily visible when tourniquet is placed;
6.2 Veins
in the fingers
however,
they 48Modern
Yemen
48
dont make good sites for infusion. They have smaller diameter which allows little or
Hospital
no blood
flow around catheter. The motion of the finger can lead to infiltration and
subsequently tissue
damage.
6.3 Most adults have many venipuncture sites or both sides of the forearm, using those
5.18.2
veins
is Once the needle is through the skin, lower the needle so that it is almost
parallel
with
theoptions for short term IV therapy because hand and arm mobility are not
usually
good
skin.
restricted.
5.18.3
When blood
backbe
into
the needle,
insert
the needle
to an
itsobese
hub.
6.4
A patients
weightflows
can also
a factor
in the tubing,
choice of
forearm
veins. In
5.18.4 Release the tourniquet, attach the infusion, and initiate flow as quickly as
patient,
possible.
example, you may not be able to see vein in the forearm. You may be able to palpate
5.19Securing
a Butterfly Needle
heavy
vein
5.19.1
Tape the
needle securely by the crisscross (chevron) method.
by knowing
the butterfly
typical locations.
5.19.2
small gauzefossa
square
under
the
needle, if
6.5
VeinsPlace
in thea antecubital
and
above
shouldnt
berequired.
used routinely for insertion of
5.20Charge the procedure and supplies used.
peripheral
6
catheter. These sites may limit the patients range of motion and interfere with blood
sample and
prevent the use of this vein for midline and PICC (Percutaneous Implanted Cardiac
Catheter)
insertion.
6.6 Starting to a distal site and making subsequent venipunctures proximal to the
previous site is
crucial. When a complication develops at proximal site, you wont be able to use
veins distal to
this site because the fluids or medication will infuse into the damaged site
compounding the
problem.
6.7 Use veins of the palm side or volar aspect of the wrist only if absolutely necessary.
The radial
nerve is very superficial here, and damage to the vein can cause severe pain in some
patients.
6.8 Common reasons for problems during venipuncture:
6.8.1 Improper tourniquet placement - too high, too low, too tight or too loose
(causing
insufficient engorgement).
6.8.2 Failure to release tourniquet promptly when vein is sufficiently cannulated.
intravascular
pressure can cause bleeding outside the vein.
6.8.3 A tentative stop and start technique - often a problem with beginners who
lacks
confidence. A tentative approach can injure the vein causing bruising.
6.8.4 In adequate vein stretching, allowing the stylet to push the vein aside.
6.8.5 Failure to recognize the cannula has gone through the opposite vein wall (as
indicated by
diminished blood return).
6.8.6 Stopping to soon after insertion, so only the stylet - not the cannula enter the
lumen.
6.8.7 Inserting the cannula too deep, below the vein. This is evident when the
cannula wont
move freely because it is embedded in fascia or muscle. The patient may also
complain of
severe discomfort.
6.8.8 Failure to penetrate the vein wall because of improper insertion angle (too
steep or not
steep enough), causing the cannula to ride on top of or below the vein.
6.9 Hematoma formation and leaking from insertion site are problems that might
require stopping of
venipuncture procedure. These problems 237
occur most commonly in the elderly, who
have fragile
vein, and in infants, who have very small ones.
6.10Each nurse should make only two attempts of cannula insertion and if still
unsuccessful get the
Republic of
Yemen 48Modern
48
Hospital
238
Republic of
Yemen 48Modern
Standard formula
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Intravenous Fluid Therapy
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the procedure during
intravenous fluid
therapy.
1 DEFINITION:
1.1 Intravenous Fluid Therapy
1.1.1 Introduction of fluid into the body through a vein by gravity.
1.1.2 Means of delivering larger volumes of fluids that could be administered
conveniently by
infusion.
1.2 Principles of Intravenous Fluid Therapy
1.2.1 Tissue cells are surrounded by semi-permeable membrane.
1.2.2 Osmotic pressure is the pulling pressure demonstrated when water moves
from an area
of weaker concentration to stronger concentration of solute. The end result is
dilution of
and equilibrium of intracellular and extracellular compartments.
1.2.3 Extracellular compartment fluids primarily include plasma and interstitial fluid
(are fluids
that surround the cell).
1.3 Types of IV solutions
1.3.1 Isotonic Solution - total electrolyte content is approximately 310 mEq/L. Total
osmolality (the number of particles per unit volume of solution) is close to that of
extracellular fluids and do not cause red blood cells to shrink. Example is .9 NaCl
or NSS.
1.3.2 Hypotonic Solution - total electrolyte content is less than 250 mEq/L. Purposes
of
hypotonic solutions are to replace cellular fluid and to provide force water for
excretion of
body wastes, cells will then expand or swell. Examples are D 5% W and .45% NSS.
1.3.3 Hypertonic Solution - total electrolyte content exceeds 375 mEq/L.
administration of this
fluid increases the solute concentration of plasma, drawing water out of the cells
and into
the extracellular compartment to restore osmotic equilibrium causing cells to
shrink.
Example are D10% W, D5 NSS and D5 LR.
1.4 Formula for computation of IV Flow Rate
FLOW RATE (gtt/min = volume (ml) x drop factor (gtt/ml)
time in minutes
Example - Infuse 500ml of D5W over 5 hours with IV set delivers 15 gtt/ml.
= 500ml x 15gtt/ml
5hr (60min./hr)
= 7500gtt = 25gtt/min.
239
Republic of
300min
Yemen 48Modern
PURPOSES:
48
2.1 To correct hypovolemia,
disturbances of osmolarity or acid-base imbalance.
Hospital
240
Republic of
Yemen 48Modern
Hospital
48
3.2 IV set
3.3 IV pole
3.4 Disposable gloves
3.5 IV tray (optional)
3.5.1 IV cannula of different sizes
3.5.2 Syringe 5cc
3.5.3 Needle
3.5.4 Transparent dressing
3.5.5 Alcohol swab and dressing
3.5.6 Adhesive tape and tourniquet
3.5.7 10cc of Distilled water or NSS solution
3.5.8 Underpad
3.5.9 Armboard or splint if necessary
4
POLICIES:
4.1 Physicians order should be checked prior to preparation of IV fluid for infusion.
4.2 IV tubing should be changed every 48 hours.
4.3 IV fluid should not hang more than 24 hours.
4.4 Every IV fluid should have label, which include flow rate, additives, date, starting
and finishing
time.
5
4.5 IV Fluid should be recorded in the IV Fluid Therapy Sheet.
PREPARATIONS:
5.1 Assess:
5.1.1 Vital signs for baseline data
5.1.2 Skin turgor
5.1.3 Allergy to tape or iodine
5.1.4 Bleeding tendencies
5.1.5 Disease or injury to extremities
5.1.6 Status of veins to determine appropriate venipuncture site
5.2 Consider:
5.2.1 How long the patient is likely to have the IV
5.2.2 What kinds of fluids will be infused
5.2.3 What medications the patient will be receiving or is likely to receive
5.3 Assemble equipment and supplies.
5.4 Unless initiating IV therapy is urgent, provide any scheduled care before
establishing the infusion
to minimize movement of the affected limb during the procedure.
5.5 Make sure that the clients clothing or gown can be removed over the IV apparatus if
necessary.
6
PROCEDURES:
6.1 Starting an IV Infusion
6.1.1 Explain to the client what you are going to do, why it is necessary, and how she
can
cooperate.
6.1.2 Wash hands and observe other appropriate infection control procedures.
6.1.3 Provide for client privacy.
6.1.4 Open and prepare the infusion set.
6.1.4.1 Remove tubing from the container and straighten it out.
6.1.4.2 Slide the tubing clamp along the tubing until it is just below the drip
chamber to
facilitate its access.
6.1.4.3 Close the clamp.
6.1.4.4 Leave the ends of the tubing covered with the plastic caps until the
infusion is
started.
241
6.1.5 Spike the solution container.
6.1.5.1 Remove the protective cover from the entry site of the bag.
6.1.5.2 Remove the cap from the spike, and insert the spike into the insertion
site of the bag
or bottle.
6.1.5.3 Follow manufacturers instructions.
of label to the solution container if a medication was added.
6.1.6Republic
Apply a medication
6.1.7
Apply a48Modern
timing label on the solution container.
Yemen
48
6.1.7.1 The timing label may be applied at the time the infusion is started.
Hospital
Republic of
Yemen 48Modern
Hospital
48
venipuncture site.
6.1.15.7Release the tourniquet.
6.1.15.8Remove the protective cap from the distal end of the tubing, and hold it
ready to
attach to the catheter, maintaining the sterility of the end.
6.1.15.9Carefully remove the needle, engage the needle safety device, and attach
the end of
the infusion tubing to the catheter hub.
6.1.15.10Initiate the infusion.
6.1.16 Tape the catheter.
6.1.16.1Tape the catheter by the U method.
6.1.16.2Using three strips of adhesive tape, each about 7.5 cm (3 in) long:
6.1.16.3Place one strip, sticky-side up, under the catheters hub.
6.1.16.4Fold each end over so that the sticky sides are against the skin.
6.1.16.5Place second strip, sticky-side down, over catheter hub.
6.1.16.6Place third strip, sticky-side down, over tubing hub.
6.1.17 Dress and label the venipuncture site and tubing.
6.1.17.1Cover venipuncture site according to policy.
6.1.17.2Remove soiled gloves and discard appropriately.
6.1.17.3Loop the tubing and secure it with tape.
6.1.17.4Label the dressing with the date and time of insertion, type and gauge of
needle or
catheter used, and your initials.
6.1.18 Ensure appropriate infusion flow.
6.1.18.1Apply a padded arm board to splint the joint, as needed.
6.1.18.2Adjust the infusion rate of flow according to the order.
6.1.19 Label the IV tubing.
6.1.19.1Label the tubing with the date and time of attachment and your initials.
6.1.20 Document relevant data. Record:
6.1.20.1The time of the start of the infusion
6.1.20.2The flow rate of the transfusion
6.1.20.3The date and time of the venipuncture
6.1.20.4The amount and type of solution used, including any additives
6.1.20.5The type and gauge of the needle or catheter
6.1.20.6The venipuncture site
6.1.20.7The clients general response
6.2 Monitoring an IV Infusion
6.2.1 Ensure that the correct solution is being infused.
6.2.1.1 If the solution in incorrect, slow the rate of flow to a minimum to maintain
the
patency of the catheter.
6.2.1.2 Change the solution to the correct one. Document and report the error
according to
agency protocol.
6.2.2 Observe the rate of flow every hour.
6.2.2.1 Compare the rate of flow regularlyfor example, every houragainst the
infusion
schedule.
6.2.2.2 If the rate is too fast, slow it so that the infusion will be completed at the
planned
time.
6.2.2.3 If the rate is too slow, check agency practice.
6.2.2.4 If the rate of flow is 150 mL/h or more, check the rate of flow more
frequentlyfor
243
example, every 1530 minutes.
6.2.3 Inspect the patency of the IV tubing and needle.
6.2.3.1 Observe the position of the solution container.
6.2.3.2 If it is less than 1 m (3 ft) above the IV site, readjust it to the correct
height of the
pole.
6.2.3.3 Observe the drip chamber. If it is less than half full, squeeze the chamber
Republic
of
to allow
the
correct
amount of fluid to flow in.
Yemen
48Modern
48
6.2.3.4 Open the drip regulator, and observe for a rapid flow of fluid from the
Hospital
solution
container into the drip chamber.
6.2.3.5 Then partially close the drip regulator to reestablish the prescribed rate
of flow.
6.2.3.6 Inspect the tubing for pinches, kinks, or obstructions to flow.
6.2.3.7 Arrange the tubing so that it is lightly coiled and under no pressure.
6.2.3.8 Observe the position of the tubing. If it is dangling below the
venipuncture, coil it
carefully on the surface of the bed.
6.2.3.9 Lower the solution container below the level of the infusion site, and
observe for a
return flow of blood from the vein.
6.2.3.10Determine whether the bevel of the catheter is blocked against the wall
of the vein.
6.2.3.11 If there is leakage, locate the source.
6.2.3.12 If the leak is at the catheter connection, tighten the tubing into the
catheter. If the
leak cannot be stopped, slow the infusion as much as possible without
stopping it,
and replace the tubing with a new sterile set.
6.2.3.13Estimate the amount of solution lost, if it was substantial.
6.2.4 Inspect the insertion site for fluid infiltration.
6.2.4.1 Assess for infiltration at IV site:
6.2.4.1.1 Swelling
6.2.4.1.2 Coolness
6.2.4.1.3 Pallor
6.2.4.1.4 Discomfort
6.2.4.1.5 If an infiltration is present, stop the infusion and remove the
catheter.
6.2.4.1.6 Restart the infusion at another site.
6.2.4.1.7 Apply a warm compress to the site of the infiltration.
6.2.4.2 If infiltration is not evident but the infusion is not flowing, determine
whether the
needle is dislodged from the vein.
6.2.4.2.1 Gently pinch the IV tubing adjacent to the needle site.
6.2.4.2.2 Use a sterile syringe of saline to withdraw fluid from the port near
the
venipuncture site.
6.2.4.2.3 If blood does not return, discontinue the intravenous solution.
6.2.4.3 Inspect the insertion site for phlebitis.
6.2.4.3.1 Inspect and palpate the site at least every 8 hours.
6.2.4.3.2 If phlebitis is detected, discontinue the infusion, and apply warm
compresses
to the venipuncture site.
6.2.4.3.3 Do not use this injured vein for further infusions.
6.2.4.4 Inspect the intravenous site for bleeding.
6.2.4.4.1 Oozing or bleeding into the surrounding tissues can occur while the
infusion
is flowing freely, but is more likely to occur after the needle has been
removed from the vein.
6.2.4.4.2 Observation of the venipuncture site is extremely important for
clients who
bleed readily, such as those receiving anticoagulants.
6.2.4.5 Teach the client ways to maintain the infusion system. For example:
6.2.4.5.1 Avoid sudden twisting or turning movements of the arm with the
needle or
catheter.
6.2.4.5.2 Avoid stretching or placing 244
tension on the tubing.
6.2.4.5.3 Try to keep the tubing from dangling below the level of the needle.
6.2.4.5.4 Instruct client to notify a nurse if:
6.2.4.5.4.1 The flow rate suddenly changes or the solution stops dripping.
Republic of
6.2.4.5.4.2 The solution container is nearly empty.
Yemen
48Modern
6.2.4.5.4.3 There is blood in the IV tubing.
48
Hospital
6.4.6.2 Remove the protective tubing cap and, maintaining sterility, insert the
tubing end
securely into the needle hub.
6.4.6.3 Twist it to secure it.
Republic
ofclamp to start the solution flowing.
6.4.6.4
Open the
6.4.7
Remove48Modern
the tape securing the needle or catheter.
Yemen
48
6.4.7.1 When removing this tape, stabilize the needle or catheter hub with one
Hospital
hand.
6.4.8 Clean the IV site.
6.4.8.1 Start with adhesive remover to remove adhesive residue.
6.4.8.2 Then, using chlorhexidine swabs or alcohol and povidone-iodine swabs,
clean the
site, beginning at the catheter or needle and cleaning outward in a 2-inch
diameter.
6.4.9 Retape the needle or catheter.
6.4.9.1 For a butterfly needle, apply strips of tape to the wings of the butterfly
using the
crisscross (chevron) method.
6.4.9.2 For a catheter; apply the tape using the U method.
6.4.10 Apply antiseptic ointment or solution, if indicated, and apply the dressing.
6.4.10.1Place povidone-iodine ointment or solution at the entry site, in
accordance with
agency protocol.
6.4.10.2Apply a sterile gauze or transparent dressing over the site.
6.4.10.3Remove gloves.
6.4.11 Label the dressing, and secure IV tubing.
6.4.11.1Place the date and time of the dressing change and your initials either on
the label
provided or directly over the top of the dressing.
6.4.11.2 Secure IV tubing with additional tape, as required.
6.4.11.3Regulate the rate of flow of the solution according to the order on the
chart.
6.4.12 Document all relevant information.
6.4.12.1Record the change of the solution container, tubing, and/or dressing in
the
appropriate place on the clients chart.
6.4.12.2Record the fluid intake, according to agency practice..
6.4.12.3Record your assessments.
6.5 Changing an IV Catheter to an Intermittent Infusion Lock
6.5.1 Assess the IV site (if visible) and determine the patency of the catheter.
6.5.1.1 If the catheter is not fully patent, or if there is evidence of phlebitis or
infiltration,
discontinue the catheter and establish a new IV site.
6.5.1.2 Expose the IV catheter hub and loosen any tape that is holding the IV
tubing in place
or that will interfere with insertion of the intermittent infusion plug into the
catheter.
6.5.1.3 Clamp the IV tubing to stop the flow of IV fluid.
6.5.1.4 Open the gauze pad and place it under the IV catheter hub.
6.5.1.5 Open the alcohol wipe and intermittent infusion plug, leaving the plug in
its sterile
package.
6.5.2 Remove the IV tubing and insert the intermittent infusion plug into the IV
catheter.
6.5.2.1 Don clean gloves.
6.5.2.2 Stabilize the IV catheter with your nondominant hand and use the little
finger to
place slight pressure on the vein above the end of the catheter.
6.5.2.3 Twist the IV tubing adapter to loosen it from the IV catheter and remove it,
placing
the end of the tubing in a clean emesis basin.
6.5.2.4 Pick up the intermittent infusion plug from its package and remove the
protective
sleeve from the male adapter, maintaining its sterility.
246 twisting it to seat it firmly or engage
6.5.2.5 Insert the plug into the IV catheter,
the Luer
lock.
6.5.3 Instill saline or heparin solution per agency policy.
6.5.4 Tape the intermittent infusion plug in place using a chevron or U method.
Republic of
Yemen 48Modern
48
Hospital
6.5.5.1 Avoid manipulating the catheter or infusion plug, and protect it from
catching on
clothing or bedding.
6.5.5.2 Cover the site with an occlusive dressing when showering; avoid
immersing the site.
6.5.5.3 Flush the catheter with saline or heparin solution as directed.
6.5.5.4 Notify the nurse or primary care provider if the plug or catheter comes
out, if the site
becomes red, inflamed, or painful, or if any drainage or bleeding occurs at
the site.
6.5.6 Document all relevant information.
7
SPECIAL CONSIDERATIONS:
7.1 Uses and Precautions of Common Types of Infusions
7.1.1 Dextrose 5% water
7.1.1.1 Used to replace water losses, supply some caloric intake, administer as
carrying
solution for numerous medications or function as a slow keep-vein-open
infusion.
7.1.1.2 Should not be used as concurrent solution infusion with blood or blood
components.
Cautious use in patients who are hyponatremic and has syndrome of
inappropriate
antidiuretic hormone release.
7.1.2 Normal Saline
7.1.2.1 Used to replace saline losses, administer with blood components or treat
patients in
hemodynamic shock.
7.1.2.2 Cautious use in patients with heart failure and renal failure.
7.1.3 Lactated Ringers
7.1.3.1 Used to replace isotonic fluid losses, replenish specific electrolyte losses
and
moderate metabolic acidosis.
8
7.2 Because isotonic solutions expand the intravascular space, patients with
hypertension and
congestive heart failure should be monitored for signs of fluid overload.
7.3 Excessive infusions of hypotonic solutions can lead to intravascular fluid depletion,
decreased
blood pressure, cellular edema and cell damage.
7.4 Rapid administration or large quantity of hypertonic solution can cause
extracellular volume
excess and precipitate circulatory overload and dehydration.
REFERENCE:
8.1 Fundamentals of Nursing concepts, process, and practice 7 th Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
247
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
CONTENTS: This General Ward policy and procedure serves as a guideline in implementing
seizure
precautions.
1 DEFINITION:
1.1 Seizure a sudden onset of a convulsion or other paroxysmal motor or sensory
activity.
1.2 Seizure Precautions safety measures taken by the nurse to protect clients from
injury should
they have a seizure.
2 PURPOSES:
2.1 To prevent occurrence of seizure.
2.2 To promote patient safety.
3 POLICIES:
3.1 Nurse should perform appropriate assessment and identify patients subject to seizure
precautions.
4 EQUIPMENT:
4.1 Blankets or other linens to pad side rails
4.2 Oral suction equipment
4.3 Oral airway or padded tongue depressor
4.4 Oxygen equipment
5 PREPARATIONS:
PROCEDURES:
5.1 Assess:
6.1 5.1.1
Explain
to theof
client
what you are going to do, why it is necessary, and how he can
History
seizures
6
cooperate.
5.1.2 Last seizure event
6.2 5.1.3
Wash Assemble
hands andequipment
observe appropriate
infection control procedures.
and supplies:
6.3 If the client is actively seizing, apply clean gloves in preparation for performing
respiratory care
measures.
6.4 Provide for client privacy.
6.5 Pad the bed.
6.6 Secure blankets or other linens around the head, foot, and side rails of the bed.
6.7 Place oral suction equipment in place, and test to confirm that it is functional.
6.8 Tape the tongue depressor that has been wrapped with gauze padding or an oral
airway within
reach of the head of the bed.
6.9 If a seizure occurs:
6.9.1 Remain with the client and call for assistance, if needed.
6.9.2 If the client is not in bed, assist client to the floor and protect the head in your
lap or on a
pillow.
6.9.3 According to policy, insert the airway or tongue depressor between the clients
upper and
lower teeth.
6.9.4 Apply oxygen by mask.
6.9.5 Turn the client to a lateral position, if 248
possible.
6.9.6 Time the seizure duration.
6.9.7 Move items in the environment to ensure the client does not experience an
injury.
Republic of
Yemen 48Modern
48
Hospital
Observe the progression of the seizure, noting the sequence and type of6.9.8
limb
6.9.9
involvement.
6.9.10
Observe skin color.
6.9.11
When the seizure allows, check pulse and respirations.
6.9.12
Administer ordered anticonvulsant medications.
Use equipment to suction the oral airway if the client vomits or has excessive oral
secretions.
6.9.13 When the seizure has finished, assist client to a comfortable position.
6.9.14 Provide hygiene as necessary. Allow the client to verbalize feelings about the
seizure.
REFERENCE:
6.10When the seizure
has subsided, document pertinent information in the client 7
7.1
Fundamentals of Nursing concepts, process, and practice
record.
7th Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
249
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Management of Burns
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the management of burns.
1 DEFINITION:
1.1 Burns - are a form of traumatic injury caused by transfer of energy from a heat source
to the
body.
1.2 Types of Burns
1.2.1 Thermal burns - results from exposure to an explosive flash or flame or from
contact
with a hot object, liquid, semi-liquid, or semi-solid material. This can be sustained
also
from fire or explosive accidents.
1.2.2 Electrical burns - results from the heat that the electric current generates as it
passes
through the tissues of the body. Sometimes classified under thermal burns.
1.2.3 Chemical burns - results from tissue or skin contact with strong acid, alkaline or
organic
compounds.
1.2.4 Radiation - results from exposure to radioactive source.
1.3 Classification of Burns according to the Depth of Tissue Destruction.
1.4 Criteria for classifying the extent of burn injury.
1.5 Determination/Calculation of the percent or burns surface area.
1.5.1 Rule of Nines (Adult)
1.5.2 Lund and Browder Method (Infants and Children)
1.6 Phases of Major Burn Injury
1.6.1 Emergent (Resuscitative) phase - begins at the time of injury and concludes with
restoration of capillary permeability, typically 48-72 hours after the major burn
injury.
1.6.2 Acute Phase - begins when the person is hemodynamically stable, when capillary
permeability has been restored,
and when diuresis has begun. This phase begins
PURPOSES:
2
48-72
2.1 Emergent Phase
hours after injury and concludes
discharge
from
the acute care setting.
2.1.1with
To give
first aid
treatment.
1.7 Rehabilitative Phase - begins during
the
acute
hospital
stay,
after the patient
is
2.1.2 To prevent shock and respiratory
distress.
stable, and
2.1.3 To detect and treat concomitant injuries.
continues until efforts to promote,2.1.4
cosmesis
(a concern
in therapeutics, especially in
To stabilize
the patient.
surgical
2.1.5 To perform wound assessment and initial
operations, for the appearance
of the patient), function and adjustment are no longer
care.
required.
2.2 Acute Phase
2.2.1 To perform wound care and closure.
2.2.2 To maintain fluid and electrolyte balance.
2.2.3 To give nutritional support.
2.2.4 To prevent complications.
2.3 Rehabilitative Phase
2.3.1 To attain quality function and cosmesis.
2.3.2 To minimize
hypertrophic scar development
250
Republic of
Yemen 48Modern
48
Hospital
251
Republic of
Yemen 48Modern
Hospital
48
4.3 Patient should be kept alone in one room. In severe cases of burns, visitors are not
allowed.
4.4 Nurses who are handling the patient should wear complete apparel - gown, mask,
apron and foot
cover - when going inside the room.
4.5 All linens to be used should be sent to CSSD for sterilization. Linens must be
PROCEDURES:
changed
twice
5.1
Emergent
daily
preferably after wound dressing.
5.1.1 Assess
of the
burns.
Determine
the percentage
of Burns
Surface
Area. 5
4.6 Linens
shouldseverity
not touch
burned
areas. Bed
cradles should
be used
to support
5.1.2 Remove clothing.
the linens.
5.1.3 Check vital signs. Do ECG. Connect to multiparameters.
5.1.4 Assess the ABCs
5.1.4.1 Establish airway.
5.1.4.2 Ensure adequate breathing provide 100% oxygen through facemask for
conscious
patients and assist on endotracheal intubation or manual ventilation for
unconscious
patients.
5.1.4.3 Assess Circulation - monitor peripheral pulses.
5.1.5 Establish intravenous line access for immediate intravenous fluid resuscitation.
Extract
blood sample and send to laboratory for investigation.
5.1.6 Start fluid therapy as ordered:
5.1.6.1 Indications:
5.1.6.1.1 Adults with burns over/greater than 15% - 20 % of body surface area.
5.1.6.1.2 Children with burns involving more than 100% of body surface area.
5.1.6.1.3 Patients with electrical injury, the elderly, or anyone with cardiac or
pulmonary disease and compromised response to burn injury.
5.1.6.2 Guidelines and Formulas for fluid Replacement in Burn Patients (Refer to
Figure
110-4).
5.1.6.3 Monitor the following:
5.1.6.3.1 Level of Consciousness
5.1.6.3.2 Urine output. (Insert indwelling catheter)
5.1.6.3.3 Pulse
5.1.6.3.4 Arterial blood pressure
5.1.6.3.5 Cardiac filling pressures and cardiac index
5.1.6.3.6 Bowel sounds
5.1.6.3.7 Serum electrolytes and hematolegic studies
5.1.7 Keep patient NPO
5.1.8 Do wound care:
5.1.8.1 Chemical Burn
5.1.8.1.1 Immediately after admission, brush off any dry chemical.
5.1.8.1.2 Remove all clothing. It may retain the chemical and continue the
burning
process.
5.1.8.1.3 Do continuous irrigation with water to dilute and remove chemicals.
5.1.8.1.4 Do not use neutralizing agents.
5.1.8.2 Cutaneous Burns
5.1.8.2.1 Cleanse the wound using aseptic technique.
5.1.8.2.2 Debride the wound of all loose, nonviable skin and blisters.
5.1.8.2.3 Examine the wound after cleaning and debridement.
5.1.8.2.4 Apply topical wound treatment as prescribed. Either the exposure
method
252
or closed method of wound care should be used to apply topical
antimicrobial creams.
5.1.9 Check patients weight.
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
Hospital
48
5.2.8.5 Splint joints to maintain proper joint positioning and help prevent or
correct wound
contractures.
5.2.9 Help facilitate coping:
5.2.9.1 Assess patient for coping abilities, and previous successful coping
strategies.
5.2.9.2 Provide an atmosphere of acceptance, trust and caring. Communicate
your
accessibility to patient.
5.2.9.3 Help patient to identify new coping strategies.
5.2.9.4 Provide positive reinforcement when effective coping strategies are
utilized.
5.2.9.5 Encourage the involvement of family in the coping process if not
contraindicated to
patients condition.
5.2.10 Prevent complications such as:
5.2.10.1Congestive Heart Failure and Pulmonary Edema
5.2.10.2Sepsis
5.2.10.3Acute Respiratory Failure/Acute Respiratory Distress Syndrome.
5.2.10.4Visceral Damage
5.3 Rehabilitative Phase
5.3.1 Monitor and manage potential complications:
5.3.1.1 Contractures:
5.3.1.1.1 Work closely with physical therapist to identify physical therapy
needs.
5.3.1.2 Impaired Psychological Adaptation.
5.3.2 Promote Home and Community - Based Care
5.3.3 Give Health Education
5.3.3.1 Benefits of functional and cosmetic reconstruction
5.3.3.2 Assist patient in transition from dependence on the health team to
independence by
helping him develop methods of communicating his needs and functioning
abilities
to others.
5.3.3.3 Guide the patient in thinking positively about himself; promote ability to
redirect
others attention from the scarred body to the self within.
5.3.3.4 Demonstrate and explain wound care procedures to be continued after
discharge.
5.3.3.5 Observe for local signs of wound infection:
5.3.3.5.1 Increased redness of normal skin around burn area.
5.3.3.5.2 Increased cloudy yellow pus or drainage.
6
SPECIAL CONSIDERATIONS:
5.3.3.5.3 Increased pain, foul odor in burn area.
6.1 Inhalation injury results from the inhalation of toxic fumes, gases and particulate
5.3.3.5.4 Elevated body temperature.
matter present in
5.3.3.6 Instruct the patient measures to enhance comfort of healing skin:
smoke. Vapors may also cause inhalation injury.50-60% of fire deaths are secondary
5.3.3.6.1 Cleanse skin with mild soap and rinse well daily.
to
5.3.3.6.2 Wear clean clothing free of irritating dyes.
inhalation injury.
5.3.3.6.3 Take antipruritics as prescribed.
6.2 The following are types of pulmonary injury in burns:
5.3.3.6.4 Protect skin form further trauma including sunburn.
6.2.1 Carbon monoxide poisoning
5.3.3.7 Provide written instructions regarding all care required in discharge.
6.3 Smoke toxicity
6.3.1 Upper airway trauma
6.3.2 Restrictive pulmonary defects
254
6.4 Flexible bronchoscopy allows direct examination of the upper airways and is used
for early
medical diagnosis of inhalation injury.
Republic of
Yemen 48Modern
48
Hospital
6.5 Hydrotherapy is the bathing of burn patients in a tub or tank of water to facilitate
cleaning of the
burn area.
6.6 Skin grafting is indicated if burn wounds are deep or extensive and spontaneous reepithelialization is not possible. The purposes of skin grafting are:
6.6.1 to decrease the risk for infection
6.6.2 to prevent further loss of protein, fluid and electrolytes through the wound
6.6.3 to minimize heat loss through evaporation
255
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Management of Client for Electroconvulsive
Therapy (ECT)
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the management of client
during
electroconvulsive therapy (ECT).
1 DEFINITION:
1.1 Electroconvulsive Therapy (ECT) - a procedure performed by psychiatrist wherein a
very
small amount of electric current is delivered to the temporal area to stimulate a
seizure as
treatment.
2 PURPOSE:
2.1 For treating acute psychotic, suicidal depression or severe depression who are
refractory or cannot
tolerate medication.
3 EQUIPMENTS/SUPPLIES:
3.1 Sphygmomanometer
3.2 Stethoscope
3.3 IVAC machine/ IVAC cover
3.4 Kidney basin
3.5 Suction machine/Suction catheter
3.6 IV pole/O2 tank with O2 devices
3.7 For ER use:
3.7.1 Pulse oximeter
3.7.2 ECT machine
3.7.3 Electroencephalographic/ Electrocardiographic electrodes
3.7.4 Bite black
3.7.5 Sphygmomanometer cuff attached to multiparameter
4 POLICIES:
4.1 Ensure patients safety by observing fall precautions and aspiration precaution.
PROCEDURES:
5
4.2 Doctors order and consent should be obtained.
5.1
Night
Prior
to
Procedure
4.3 Infection control policy should be observed.
5.1.1 Verify doctors order and check for the signed consent.
5.1.2 Instruct or assist patient in shampooing hair to remove hair products that may
interfere
with conduction.
5.1.3 Administer any premeds a night prior to procedure, if there is any.
5.1.4 Keep the patient NPO from 12 midnight. Remove the tray or any food from the
room if
patient is alone.
5.2 Morning of the Procedure
5.2.1 Explain and remind the patient about the procedure to be done.
5.2.2 Assist the patient to change into hospital gown.
5.2.3 Ensure that patient is wearing the correct ID band.
5.2.4 Remove hairpins, hairnets or prosthesis like hearing aids, dentures, and
glasses if any.
256
5.2.5 Encourage the patient to void before the procedure.
5.2.6 Put patient on bed and kept in a comfortable position.
5.2.7 Check vital signs and record.
Republic of
Yemen 48Modern
48
Hospital
257
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Management of Foreign Body Airway Obstruction
Republic of
Yemen 48Modern
Hospital
48
5.3 Chest thrust with conscious patient standby or sitting - used only in advanced
stages of
pregnancy or in markedly obese person.
5.3.1 Stand behind the patient with arm under his axillae to encircle the patients
chest.
5.3.2 Place thumb side of your fist on middle of patients sternum taking care to
avoid xiphoid
process and rib cage margins.
5.3.3 Grasp your fist with the other hand and perform backward thrusts until the
foreign body
is expelled or patient becomes unconscious.
PROCEDURES:
5.4
Chest thrust(Infant)
with unconscious patient lying.
6.1
Back
blows
cheston
thrust
for conscious
5.4.1
Place
theand
patient
his back
and knee; infants.
close to the side of his body.
6.1.1
Holdthe
theheel
infant
face down,
resting
on the
forearm.
Support the infants head6
5.4.2
Place
of your
hand on
the lower
half
of the sternum.
byDeliver
firmly each chest thrust slowly and distinctly with the intent of relieving the
5.5
holding the jaw. Rest your forearm on your thigh to support the infant. Head
obstruction.
should be
lower than the trunk.
6.1.2 Deliver up to five back blows forcefully between the infants shoulder blades,
using the
heel of the hand.
6.1.3 After delivery the back blows, place your free hand on the infants back,
holding the
infants head. The infant is effectively sandwiched between your two hands and
arms.
One hand supports the head and neck jaw and chest while the other supports
the back.
6.1.4 Turn the infant while the head and neck one carefully position, draped on the
thigh. The
infants head should remain lower than the trunk.
6.1.5 Give up to five quick downward chest thrusts in the same location and manner
as chest
compressions two fingers placed on the lower half of the sternum
approximately one
fingers breadth below the nipples. Steps 6.1.1. - 6.1.5. should be repeated
until the
object is expelled or the infant loses consciousness.
6.2 If the victim is or becomes unconsciousness:
6.2.1 Open the infants airway. If the loss of consciousness is witnessed and foreign
body
obstruction is suspected, lift the chin using a tongue-jaw lift and if you see a
foreign
object, remove it with a finger sweep.
6.2.2 Attempt rescue breathing.
6.2.3 If the first attempt is unsuccessful, reposition the head and reattempt
ventilation.
6.2.4 If ventilation is unsuccessful, give five back blows and five chest thrusts.
6.2.5 Open the mouth using a tongue-jaw lift and remove the foreign object if seen.
7
SPECIAL CONSIDERATIONS:
6.2.6 Repeat steps 6.2.2. - 6.2.4. until ventilation is successful (chest uses)
7.1 Serious internal injury may result due to Heimlich maneuver such as:
6.3 Document the following:
7.1.1 Rupture or laceration of abdominal or thoracic viscera secondary to fractured
6.3.1 Date and time of the procedure.
ribs or
6.3.2 Patients activity prior to the onset of the obstruction.
sternum.
6.3.3 Appropriate length of time required to clean the airway.
7.1.2 The Heimlich maneuver should not be used in infants because of the risk of
6.3.4 Type and size of foreign body removed.
259
injury to
6.3.5 Vital signs afterward
abdominal organs especially the liver.
6.3.6 Any complications and the nursing action taken.
6.3.7 Tolerance to the procedure.
Republic of
Yemen 48Modern
48
Hospital
260
Republic of
Yemen 48Modern
Hospital
48
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Managing Patient With PCA Pump
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure serves as a guideline in the
management of patient
on Pain-Controlled Analgesia (PCA) Pump.
1
DEFINITION:
1.1 Pain Controlled Analgesia (PCA) a pain management technique that allows the
client to take
an active role in managing pain.
2
PURPOSES:
2.1 To relieve pain experienced by the patient under his/her
control.
2.2 To provide safe, consistent and effective pain
management.
POLICIES:
3
3.1 Nurse should assess the knowledge and skills of the patient on PCA pump using the
return
demonstration technique.
3.2 Pain assessment should be done every 30 minutes or extended every 2-4 hours
according to the
intensity of pain experienced by the patient.
EQUIPMENT:
4
4.1 Disposable gloves
4.2 IV start kit
4.3 IV catheter
4.4 Primary line IV tubing
4.5 Primary IV fluid (per orders)
4.6 PCA pump and appropriate tubing
4.7 Operational manual for specific pump to be
used
4.8 PCA flow sheet
4.9 Premixed medication in appropriate syringe
5
PREPARATIONS:
5.1 Assess:
5.1.1 Pain (intensity, location, presence of radiation, associated factors, precipitating
factors,
and alleviating factors)
5.1.2 Clients allergies
5.1.3 Baseline vital signs
5.1.4 Clients understanding of the pump
5.1.5 Assemble equipment and supplies
5.2 Determine:
5.2.1 Factors that may contraindicate
5.2.2 The amount of narcotic specified by the order
5.2.3 Bolus and continuous infusion dosage parameters
5.2.4 Type of primary fluid
5.2.5 Compatibility of the primary IV fluid and the PCA medication in the same line
5.3 Calculate:
5.3.1 The initial bolus dose based on the number
of milligrams of drug per milliliter of
261
fluid
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
6.15.1 Record the initiation of PCA, the dose setting, the doses received, pain
intensity, and all
assessments. See agency protocol.
7
REFERENCE:
7.1 Fundamentals of Nursing concepts, process, and practice
7th Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
263
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Measuring Fluid Intake and Output
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the procedure in the
measurements of
fluid intake and output.
1 DEFINITION:
1.1 Measuring Fluid Intake and Output - a continuous monitoring and recording of
patients fluid
intake and output to assess fluid and electrolyte balance on a 24 hours period.
1.1.1 Intake includes all fluids taken by oral, enteral and parenteral route.
1.1.1.1 Oral intake includes all liquids taken by mouth such as gelatin, ice cream,
soup,
juice and water.
1.1.1.2 Enteral intake includes all liquids given through nasogastric or
jejunostomy feeding
tube.
1.1.1.3 Parenteral route intake includes all liquids given as IV fluids, IV medicines,
and
blood and its components.
1.1.2 Output includes urine, stool, vomitus, gastric suction and drainage from post
surgical or
other tubes.
2 PURPOSES:
2.1 To maintain an ongoing evaluation of patients hydration status to prevent severe
imbalances.
2.2 To serve as a basis to calculate and measure daily caloric requirements.
2.3 To serve as a guideline for replacement of fluid loss.
3 INDICATIONS:
3.1 After surgery
3.2 Patients with critical and unstable condition
3.3 Patients on fluid restriction
3.4 Patients who are receiving diuretics or intravenous therapy
3.5 Patients with chronic cardiopulmonary and renal illnesses
3.6 Patients whose health status is deteriorating
4 POLICIES:
4.1 Follow
infection control policy.
NURSING
RESPONSIBILITIES:
5
4.2
Measuring
of fluid
intake
and output
is done
with
doctors
order
or asand
necessary.
5.1 Explain the reason
for
measuring
fluid intake
and
output
to the
patient
Record
in
Form
relatives to gain
M1024.
cooperation.
The starting
time and
of measuring
a 24-hour
intake
and urinal
outputorisurine
at 6am
and
5.24.3
Instruct
the patient
the relatives
not to fluid
empty
bedpan,
bag
butends
at
5am ask
of the
should
the
following
day.
nurse
to do so.
The morning
shift
records
the totalto
intake
andinoutput
for 12or
hours
atand
7pm.
Thenot
night
5.34.4
Instruct
a patient
who
is ambulatory
urinate
the bedpan
urinal
must
shift
discard
calculates
his/her
urine.the total 24 hours intake and output
264 at 5am indicating the cumulative
balance.
5.4 Record the output of a patient who has an indwelling foley catheter or drainage
tube frequently or
as necessary.
Republic of
Yemen 48Modern
48
Hospital
5.5 Report immediately any abnormality noted on the color, amount and character of
output to
attending physician or resident on duty.
5.6 Inform immediately any malfunction or accidental removal of catheters, drains or
other tubes to
attending physician or resident on duty.
265
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Medication Preparation and Administration
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the procedure in the
preparation and
administration of medications.
1 DEFINITION:
1.1 Medication - a substance used to promote health, to prevent, to diagnose, to
alleviate or cure
diseases.
1.2 Medication Preparation - is one of the nursing functions of setting the medicines
ready for
administration. The process involves accurate dosage, calculation, measurement and
proper
handling of medicines.
1.3 Medication Administration - is an act of giving the medicines according to the route,
drug
preparation and safety of the patient.
1.3.1 Routes
1.3.2 Oral
1.3.3 Oral
1.3.4 Sublingual
1.3.5 Buccal
1.3.6 Parenteral
1.3.7 Subcutaneous
1.3.8 Intramuscular
1.3.9 Intravenous
1.3.10 Intradermal
1.3.11 Intrathecal
1.3.12 Intra articular
1.3.13 Topical
1.3.14 Skin
1.3.15 Mucous membranes
1.3.16 Eyes
1.3.17 Ears
1.3.18 Nose
1.3.19 Vaginal
1.3.20 Rectal
1.3.21 Bladder
EQUIPMENTS/SUPPLIES:
3
1.3.22 Inhalation
3.1 Prescribed medicine
2 PURPOSE:
3.2 Medication tray
2.1 To ensure patient and staff safety.
3.3 Syringe and needle of different sizes
3.4 Medication cups
3.5 Sterile gauze
3.6 Alcohol swabs, band aids, tongue
depressor
266
3.7 Disposable
gloves, blue pads
Republic of
Yemen 48Modern
Hospital
48
3.8 Scissor
3.9 Saline solution, Sterile water
3.10Sharp disposal container
3.11Razor (if needed)
3.12Water soluble lubricant
3.13Tissues
3.14Oxygen tank
3.15Nebulizer machine
3.16Nebulizer set (cup, tubing,
mask)
3.17Mortar and pestle
3.18Butterfly needle
POLICIES:
4.5 Preparation
4.5.1 Assess:
4.5.1.1 Allergies to medication(s)
4.5.1.2 Clients ability to swallow the medication
4
4.5.1.3 Presence of vomiting or diarrhea that would interfere with the ability to
absorb the
medication
4.5.1.4 Specific drug action, side effects, interactions, and adverse reactions
4.5.1.5 Clients knowledge of and learning needs about the medication
4.5.1.6 Perform appropriate assessments specific to the medication.
4.5.1.7 Know the reason why the client is receiving the medication, the drug
classification,
contraindications, usual dosage range, side effects, and nursing
considerations for
administering and evaluating the intended outcomes for the medication.
4.5.1.8 Aseptic technique and proper procedure in handling and preparation of
medication
must be observed.
4.5.1.9 Special precaution should be taken for the preparation of cytotoxic drugs.
Refer to
chemotherapy policy and procedure. (Refer to GW-061).
4.5.1.10Restricted antibiotic form (see attached form) must be filled up and
presented to the
pharmacy when order is made.
4.5.1.11Follow standard drug calculation and measurement in preparing medications.
4.5.1.12Physician must be informed for the non-availability of the medicines and or if
any
substitute drug is issued.
4.5.1.13Follow hospital standard time in medication administration.
4.5.1.14 OD= 8am
4.5.1.15 BID= 88
4.5.1.16 TID= 818
4.5.1.17 QID= 8 12 4 8
4.5.1.18 q4o= 8 12 4 8 12 4
o4.5.1.19 q6= 6 12 6 12
o4.5.1.20 q8= 6 2 10
o4.5.1.21 q12= 66
4.5.1.22 HS= 10pm
4.6 Each unit should have a drug reference book.
4.7 Never leave prepared medicine unattended.
4.8 Any doubt with the doctors order should be referred to HN/CN and the attending
physician, and to
the CMO, if necessary.
4.9 Verbal or telephone order is not allowed except in emergency cases and unless ordered
by
anesthesiologist.
267 file is obtained within 24 hours.
4.10Signature of ordering physician on the patients
4.11The nurse must be aware of the pharmacological interactions of different drugs during
preparation as
follows:
4.11.4 TheHospital
nurse must have the knowledge of certain medication that is to be delayed
or
omitted.
4.11.5 Medicines should be prepared in the medication preparation area properly lighted.
4.11.6 Each medicine should have a corresponding medication card (Form M1022C)
properly
filled-up as to the following:
4.11.6.1Name and PIN
4.11.6.2Room Number and Bed location
4.11.6.3Route of Administration
4.11.6.4Name of medicine
4.11.6.5Dosage
4.11.6.6Time of Administration
4.11.6.7Date Started
4.11.6.8Date of Discontinue
4.11.7 The one who carried out the doctors order should be the one to prepare the
medication card.
He/She must write his/her complete name at the back of the card.
4.11.8 Once the medicine is discontinued as ordered by the doctor, the card should be
discarded
immediately.
4.11.9 If there is an order to hold the medicine temporarily, the card should be kept in
the kardex
and must be labeled HOLD.
4.11.10 The name of the patient and PIN should be embossed on the medication card.
4.11.11 If the patient is transferred to a different room in the same unit, the room
number in the
medication card should be changed. Crash out the previous and write the present
room
number.
4.11.12 In case a newly admitted patient has his/her own medicine taken at home, the
discretion of
the attending doctor should be solicited whether to continue those medicines or not.
If the
doctor agreed to do so, a written order should be obtained and those medicines
should be
written on the medication sheet and a medication card should be made with a
remark c/o
patient.
4.12Administration
4.12.1 Nurses observe 7 rights in medication administration
4.12.1.1Right patient
4.12.1.2Right medicine
4.12.1.3Right dose
4.12.1.4Right time
4.12.1.5Right route
4.12.1.6Right documentation
4.12.1.7Right frequency
4.12.2 Observe and maintain patients rights in giving medication
4.12.3 Be informed for drug name, purpose, action and potential undesired effects.
4.12.4 Refuse a medication regardless of the consequences.
4.12.5 Have qualified nurse or physician assess a drug history including allergies.
4.12.6 Not to receive unnecessary medications.
4.12.7 Receive appropriate treatment in relation to drug therapy.
4.12.8 Receive labeled medication safely without discomfort in accordance with 7 rights
in drug
administration.
4.12.9 When administering medication, nurses reduce risk of medication errors by:
4.12.9.1use of two (2) identifiers (neither to be patients room number).
4.12.9.2double-checking with each other for any dosage calculations of high-risk
medications;
268as dangerous via policy should not be
both nurses sign. Medications identified
administered by nurses in the ward.
4.12.10 Any medication error incurred, the head nurse, supervisor, director of nursing
and the
Republic of
Yemen
medicine.
4.12.14 Medicines that cannot be administered/given for whatever reason, Head Nurse
and attending
physician should be notified.
4.12.15 Pre aspirated medicine should be used immediately.
4.12.16 Upon administering of medications, the nurse must identify the patient by asking
the full
name and checking the ID band.
4.12.17 Never leave the patient until the medicine is given.
4.12.18 Automatic cancellation of medicines, narcotic, controlled drugs and/or
anticoagulant for
patient who will undergo operation must be followed.
4.13Labeling
4.13.1 Medicine should be labeled as to time and date of opening, name, PIN and expiry
date. Use
Form M0253 to label oral and injectable medications and Form M0252 to label
medicines
for external use.
4.13.2 Must be labeled clearly and legibly.
4.14Storage
4.14.1 Medication storage areas should be kept locked at all times except when nurses
are preparing
medications.
4.14.2 Medication preparation area is well-lit, clean, and located preferably in a closed
area to
avoid distraction.
4.14.3 Excess medicine or medicine refused by the patient should not be returned back
to stock
cabinet or medicine cart.
4.14.4 Any unused and/or left over medicine should be returned back to the pharmacy as
soon as
patient is discharged.
4.14.5 Separate storage for preparations for oral use and those for topical use is a must.
4.14.6 Those medicines that required to be refrigerated must be kept in medicine
refrigerator at
required temperature of 4-8 degree centigrade.
4.14.7 A system of stock rotation must be operated to ensure that there is no
accumulation of old
stocks (e.g. first in, first out)
4.14.8 Regular stock checks should be carried out every shift daily.
4.14.9 Medicines that will be expired within 3 months should be returned back to the
pharmacy and
to be replaced by new one.
4.14.10 Multi-dose vials will be dated with date first used/the seal is broken and will
expire at the
earliest of the following dates:
4.14.10.1Multi-dose Injectables : 30 days
4.14.10.2Allergy Clinic Preparations : 30 days
4.14.10.3Multi-dose Ophthalmic Preparations for clinic use : 14 days
4.14.10.4Nasal Preparations : 30 days
4.14.10.5Optic Drops : 30 days
4.14.10.6Inhalation Solution : 7 days
4.15Documentation
4.15.1 Transcribed the doctors order correctly in the medication sheet (Form M1022),
medication
card and kardex and indicates the following:
4.15.2 Name, PIN and Rm. No.
4.15.3 Name of medicine, dose, route and duration
4.15.4 Starting date of the medicines and discontinuing date, if any
4.15.5 Patients allergies must be highlighted on medication sheet, and to be noted on
top of the
269
file.
4.15.6 Any medication error or adverse drug reaction reported to be written in the
specified form.
4.15.7 Medication error - Incidental report form
Republic of
Yemen
Republic of
Yemen 48Modern
Hospital
48
5.1.2 Wash hands and observe other appropriate infection control procedures.
5.1.3 Gather and arrange all the equipments and supplies needed.
5 or
5.1.4 Observe 7 rights of drug administration and report any discrepancy to HN/CN
Physician.
5.1.5 Obtain appropriate medication.
5.1.6 Read the MAR and take the appropriate medication from the shelf, drawer,
or
the
the
refrigerator.
5.1.7 Compare the label of the medication container or unitdose package against
order on the MAR or computer printout.
5.1.8 Report discrepancies.
5.1.9 Check the expiration date of the medication. Return expired medications to
pharmacy.
5.1.10 Use only medications that have clear, legible labels.
5.1.11 Prepare the medication.
5.1.12 Calculate medication dosage accurately.
5.1.13 Prepare the correct amount of medication for the required dose, without
contaminating the medication.
5.1.14 While preparing the medication, recheck each prepared drug and container
with the
MAR again.
5.1.15 Identify the patient by asking the full name and checking the ID band.
5.2 Medicine by oral route
5.2.1 Types
5.2.1.1 Oral - easiest and commonly used given by mouth and swallowed with
fluid.
5.2.1.2 Sublingual - place under the tongue to dissolve.
5.2.1.3 Buccal - involves placing solid medication in the mouth and against the
mucous
membrane of the cheek until the drug dissolve.
5.2.2 Contraindication
5.2.2.1 Nausea, vomiting and inability to swallow
5.2.2.2 Decrease level of consciousness, comatose
5.2.2.3 Esophageal stricture, lesion of the mouth and oral cancer.
5.2.2.4 Surgery of the mouth/throat.
5.2.2.5 Recent gastrointestinal surgery.
5.2.2.6 Patient with NGT and gastrostomy tube
5.2.3 Preparation
5.2.3.1 Tablet/Capsule
5.2.3.1.1 Refer to general procedure from 5.1.1. - 5.1.5.
5.2.3.1.2 Assess for contraindications to patient receiving oral medication
as
mentioned.
5.2.3.1.3 Locate medicine in the cupboard. Read label of the medicine at
least
270
three times together with the medication sheet and card.
5.2.3.1.4 When removing from medicine cabinet.
5.2.3.1.5 Before pouring medicine.
cup
Republic
of touching with fingers.
without
5.2.3.1.9
Package tablet/capsule to be placed directly into medicine
Yemen
48Modern
48cup
without
for those
Hospital
removing the wrapper.
5.2.3.1.10 Place all tablets/capsule given at same time in one cup except
impossible.
5.3.6 Entire coated pills should not be crushed, since the purpose of coating is to
delay
Republic
absorption,
of thus preventing gastric irritation.
5.3.7 Tablets for buccal or sublingual administration should not be crushed.
Yemen
48Modern
48
5.3.8 Effervescent powder and tablets should be given immediately after
Hospital
dissolving
since
this improves its taste and therapeutic effect.
5.3.9 Cough medicine should be given undiluted and not followed with water.
5.3.10 Protect patient against aspiration by giving a tablet or capsule one at a
time.
5.3.11 Do not administer buccal, sublingual or enteric-coated tablets or
sustained action
medication through an enteral feeding tube.
5.4 Parenteral Route
5.4.1 Types
5.4.1.1 Subcutaneous - injection into tissues just below the dermis of the
skin.
5.4.1.2 Intramuscular - injection into a muscle.
5.4.1.3 Intravenous - injection into a vein
5.4.1.4 Intradermal - injection into the dermis just under the epidermis.
5.4.1.5 Intrathecal - direct administration of medication into sub arachnoids
space.
5.4.1.6 Intra articular - injection to the synovial cavity of a joint.
5.4.2 Contraindication
5.4.2.1 Subcutaneous/Intradermal
5.4.2.1.1 Sites that are inflamed, edematous, scarred or covered with
moles,
birthmarks or other lesions.
5.4.2.1.2 Patients with impaired coagulation mechanisms.
5.4.2.2 Intramuscular
5.4.2.2.1 Same as subcutaneous 5.3.2.1.1. & 5.3.2.1.2.
5.4.2.2.2 Patients with occlusive peripheral vascular disease, edema and
shock.
5.4.2.3 Intravenous
5.4.2.3.1 IV bolus injections are contraindicated when rapid administration
of
drug could cause life threatening complications or when the drug
requires dilution.
5.4.3 Preparation
5.4.3.1 Refer to General Procedure (5.1.1. - 5.1.5.)
5.4.3.2 Prepare the injectable medicine to be given.
5.4.3.2.1 Ampule preparation
5.4.3.2.1.1
5.4.3.2.1.1.1 Tap top of ampule lightly and quickly with finger until
fluid
leaves neck.
5.4.3.2.1.1.2 Place small gauze pad around neck of ampule.
5.4.3.2.1.1.3 Use ampule pile if needed and snap neck fast and firm
away
from hands.
5.4.3.2.1.1.4 Draw-up medication quickly. Hold ampule upside down or
set it on that surface.
5.4.3.2.1.1.5 Insert syringe needle into center of ampule opening
without
touching the rim or shaft of ampule.
5.4.3.2.1.1.6 Aspirate medication into the syringe by gently pulling
back
the plunger.
5.4.3.2.1.1.7 If air bubbles sets in, hold syringe with needle pointing
up.
Tap side of syringe to cause bubble to rise toward needle.
Draw backs slightly on plunger and push plunger upward to
eject air.
272
5.4.3.2.1.1.8 If syringe contains excess fluid, use sink for disposal.
5.4.3.2.1.1.9 Recap needle by scoop method and replace with a new
one.
container.
Republic
5.4.3.2.1.2
of Preparing injections from vials:
5.4.3.2.1.2.1 Remove metal cap/plastic covering top of unused vial.
Yemen
48Modern
48
(wipe
Hospital
Republic of
5.4.3.5.24
Evaluate response to procedure.
5.4.3.5.25 Charge supplies used and procedure.
5.4.3.6 Intravenous
5.4.3.6.1 Place the prepared injectable medicine in the tray together with
the
medication card, alcohol swab, disposable gloves, labeled syringe
with
saline solution, small sharp container, tourniquet.
5.4.3.6.2 Identify the patient carefully by:
5.4.3.6.3 Ask patient his/her name.
5.4.3.6.4 Check ID band.
5.4.3.6.5 Explain the procedure, reason drugs is given and the expected
common side
effect.
5.4.3.6.6 Provide privacy, assist patient in a comfortable position.
5.4.3.6.7 Assess patient intravenous insertion site for signs of infiltration
and
phlebitis. If present, do not give medication; restart IV line in another
site.
5.4.3.6.8 IV push through:
5.4.3.6.8.1 Intravenous lock:
5.4.3.6.8.1.1 Clean off injection port with antiseptic swab.
5.4.3.6.8.1.2 Aspirate for blood return. Clear lock with 1ml saline (a
central venous port may require 5-10ml saline)
5.4.3.6.8.1.3 Administer medication over specified time
recommended.
Use a watch to time administration.
5.4.3.6.8.1.4 After administering medicine clear lock with 1ml saline.
5.4.3.6.8.2 Existing line:
5.4.3.6.8.2.1 Select injection port closest to patient.
5.4.3.6.8.2.2 Clean injection port with antiseptic swab
5.4.3.6.8.2.3 Occlude the intravenous line by pinching tubing just above
injection port.
5.4.3.6.8.2.4 Gently aspirate for blood return, if there is administer
medication over specified time recommended.
5.4.3.6.8.3 Butterfly needle
5.4.3.6.8.3.1 Connect the syringe with medicine to the port of the
butterfly
tubing and push slowly the plunger to fill the tubing with
medicine and to expel the air.
5.4.3.6.8.3.2 Select the site for the IV insertion.
5.4.3.6.8.3.3 Place the tourniquet 4-6 inches above the selected site,
ask the
patient to open and close his/her fist.
5.4.3.6.8.3.4 Clean the site with alcohol swab.
5.4.3.6.8.3.5 Inject the needle at an angle of 25-45 degrees & check for
return flow.
5.4.3.6.8.3.6 Release the tourniquet and stabilize the needle with one
hand.
5.4.3.6.8.3.7 When return flow is present, slowly inject the medicine.
5.4.3.6.8.3.8 Pinch the tubing after medicine is completely injected and
replace the syringe with saline syringe and flush the tubing.
5.4.3.6.8.3.9 Place sterile gauze with alcohol swab over the insertion
site and
remove the needle.
5.4.3.6.8.4 Apply band aid over the site
5.4.3.6.8.5 Inspect the area for redness, pain, swelling, edema.
5.4.3.6.8.6 Observe closely for adverse
275 reaction as the drug is administer
and for
several minutes there after.
5.4.3.6.8.7 Dispose uncap needle and syringe in sharp container.
theYemen
48Modern
48
medication card, alcohol swab and small sharp container.
Hospital
edema,
5.4.3.6.9.3
5.4.3.6.9.4
5.4.3.6.9.5
5.4.3.6.9.6
5.4.3.6.9.7
5.4.3.6.9.8
5.4.3.6.9.9
Republic of
Yemen 48Modern
48
Hospital
with
5.4.4.8
If diazepam of chlordiazepoxide HCL is given through IV push, flush
5.6.3.1.20
Return within 5 minutes to determine whether suppository was
expelled.
5.6.3.1.21 Record drug name, dosage, route of administration, tolerance to
procedure,
date and time.
5.6.3.1.22 Observe for any effects of suppository (e.g. bowel movement,
relief of
nausea) 30 minutes after administration and record.
5.6.3.2 Vaginal Pessaries
5.6.3.2.1 Verify doctors order.
5.6.3.2.2 Wash hands.
5.6.3.2.3 Prepare all supplies and bring to patients bedside.
5.6.3.2.4 Identify patient properly by asking the full name and checking ID
band.
5.6.3.2.5 Explain the procedure to the patient.
5.6.3.2.6 Provide privacy.
5.6.3.2.7 Assist patient to lie in dorsal recumbent position.
5.6.3.2.8 Keep abdomen and lower extremities draped.
5.6.3.2.9 Wear disposable gloves.
5.6.3.2.10 Inspect condition of external genitalia and vaginal canal.
5.6.3.2.11 Be sure vaginal orifice is well illuminated by room light or
examination
lamp.
5.6.3.2.12 Do perineal care (refer to perineal care procedure)
5.6.3.2.13 Replace new disposable gloves if previous are soiled.
5.6.3.2.14 Remove suppository from foil wrapper and apply lubricant to
rounded end.
Lubricate index finger of dominant hand.
5.6.3.2.15 Gently retract labial fold with non-dominant hand.
5.6.3.2.16 Insert rounded end of suppository along posterior wall of vaginal
canal,
entire length of finger (7.5-10cm or 3-4 inches)
5.6.3.2.17 Withdraw finger and wipe away remaining lubricant from vaginal
orifice of
labia.
5.6.3.2.18 Instruct patient to remain on back at least 10 minutes. (for Prostin
E2 at least
1 hr.)
5.6.3.2.19 Discard all supplies used properly.
5.6.3.2.20 Remove gloves and wash hands.
5.6.3.2.21 Offer perineal pad when patient resumes ambulation.
5.6.3.2.22 Document medication given, date, time, observation made.
5.6.3.2.23 Charge supplies used.
5.6.3.3 Inhalation can be given either by nebulization or aerosolization with
rapid relief for
local respiratory problems, or an easy access for introduction of general
anesthesia
gases.
5.6.3.3.1 Contraindications:
5.6.3.3.1.1 Patients with tachycardia/cardiac arrythmias are
contraindicated to use
of bronchodilators.
5.6.3.3.2 Administration
5.6.3.3.2.1 Follow general procedure (5.1.1. - 5.1.5)
5.6.3.3.2.2 Assess patients ability to use the nebulizer.
5.6.3.3.2.3 Select the proper size of mask appropriate for the patient.
5.6.3.3.2.4 Prepare the medication to be given per doctors order.
5.6.3.3.2.5 Check the nebulizer machine
and O2 tank for proper working
279
condition.
5.6.3.3.2.6 Assist the patient to sit in upright position (if not
contraindicated).
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
Hospital
48
Figure : 059-1
* Formulas for Computing Drug Dosages *
Adult:
dose desired
---------------- X quantity on hand = desired quantity to
administer.
dose on hand
dose desired - is the amount of pure drug the physician prescribed.
dose on hand - weight or volume of drug available in units supplied by the
pharmacy.
quantity on hand - is the basic unit or quantity that contains amount on
hand.
amount to administer
of medicine
the nurse
will administer.
Example : Amoxicillin
625mg PO -isactual
ordered.
It is supplied
as liquid
preparation
containing 250mg in 5 ml. How much would the nurse would give?
625mg
---------- X 5ml = 12.5ml
250mg
Pedia
Frieds Rule is usually used to estimate dosages for infants
under age 1.
Childs dose =
childs age in months
--------------------- X average adult dose
150 months
Youngs Rule is usually used to estimate dosage for children ages
2 to 12.
childs age in years
Childs dose =
-------------------------- X average adult dose
childs age in years + 12
Clarks rule - pediatric dosages are calculated by multiplying the weight of the drug
(usually in
milligrams) by weight of the child (in kilograms).
Childs dose = usual adult dose X weight of child in pounds
150
Body Surface Area - Formula used to estimate the pediatric dosages based on the
childs body
surface area.
Surface area in sq. meters X Dose per sq. meter = Approximate child dose
Surface area of child
------------------------- X Dose of Adult = Approximate child dose
Surface area of adult
Surface area of child in sq. meters
----------------------------------- X adult dose = child dose
175
Recommended Dosage (mg or gm/kg/day X body weight/kg = Dose
(mg/day)
---------------------------------------------------------------------------------------------281
Daily Dose
Republic of
Yemen 48Modern
48
Hospital
REFERENCE:
Fundamentals of Nursing concepts, process, and practice 7 th
Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
282
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Mouth/Oral Care
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the procedure in rendering
mouth/oral
hygiene.
1 DEFINITION:
1.1 Mouth/oral hygiene - a hygienic care of the buccal cavity by brushing, flossing,
irrigating,
massaging or use of other devices.
2 PURPOSES:
2.1 To keep the mucosa and lips clean, soft, moist, and intact.
2.2 To prevent infection.
2.3 To remove food debris and dental plaques.
2.4 To alleviate pain, discomfort, and enhance oral intake.
2.5 To prevent halitosis/tooth decay and freshen the mouth.
3 INDICATIONS:
3.1 Dysphagia or difficulty of swallowing
3.2 Febrile condition
3.3 Unconscious patient
3.4 Dehydrated patients
3.5 Artificial feeding
4
EQUIPMENTS/SUPPLIES:
4.1 Towel
4.2 Curved basin (emesis basin)
4.3 Disposable clean gloves
4.4 Bite-block to hold the mouth open and teeth apart (optional)
4.5 Toothbrush
4.6 Cup of tepid water
4.7 Dentifrice or denture cleaner
4.8 Tissue or piece of gauze to remove dentures (optional)
4.9 Denture container, as needed
4.10Mouthwash
4.11Rubber-tipped bulb syringe
4.12Suction catheter with suction apparatus (optional)
4.13Foam swabs and cleaning solution for cleaning the mucous
membranes
4.14Petroleum jelly (Vaseline)
4.15Brushing and flossing
4.15.1 Towel
4.15.2 Disposable gloves
4.15.3 Curved basin (emesis basin)
4.15.4 Toothbrush
4.15.5 Cup of tepid water
4.15.6 Dentifrice (toothpaste)
4.15.7 Mouthwash
4.15.8 Dental floss, at least two pieces 20 cm (8 in) in length
283
4.15.9 Floss holder (optional)
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
Hospital
48
7.6.2 Picking up a moistened foam swab, wipe the mucous membrane of one cheek.
If no foam
swabs are available, wrap a small gauze square around a tongue blade and
moisten it.
7.6.3 Discard the swab or tongue blade in a waste container and, with a fresh one,
clean the
next area.
7.6.4 Clean all the mouth tissues in an orderly progression, using separate
applicators: the
cheeks, roof of the mouth, base of the mouth, and tongue.
7.6.5 Observe the tissues closely for inflammation and dryness.
7.6.6 Rinse the clients mouth.
7.97.6.7
Brushing
andand
Flossing
thegloves.
Teeth
Remove
discard
Explain
the client what you are going to do, why it is necessary, and how she
7.7 7.9.1
Ensure
client to
comfort.
can
7.7.1 Remove the basin, and dry around the clients mouth with the towel.
7.7.2 cooperate.
Replace artificial dentures, if indicated.
7.9.2Lubricate
Wash hands
observe
otherpetroleum
appropriate
infection
control
procedures.
7.7.3
theand
clients
lips with
jelly.
If the client
is on
oxygen
7.9.2.1
Assist the client to a sitting position in bed, if health permits. If not, assist
therapy,
do not
the client
use petroleum jelly, because it can cause burns to the skin and mouth. Use
to a side-lying position with the head turned.
another mouth
7.9.3
Prepare
thethat
equipment.
care
product
does not have petroleum in it.
7.9.3.1 Place the towel under the clients chin.
7.8 Document:
7.9.3.2
Put on of
clean
7.8.1
Assessment
the gloves.
teeth, tongue, gums, and oral mucosa
7.9.3.3
Moisten the
of or
the
toothbrush with
tepid water
andgums
apply the
7.8.2
Any problems
suchbristles
as sores
inflammation
and swelling
of the
dentifrice to the
toothbrush.
7.9.3.4 Use a soft toothbrush and the clients choice of dentifrice.
7.9.3.5 For the client who must remain in bed, place or hold the curved basin
under the
clients chin, fitting the small curve around the chin or neck.
7.9.3.6 Inspect the mouth and teeth.
7.9.4 Brush the teeth.
7.9.5 Hand the toothbrush to the client, or brush the clients teeth as follows:
7.9.5.1 Hold the brush against the teeth with the bristles at a 45-degree angle
7.9.5.2 The tips of the outer bristles should rest against and penetrate under the
gingival
7.9.5.3 Move the bristles up and down, using a vibrating or jiggling motion from
the sulcus
to the crowns of the teeth.
7.9.5.4 Repeat until all outer and inner surfaces of the teeth and sulci of the
gums are
cleaned.
7.9.5.5 Clean the biting surfaces by moving the brush back and forth over them in
short
strokes.
7.9.5.6 If the tongue is coated, brush it gently with the toothbrush.
7.9.5.7 Hand the client the water cup or mouthwash to rinse the mouth
vigorously. Then ask
the client to spit the water and excess dentifrice into the basin.
7.9.5.8 Repeat the preceding steps until the mouth is free of dentifrice and food
particles.
7.9.5.9 Remove the curved basin and help the client wipe her mouth.
7.9.6 Floss the teeth. Assist the client to floss independently, or floss the teeth as
follows:
285
7.9.6.1 Wrap one end of the floss around the third finger of each hand.
7.9.6.2 To floss the upper teeth, use your thumb and index finger to stretch the
floss.
Republic of
Yemen 48Modern
Hospital
48
7.9.6.3 Move the floss up and down between the teeth from the tops of the
crowns to the
gum and along the gum lines as far as possible.
7.9.6.4 Make a C with the floss around the tooth edge being flossed.
7.9.6.5 Start at the back on the right side and work around to the back of the left
side, or
work from the center teeth to the back of the jaw on either side.
7.10Variation:
Artificial
Dentures
7.9.6.6 To floss
the lower
teeth, use your index fingers to stretch the floss and
7.10.1 Remove the dentures.
follow
7.10.1.1Put
onas
gloves.
instructions
above.
7.10.1.2If
the client
client tepid
cannot
remove
the dentures,
take the tissue
gauze,
grasp
7.9.6.7
Give the
water
or mouthwash
to rinse
mouth or
and
a
the upper
curved
basin in
plate
the
front
teeth with your thumb and second finger, and move the
which
to at
spit
the
water.
denture
upAssist the client in wiping the mouth.
7.9.6.8
andand
down
slightly.
7.9.7 Remove
dispose
of equipment appropriately.
7.10.1.3Lower
theclean
upper
plate,
move
it out of the mouth, and place it in the
7.9.7.1
Remove and
the
curved
basin.
denture
7.9.7.2 Remove and discard the gloves.
container.
7.9.8 Document
assessment of the teeth, tongue, gums, and oral mucosa.
7.10.1.4 Lift the lower plate, turning it so that the left side, for example, is
slightly lower
than the right, to remove the late from the mouth without stretching the lips.
Place
the lower plate in the denture container.
7.10.1.5Remove a partial denture by exerting equal pressure on the border of
each side of
the denture, not on the clasps, which can bend or break.
7.10.2 Clean the dentures.
7.10.2.1Take the denture container to a sink.
7.10.2.2Using a toothbrush or special stiffbristled brush, scrub the dentures with
the
cleaning agent and tepid water.
7.10.2.3Rinse the dentures with tepid running water.
7.10.2.4If the dentures are stained, soak them in a commercial cleaner.
7.10.3 Inspect the dentures and the mouth.
7.10.3.1Observe the dentures for any rough, sharp, or worn areas that could
irritate the
tongue or mucous membranes of the mouth, lips, and gums.
7.10.3.2Inspect the mouth for any redness, irritated areas, or indications of
infection.
7.10.4 Assess the fit of the dentures.
7.10.5 Return the dentures to the mouth.
7.10.5.1Offer some mouthwash and a curved basin to rinse the mouth. If the client
cannot
insert the dentures independently, insert the plates one at a time.
7.10.5.2Hold each plate at a slight angle while inserting it, to avoid injuring the
lips.
7.10.6 Assist the client as needed.
7.10.6.1Wipe the clients hands and mouth with the towel.
7.10.6.2If the client does not want to or cannot wear the dentures, store them in a
denture
container with water.
286
7.10.7 Label the cup with the clients name and identification number.
7.10.8 Remove and discard gloves.
7.10.9 Document all assessments and include any problems.
Republic of
Yemen 48Modern
48
Hospital
REFERENCE:
8
8.1 Fundamentals of Nursing concepts, process, and practice
7th Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
287
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Nail Care / Foot Care
Republic of
Yemen 48Modern
48
Hospital
6
SPECIAL CONSIDERATIONS:
6.1 Commercial polish and cuticle removers should not be used.
6.2 Podiatrist should be consulted when corns and calluses are present.
6.2.1 Non-prescribed preparation should not be used to treat athletes foot and
ingrown
toenails, as it may contain composition that may lead to skin reaction/infection.
6.3 Keep feet clean and dry before wearing socks/stockings and shoes.
6.4 Advice patient to break in new shoes gradually, begin on a half hour of wear on the
first day and
increase time by an hour a day.
6.5 Instruct to report immediately, if any of the following signs are noticed:
6.5.1 Infection or inflammation
6.5.2 Ingrown nails
6.5.3 Breakage of skin in the interdigital areas
6.5.4 Corns or calluses
6.5.5 Burns and pressure
289
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
Hospital
48
PREPARATIONS:
7
7.1 Assess:
7.1.1 For any clinical signs of malnutrition or dehydration.
7.1.2 For allergies to any food in the feeding.
7.1.3 For the presence of bowel sounds.
7.1.4 For any problems that suggest lack of tolerance of previous feedings.
7.2 Determine:
7.2.1 Type, amount, and frequency of feedings
7.2.2 Tolerance of previous feedings
7.3 Assemble equipment and supplies:
7.3.1 Correct amount of feeding solution
7.3.2 20- to 50-mL syringe with an adapter
7.3.3 Emesis basin
7.3.4 Disposable gloves
7.3.5 Large syringe with plunger, or calibrated plastic feeding bag with tubing
7.3.6 pH test strip or meter
7.3.7 Measuring container from which to pour the feeding
7.3.8 Water at room temperature
7.3.9 Feeding pump as required
PROCEDURES:
7.4
Assistdoctors
the client
to a for
Fowlers
position
infrequency.
bed, or a sitting position in a chair.
8.1 Verify
order
rate, route,
and
7.4.1
If
a
sitting
position
is
contraindicated,
a slightly
elevated
right
side-lying
8.2 Explain to the client what you are going to do,
why it is
necessary,
and
how he can
position
is
cooperate.
8.3 Washacceptable.
hands and observe other appropriate infection control procedures.
8.4 Provide for client privacy.
8.5 Assess tube placement.
8
8.5.1 Attach the syringe to the open end of the tube, and aspirate alimentary
secretions. Check
the pH.
8.5.2 Allow 1 hour to elapse before testing the pH, if the client has received a
medication
8.5.3 Use a pH meter rather than pH paper, if the client is receiving a continuous
feeding or if
food coloring has been added to the formula.
8.6 Assess residual feeding contents.
8.6.1 Aspirate all the stomach contents, and measure the amount before
administering the
feeding.
8.6.2 If 100 mL (or more than half the last feeding) is withdrawn, check before
proceeding
with the nurse in charge or refer to agency policy
8.6.3 Reinstill the gastric contents into the stomach, if this is the agency policy or
physicians
order. Remove the syringe bulb or plunger, and pour the gastric contents via the
syringe
into the nasogastric tube.
8.6.4 If the client is on a continuous feeding, check the gastric residual every 46
hours
8.7 Administer the feeding.
8.7.1 Before administering feeding:
8.7.1.1 Check the expiration date of the feeding.
8.7.1.2 Warm the feeding to room temperature.
8.7.1.3 When an open system is used, clean the top of the feeding container with
alcohol
before opening it.
8.7.2 Feeding Bag (Open System)
291
8.7.2.1 Hang the bag from an infusion pole about 30 cm (12 in) above the tubes
point of
insertion into the client.
8.7.2.2 Clamp the tubing, and add the formula to the bag.
8.7.2.3 Open the clamp, run the formula through the tubing, and reclamp the
tube.
8.7.2.4 Attach the bag to the nasogastric/nasoenteric tube, and regulate the drip
Republic of
by adjusting
the clamp
to the drop factor on the bag.
Yemen
48Modern
48
8.7.3 Syringe (Open System)
Hospital
8.7.3.1 Remove the plunger from the syringe, and connect the syringe to a
pinched or
clamped nasogastric tube.
8.7.3.2 Add the feeding to the syringe barrel.
8.7.3.3 Permit the feeding to flow in slowly at the prescribed rate.
8.7.3.4 Raise or lower the syringe to adjust the flow as needed.
8.7.3.5 Pinch or clamp the tubing to stop the flow for a minute, if the client
experiences
discomfort.
8.7.4 Prefilled Bottle with Drip Chamber (Closed System)
8.7.4.1 Remove the screw-on cap from the container, and attach the
administration set with
the drip chamber and tubing.
8.7.4.2 Close the clamp on the tubing.
8.7.4.3 Hang the container on an intravenous pole about 30 cm (12 in) above the
tubes
insertion point into the client.
8.7.4.4 Squeeze the drip chamber to fill it to one-third to one-half of its capacity.
8.7.4.5 Open the tubing clamp, run the formula through the tubing, and reclamp
the tube.
8.7.4.6 Attach the feeding set tubing to the feeding tube, and regulate the drip
rate to
deliver the feeding over the desired length of time.
8.8 Rinse the feeding tube immediately before all of the formula has run through the
tubing.
8.8.1.1 Instill 50100 mL of water through the feeding tube.
8.8.1.2 Be sure to add the water before the feeding solution has drained from the
neck of a
syringe, or from the tubing of an administration set.
8.9 Clamp and cover the feeding tube.
8.9.1.1 Clamp the feeding tube before all of the water is instilled.
8.9.1.2 Cover the end of the feeding tube with gauze held by an elastic band.
8.10Ensure client comfort and safety.
8.10.1.1Pin the tubing to the clients gown.
8.10.1.2Ask the client to remain sitting upright in Fowlers position or in a
slightly elevated
right lateral position for at least 30 minutes.
8.11Dispose of equipment appropriately.
8.11.1.1If the equipment is to be reused, wash it thoroughly with soap and water,
so that it is
ready for reuse.
8.11.1.2Change the equipment every 24 hours or according to agency policy.
8.12Document all relevant information.
8.12.1.1Document the feeding, including amount and kind of solution taken,
duration of the
feeding, and assessments of the client.
8.12.1.2Record the volume of the feeding and water administered on the clients
intake and
output record.
8.13Monitor the client for possible complications.
8.13.1.1Carefully assess clients receiving tube feedings for problems
8.13.1.2To prevent dehydration, give the client supplemental water in addition to
the
prescribed tube feeding, as ordered.
8.13.2 Variation: Continuous-Drip Feeding
8.14If the feeding is a continuous-drip tube feeding, place a label on the container.
8.14.1.1Clamp the tubing at least every 46 hours or as indicated by agency
292
protocol or the
manufacturer, and aspirate and measure the gastric contents. Then flush the
tubing
with 3050 mL of water.
8.14.1.2 Determine agency protocol regarding withholding a feeding.
Republic of
Yemen 48Modern
48
Hospital
293
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Nasogastric Tube Insertion
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with nasogastric tube insertion.
1 DEFINITION:
1.1 Nasogastric tube (NGT) insertion - a procedure wherein a nasogastric tube is inserted
into the
stomach through the nose for diagnostic and therapeutic purposes.
2 PURPOSES:
2.1 To assess and treat upper gastrointestinal bleeding.
2.2 To aspirate gastric secretions to collect gastric contents for analysis.
2.3 To perform gastric lavage.
2.4 To sustain nutritional needs.
2.5 To administer medication.
2.6 To prevent or relieve nausea and vomiting after surgery by decompressing the
stomach.
3 EQUIPMENTS/SUPPLIES:
3.1 NGT # 14 or 16
3.2 Underpad
3.3 Tissues
3.4 Emesis basin
3.5 Penlight
3.6 Non-allergenic tape
3.7 Water-soluble lubricant
3.8 Stethoscope
3.9 Normal saline
3.10Sterile and disposable gloves
3.11Asepto syringe
3.12Thermometer
3.13Sphygmomanometer
3.14Sterile gauze
4 POLICIES:
4.1 Obtain physicians order.
4.2 Proper information regarding the procedure, outcome, and undesirable effect must be
explained
prior to the procedure.
4.3 NGT should be changed every 2 weeks, as required.
4.4 Ensure safety by observing aspiration precaution.
4.5 Follow standard infection control measures.
4.6 Primary responsibility of PREPARATIONS:
the doctor, assisted by the nurse except in ICU wherein5the
5.1 Assess:
nurses are
5.1.1 Patency of nares and intactness of nasal tissues
allowed.
5.1.2 For history of nasal surgery or deviated septum
5.1.3 Presence of gag reflex
5.1.4 Mental status or ability to cooperate with
procedure
294
Republic of
Yemen 48Modern
Hospital
48
5.2 Determine:
5.2.1 The size of tube to be inserted
5.2.2 Whether the tube is to be attached to suction
5.3 Assemble equipment and supplies:
5.3.1 Large- or small-bore tube
5.3.2 Guide wire or stylet for smallbore tube
5.3.3 Solution basin filled with warm water (if a plastic tube is being used) or ice (if a
rubber
tube is being used)
5.3.4 Nonallergenic adhesive tape, 2.5 cm (1 in) wide
5.3.5 Disposable gloves
5.3.6 Water-soluble lubricant
5.3.7 Facial tissues
5.3.8 Glass of water and drinking straw
5.3.9 20- to 50-mL syringe with an adapter
5.3.10 Basin
5.3.11 pH test strip or meter
5.3.12 Stethoscope
5.3.13 Disposable pad or towel
5.3.14 Clamp or plug (optional)
PROCEDURES:
5.3.15 Suction
apparatus,
if required
6.1 Explain
to the client
what you
are going to do, why it is necessary, and how he can
5.3.16
Gauze
square
or
plastic
specimen bag and elastic band
cooperate.
5.3.17
Safety
pin
and
elastic
band
6.2 Wash hands and observe other appropriate infection control procedures.
5.4Provide
Assist the
a high-Fowlers position if his health condition permits, and
6.3
for client
client to
privacy.
support
his
head
6.4 Assess the clients nares.
on a pillow.
6.4.1
Ask the client to hyperextend his head, and, using a flashlight, observe the 6
intactness of
the tissues of the nostrils, including any irritations or abrasions.
6.4.2 Examine the nares for any obstructions or deformities by asking the client to
breathe
through one nostril while occluding the other.
6.4.3 Select the nostril that has the greater airflow.
6.5 Prepare the tube.
6.5.1 If a rubber tube is being used, place it on ice for 5 to 10 minutes. If a plastic
tube is being
used, place it in warm water until the tube is softer and more flexible.
6.5.2 If a small-bore tube is being used, insert stylet or guide wire into the tube,
making sure
that it is secured in position.
6.6 Determine how far to insert the tube.
6.6.1 Use the tube to mark off the distance from the tip of the clients nose to the tip
of the
earlobe and then from the tip of the earlobe to the tip of the xyphoid.
6.6.2 Mark this length with adhesive tape, if the tube does not have markings.
6.7 Insert the tube.
6.7.1 Put on gloves.
6.7.2 Lubricate the tip of the tube well with water-soluble lubricant or water, to ease
insertion.
6.7.3 Insert the tube, with its natural curve toward the client, into the selected
nostril. Ask the
client to hyperextend the neck, and gently advance the tube toward the
nasopharynx.
6.7.4 Direct the tube along the floor of the nostril
295 and toward the ear on that side.
6.7.5 Slight pressure is sometimes required to pass the tube into the nasopharynx,
and some
clients eyes may water at this point.
swallow
6.7.10 If the client gags, stop passing the tube momentarily. Have the client rest,
take a few
breaths, and take sips of water to calm the gag reflex.
6.7.11 In cooperation with the client, pass the tube 510 cm (24 in) with each
6.7.6
swallow, until
6.7.7
the indicated length is inserted.
6.7.8
6.7.12 If the client continues to gag, and the tube does not advance with each
swallow, withdraw
it slightly, and inspect the throat by looking through the mouth.
6.8 Ascertain correct placement of the tube.
6.8.1 Aspirate stomach contents, and check the pH.
6.8.2 Auscultate air insufflation by placing a stethoscope over the clients
epigastrium and
injecting 1030 mL of air into the tube while listening for a whooshing sound.
6.8.3 If the signs do not indicate placement in the stomach, advance the tube 5 cm (2
in), and
repeat the tests.
6.8.4 If a small-bore tube is used, leave the stylet or guide wire in place until correct
position is
verified by x-ray.
6.9 Secure the tube by taping it to the bridge of the clients nose.
6.9.1 If the client has oily skin, wipe the nose first with alcohol.
6.9.2 Cut 7.5 cm (3 in) of tape, and split it lengthwise at one end, leaving a 2.5- cm
(1-in) tab
at the end. Place the tape over the bridge of the clients nose, and bring the split
ends
either under and around the tubing, or under the tubing and back up over the
nose.
6.10Attach the tube to a suction source or feeding apparatus, as ordered, or clamp the
end of the
tubing.
6.10.1 The tube, if inserted preoperatively, is usually clamped or plugged, or it may
be covered
with a gauze square or plastic specimen bag and an elastic band.
6.11Secure the tube to the clients gown.
6.11.1 Loop an elastic band around the end of the tubing, and attach the elastic band
to the gown
with a safety pin. Or
6.11.2 Attach a piece of adhesive tape to the tube, and pin the tape to the gown.
6.12Document relevant information.
6.12.1 Document the insertion of the tube, the means by which correct placement
was
determined, and client responses.
6.13Establish a plan for providing daily nasogastric tube care.
6.13.1 Inspect the nostril for discharge and irritation.
6.13.2 Clean the nostril and tube with moistened, cotton-tipped applicators.
6.13.3 Apply water-soluble lubricant to the nostril, if it appears dry or encrusted.
6.13.4 Change the adhesive tape as required.
6.13.5 Give frequent mouth care. The client may breathe through the mouth, and
cannot drink.
6.14If suction is applied, ensure that the patency of both the nasogastric and suction
tubes is
maintained.
6.14.1 Irrigations of the tube with 30 mL of normal saline may be required at regular
intervals.
6.14.2 Keep accurate records of the clients fluid intake and output, and record the
296
amount and
characteristics of the drainage.
6.14.3 Document the type of tube inserted, date and time of tube insertion, type of
suction used,
color and amount of gastric contents, and the clients tolerance of the
Republic of
Yemen 48Modern
48
Hospital
6.15.2 When the tube has advanced to the premarked point, test the pH of the
aspirate to
determine placement in the intestine.
6.15.3 Have proper placement confirmed by x-ray, and tape the tube in place when
confirmation
is received.
SPECIAL CONSIDERATIONS:
7
7.1 Patient with nasogastric tube should have a routine mouth and nares care.
7.2 Maintain and check patency of the tube every 4 hours.
7.3 If nasogastric tube is for drainage, note the color and amount of drainage.
7.4 Maintain an intake and output recording every 12 hours and/or as ordered
8
by the doctor.
REFERENCE:
8.1.Fundamentals of Nursing concepts, process, and practice 7th Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
297
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Nasogastric Tube Removal
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with nasogastric tube removal.
1 DEFINITION:
1.1 Nasogastric tube removal - withdrawing/pulling off the NGT in place per medical
advises of
the doctor.
2 PURPOSES:
2.1 To provide comfort.
2.2 To prevent occurrence of complication like gastric ulceration, sinusitis, esophagitis,
pulmonary
and oral infection, skin erosion at the nostril.
2.3 When a maximum therapeutic effect is achieved.
3 EQUIPMENTS/SUPPLIES:
3.1 Stethoscope
3.2 Syringe catheter tip (Asepto syringe)
3.3 Emesis basin
3.4 Disposable gloves
3.5 Penlight, tongue depressor
3.6 Normal saline
3.7 Mouthwash
3.8 Disposable gown (optional)
3.9 Underpads, tissues
4 POLICIES:
4.1 Obtain physicians order for removal of NG tube.
4.2 Follow infection control measures.
4.3 Primarily the responsibility of the nurse unless difficulties are encountered.
5 PREPARATIONS:
5.1 Assess:
5.1.1 For the presence of bowel sounds
5.1.2 For the absence of nausea or vomiting when tube is clamped
5.2 Assemble equipment and supplies:
5.2.1 Disposable pad
5.2.2 Tissues
5.2.3 Disposable gloves
5.2.4 50-mL syringe (optional)
5.2.5 Plastic disposable bag
5.3 Confirm the physicians order to remove the tube.
5.4 Assist the client to a sitting position, if health permits.
5.5 Place the disposable pad across the clients chest to collect any spillage of mucous
and gastric
secretions from the tube.
5.6 Provide tissues to the client to wipe the nose and mouth after tube removal.
PROCEDURES:
6.1 Explain to the client what you are going to do, why it is necessary, and how she can cooperate.
298
Republic of
Yemen 48Modern
6.2 Explain to the client what you are going to do, why it is necessary, and how she can cooperate.
48
Hospital
299
Republic of
Yemen 48Modern
48
Hospital
300
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
Hospital
48
3
EQUIPMENTS/SUPPLIES:
3.1 Padded siderails
3.2 Suction machine
3.3 Suction catheter
3.4 Padded tongue depressor
3.5 Oxygen tank with oxygen devices
3.6 Penlight
3.7 Oral airway
3.8 Sphygmomanometer and
stethoscope
3.9 Blue sheets
3.10Towels
3.11Gauze
3.12Disposable gloves
3.13Mask
3.14Additional pillows
3.15Thermometer
POLICIES:
4
PROCEDURES:
4.1 Ensure patients safety at all time.
5.1 Admission of patient with history of seizure.
4.2 Observe fall and aspiration precautions.
5.1.1 Preparation of the unit.
4.3 Follow hospital infection control
5.1.1.1 Gather all equipments and supplies
needed.
measures.
5.1.2 Orientation of the patient and relatives to the unit.
5.1.3 Admission care. Check vital signs. Establish IV line. Check doctors order for 5
blood
investigation prior to treatment.
5.1.4 Assessment of patients general status:
5.1.4.1 Thorough physical assessment
5.1.4.2 History taking about seizure onset, pattern and precipitating events
5.2 Give the following health instructions:
5.2.1 Encourage patient to study himself and his environment to determine what
specific factors
precipitate his seizures - illness, emotional and physical stress, altered sleep
pattern,
photosensitivity, hyperventilation, menses or other sensory stimulant - and to
avoid them.
5.2.2 Have one member of the family stay with the patient always.
5.2.3 Dentures should be removed if seizure is preceded by aura.
5.3 During seizure attack:
5.3.1 Provide privacy and protect the patient from curious onlookers.
5.3.2 If the patient is in bed, support the head and foot part of the bed with pillow.
5.3.3 If the patient is ambulatory, ease him to the floor if there is enough time. Push
aside any
furniture that may injure the patient during attack.
5.3.4 Loosen constrictive clothing.
5.3.5 If an aura precedes the seizure, insert an oral airway to reduce the possibility
of the
tongue or cheek being bitten.
5.3.6 Do not attempt to open jaws that are clenched in a spasm to insert anything.
Broken teeth
and injury to the lips and tongue may result from such an action.
5.3.7 Try to hold the lower jaw forward if the patient is in flaccid stage. Turn his head
to the
side to facilitate drainage of mucus and saliva to prevent aspiration.
5.3.8 If possible, place the patient on one side with head flexed forward, which allows
the
302
tongue to fall forward and facilitates drainage of saliva and mucus. If suction is
available,
use it if necessary to clear secretions.
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
304
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
305
Discard the dressing in the moisture proof bag. Handle it carefully, so that the
dressing
does not touch the outside of the bag.
6.4.6Republic
Remove yourof
gloves and dispose of them properly.
6.4.7 Open the sterile dressing set using sterile technique.
Yemen 48Modern
48
6.4.8 Assess the wound.
Hospital
6.4.8.1
Put on sterile gloves.
6.4.8.2 Assess the appearance of the tissues in and around the wound and the
drainage.
6.4.9 Clean the wound.
6.4.9.1 Irrigate the wound with normal saline until all visible exudates have been
6.4.5
washed
away.
6.4.9.2 After irrigating, apply a sterile gauze pad to the wound.
6.4.9.3 If a topical antimicrobial ointment or cream is being used to treat the
wound, use a
swab to remove it.
6.4.9.4 Remove and discard sterile gloves.
6.4.10 Obtain the aerobic culture:
6.4.10.1Open a specimen tube, and place the cap upside down on a firm, dry
surface, or, if
the swab is attached to the lid, twist the cap to loosen the swab.
6.4.10.2Hold the tube in one hand and take out the swab in the other.
6.4.10.3Rotate the swab back and forth over clean areas of granulation tissue
from the sides
or base of the wound.
6.4.10.4 Do not use pus or pooled exudates to culture.
6.4.10.5 Avoid touching the swab to intact skin at the wound edges.
6.4.10.6Return the swab to the culture tube, taking care not to touch the top or
the outside of
the tube.
6.4.10.7Crush the inner ampule containing the medium for organism growth at
the bottom
of the tube.
6.4.10.8Twist the cap to secure.
6.4.10.9 If a specimen is required from another site, repeat the steps. Specify the
exact site
on the label of each container. Be sure to put each swab in the appropriately
labeled
tube.
6.4.11 Dress the wound.
6.4.11.1Apply any ordered medication to the wound.
6.4.11.2Cover the wound with a sterile moist transparent wound dressing.
6.4.11.3Arrange for the specimen to be transported to the laboratory
immediately. Be sure
to include the completed requisition.
6.4.12 Document all relevant information.
6.4.12.1Record on the clients chart the taking of the specimen and source.
6.4.12.2Include:
6.4.12.2.1 Date and time
6.4.12.2.2 Appearance of the wound
6.4.12.2.3 Color, consistency, amount, and odor of any drainage
6.4.12.2.4 Type of culture collected
6.4.12.2.5 Any discomfort experienced by the client
6.5 Variation: Obtaining a Specimen for Anaerobic Culture
6.5.1 Insert a sterile 10-mL syringe (without needle) into the wound, and aspirate 1
5 mL of
drainage into the syringe.
6.5.1.1 Attach the needle to the syringe, and expel all air from the syringe and
needle.
6.5.1.2 Immediately inject the drainage into the anaerobic culture tube, and cap
the tube
tightly.
6.5.1.3 Use an anaerobic culture swab system
in which the swab is immediately
306
placed into
a tube filled with an oxygen-free gas or gel environment.
6.5.1.4 Label the tube or syringe appropriately.
Republic of
Yemen 48Modern
48
Hospital
307
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Obtaining Specimens for Culture and
Sensitivity
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the procedure of obtaining
specimens
for culture and sensitivity.
1 DEFINITION:
1.1 Obtaining Specimens for Culture and Sensitivity a sterile method or technique used
in
obtaining specimen for specific laboratory cultures and sensitivity.
1.1.1 Sputum Culture
1.1.1.1 Tracheostomy tube
1.1.2 Throat Swab Culture
1.1.3 Wound Culture
1.1.4 Stool Culture - Refer to stool specimen collection.
1.1.5 Urine Culture - Refer to urine specimen collection.
1.1.6 Blood Culture - collected by phlebotomist
2 PURPOSES:
2.1 To diagnose fever of unknown origin.
2.2 To determine the casual organism for an obvious infection and to enable the
physician to identify
the drug of choice.
2.3 To determine the source of an epidemic.
2.4 To test for complete resolution of infection, especially in urinary tract infection.
3 EQUIPMENTS/SUPPLIES:
3.1 Sterile specimen bottle
3.2 Disposable gloves
3.3 Tongue depressor
3.4 Penlight
3.5 Sterile swab stick
3.6 Betadine solution
3.7 Sterile gauze
3.8 Underpad
3.9 Kidney basin
4 POLICIES:
4.1 Doctors order should be obtained.
4.2 Instructions are thoroughly explained to the patient if he or she is to obtain the
specimen.
4.3 Specimens are send to the laboratory with proper label as soon as they are
obtained.
PROCEDURES:
5
4.4 Culture should be obtained as much as possible prior to the start of antibiotic. If
5.1 Verify
patient
is on doctors order.
5.2antibiotic
Purpose for
thetime
culture
and was
the procedure
for obtaining
are
at the
culture
obtained, the
laboratorythe
slipspecimen
should indicate
the
explained to the patient.
medication
5.3being
Gather
the equipments/supplies according to the type of culture to be obtained:
taken.
Culture
By Patient
4.55.3.1
DoneSputum
and obtained
under
sterile technique.
308
5.3.1.1 Provide sterile sputum container the night before the sputum is to be
collected.
5.3.1.2 Instruct the patient that early morning specimen can be obtained after
rinsing Republic
the
of
mouth with water.
Yemen 48Modern
48
5.3.1.3 Instruct the patient that only sputum that has come from deep within
the
Hospital
lungs
should be collected.
5.3.1.4 At least (4cc) of sputum must be collected in a sterile sputum container.
5.3.1.5 Provide the patient with an ample supply of tissues to wipe the mouth
after
expectorating the sputum.
5.3.1.6 For hygienic reason, wrap the sputum container with paper towels so the
contents
cannot be seen.
5.3.1.7 As soon as the specimen is obtained, wear gloves and clean the external
surface of
specimen container for any spilled sputum.
5.3.1.8 Label the specimen bottle with patients name, pin no., date and time the
specimen
was obtained.
5.3.1.9 Charge the test and send the specimen to the lab with request.
5.3.2 Sputum Culture through Tracheostomy Tube
5.3.2.1 Check the suction machine if functioning well.
5.3.2.2 Wash hands, wear mask and disposable gloves.
5.3.2.3 Position the patient in high or semi fowlers.
5.3.2.4 Clean the surrounding area of tracheostomy site
5.3.2.5 Connect the sterile suction catheter to the suction tube.
5.3.2.6 Remove disposable gloves and put on sterile one.
5.3.2.7 Remove the sterile suction catheter from the package.
5.3.2.8 Insert the catheter into the trachea without suction.
5.3.2.9 Apply suction while gently rotating the catheter.
5.3.2.10Stop suction and remove catheter immediately once the sputum has
collected inside
the tubing.
5.3.2.11Put the suction catheter inside the sterile specimen container labeled
with patients
name, pin number and room number and close immediately.
5.3.2.12Remove gloves, wash hands.
5.3.2.13Keep patient in comfortable position.
5.3.2.14Note consistency and color of specimen obtained in nursing notes.
5.3.2.15Give the laboratory request to the ward secretary for charging and send
through
computer.
5.3.2.16Keep the specimen in the container box and send to laboratory as soon
as possible.
5.3.2.17Charge the supplies used.
5.3.3 Throat Swab Culture
5.3.3.1 Wash hands and wear disposable gloves.
5.3.3.2 Position the patient in semi-fowler or high fowlers.
5.3.3.3 Depress the patients tongue with spatula using penlight as light source.
5.3.3.4 Quickly but gently, rub the swab over the tonsillar fossa or any area with
lesion or
visible exudate.
5.3.3.5 Avoid touching any other area of the mouth or tongue with the swab.
5.3.3.6 After swabbing the area, return the swab stick to its container and closed
it tightly.
5.3.3.7 Remove gloves, wash hands.
5.3.3.8 Label the container with patients name, PIN, date and time specimen is
collected.
5.3.3.9 Charge the request and send through computer.
5.3.3.10Document the procedure done, date and time the specimen was sent.
5.3.3.11Keep the specimen in the container box and send to laboratory as soon
as possible.
309
5.3.3.12Charge the supplies used.
5.3.4 Wound Swab Culture
5.3.4.1 Wash hands and wear disposable gloves.
Republic of
Yemen 48Modern
48
Hospital
310
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
5.18Discard tissue, and use more until the patient is clean. Turn the patient on his/her
side, and spread
the buttocks to clean the anal area. Cover bedpan.
5.19If specimen is required or intake or output is measured, do not place toilet tissue in
the bedpan.
Place tissue in proper receptacle.
5.20Assist the patient to wash and dry his/her hands.
5.21Empty bedpan contents properly.
5.22Dispose gloves and wash hands.
5.23Record intake and output if ordered.
6
5.24Charge
all supplies used
SPECIAL
CONSIDERATIONS:
6.1 A fracture bedpan maybe substituted when it is difficult or uncomfortable to use a
regular bedpan.
6.2 If it is difficult to slide patient onto the bedpan, powder maybe used on the resting
surfaces of the
pan to eliminate friction. Powder should not be used if a specimen is required
because
contamination could result.
6.3 Avoid placing a bedpan or urinal on top of the bedside stand or overbed table to
avoid
contamination of clean equipment and food trays.
6.4 Try to anticipate elimination needs, and offer the bedpan or urinal frequently to help
reduce
embarrassment and minimize the risk of incontinence.
312
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Applies to: General Ward and Specialty Units
CONTENTS: This policy and procedure describes the responsibility of nurses with regards to
Title: Oxygen Therapy
the
administration of oxygen therapy.
1 DEFINITION:
1.1 Oxygen a drug and must be initiated by a physicians order.
1.2 Oxygen Therapy the treatment of patients with hypoxemia.
1.3 Hypoxemia- a decreased oxygen tension in the blood.
1.4 Hypoxia decreased oxygen in the tissue.
1.5 Oxygen Therapy Modalities including the following:
1.5.1 Nasal Cannula is used when the patient requires a low-to-medium concentration
of
oxygen for which precise accuracy is not essential. This method is relatively
simple and
allows the patient to move about in bed, talk, cough and eat without interruption
of
oxygen flow.
1.5.2 Nasal Catheter is used less frequently than nasal cannula. This procedure
involves
inserting an oxygen catheter into the nose to the nasopharynx. The catheter
must be
changed at least every 8 hours and inserted into the other nostril. For this
reasons the
nasal catheter is often a less desirable method because insertion may be painful
and
cause trauma to the nasal mucosa.
1.5.3 Oxygen Mask is a device used to administer oxygen, humidity, or heated
humidity. It is
shaped to fit snugly over the mouth and nose and is secured in place with a
strap. The
two primary types of oxygen masks are high and low concentration. A plastic
face mask
with a reservoir bag and a venturi mask can deliver higher concentrations of
oxygen. The
simple face mask delivers oxygen concentrations from 30% to 60%.
2 PURPOSE:
2.1 To prevent or correct hypoxemia.
2.2 To provide guidelines for the use of oxygen therapy equipment.
3 INDICATIONS:
3.1 Hypoxemia documented by clinical laboratory data or suspected by physical
examination.
3.2 Clinical situation where oxygen transport to the tissues may be impaired e.g. shock,
5
EQUIPMENTS/SUPPLIES:
acute
5.1
Cannula
coronary insufficiency, acute cerebrovascular accident.
5.1.1 Oxygen supply with a flow meter and adapter
4 COMPLICATIONS:
5.1.2 Humidifier
distilled
or tap
water, according
agencywith
4.1 Hypoventilation
with CO2with
retention
andwater
possible
respiratory
arrest into
patients
protocol
chronic
5.1.3
Nasal cannula
and
tubing
obstructive
pulmonary
disease
(COPD)
who are stimulated to breath by their hypoxic
5.1.4 Tape
drive.
313
4.2 Absorption atelectasis secondary to nitrogen wash out.
4.3 Retrolental fibroplasias primarily in neonates.
4.4 Oxygen toxicity.
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
8.5.1 Check that the oxygen is flowing freely through the tubing.
8.5.2 There should be no kinks in the tubing, and the connections should be airtight.
8.5.3 There should be bubbles in the humidifier as the oxygen flows through.
8.5.4 You should feel the oxygen at the outlets of the cannula, mask, or tent.
8.5.5 Set the oxygen at the flow rate ordered.
8.6 Apply the appropriate oxygen delivery device.
8.6.1 Cannula
8.6.1.1 Put the cannula over the clients face, with the outlet prongs fitting into
the nares
and the elastic band around the head.
8.6.1.2 If the cannula will not stay in place, tape it at the sides of the face.
8.6.1.3 Pad the tubing and band over the ears and cheekbones as needed.
8.6.2 Face Mask
8.6.2.1 Guide the mask toward the clients face, and apply it from the nose
downward.
8.6.2.2 Fit the mask to the contours of the clients face.
8.6.2.3 Secure the elastic band around the clients head so that the mask is
comfortable but
snug.
8.6.2.4 Pad the band behind the ears and over bony prominences.
8.6.3 Face Tent
8.6.3.1 Place the tent over the clients face, and secure the ties around the head.
8.7 Assess the client regularly.
8.7.1 Assess the clients vital signs, level of anxiety, color, and ease of respirations,
and
provide support while the client adjusts to the device.
8.7.2 Assess the client in 1530 minutes, depending on the clients condition, and
regularly
thereafter.
8.7.3 Assess the client regularly for clinical signs of hypoxia, tachycardia, confusion,
dyspnea,
restlessness, and cyanosis. Review arterial blood gas results if they are
available.
8.7.3.1 Nasal Cannula
8.7.3.1.1 Assess the clients nares for encrustations and irritation. Apply a
watersoluble lubricant as required to soothe the mucous membranes.
8.7.3.2 Face Mask or Tent
8.7.3.2.1 Inspect the facial skin frequently for dampness or chafing, and dry
SPECIAL
9
and treatCONSIDERATIONS:
9.1 Oxygen is delivered
to
a
patient
with
artificial
airway
(tracheostomy,
endotracheal
it as needed.
tube)
with the
8.8 Inspect
the equipment on a regular basis.
use
ofCheck
T-tubethe
adapter
or by
a tracheostomy
maskinorthe
manual
resuscitation
bag. and
8.8.1
liter flow
and
the level of water
humidifier
in 30 minutes
9.2
Use
of
oxygen
facemask
is
contraindicated
to
patient
with
carbon
dioxide
retention.
when
9.3 If the
patients
level
of
consciousness
decreases,
intubation
may
be
necessary.
providing care to the client. Make sure that safety precautions are being
9.4 Diseases that benefit from oxygen therapy includes chronic obstructive pulmonary
followed.
diseases,
8.9 Document findings in the client record.
airway obstruction, pulmonary edema, acute respiratory distress, metabolic
disorders, cardiac 10 REFERENCE:
10.1Fundamentals of Nursing concepts, process, and practice 7th
disorders and shock.
Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
10.2 SAMSO Operating Manual Oxygen
Therapy
315
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
316
Republic of
Yemen 48Modern
PREPARATIONS:
48
Hospital
6.1 Explain to
the client what you are going to do, why it is necessary, and how he
or
she can
cooperate.
6.2 Wash hands and observe other appropriate infection control procedures.
Self-care
abilities
6.3 Provide 5.2.2
for client
privacy.
5.2.3
Whether
the
client is experiencing any discomfort in the perineal
6.4 Prepare the client.
genital
area
6.4.1 Fold the top bed linen to the foot of the bed and fold the gown up to expose
5.3 Assemble equipment and supplies.
the genital
area.
6
6.4.2 Place a bath towel under the clients hips.
6.5 Position and drape the client and clean the upper inner thighs.
6.5.1 For Females
6.5.1.1 Position the female in a back-lying position with the knees flexed and
spread well
apart.
6.5.1.2 Cover her body and legs with the bath blanket. Drape the legs by tucking
the
bottom corners of the bath blanket under the inner sides of the legs.
6.5.1.3 Bring the middle portion of the base of the blanket up over the pubic
area.
6.5.1.4 Put on gloves, and wash and dry the upper inner thighs.
6.5.2 For Males
6.5.2.1 Position the male client in a supine position with knees slightly flexed
and hips
slightly externally rotated.
6.5.2.2 Put on gloves, and wash and dry the upper inner thighs.
6.6 Inspect the perineal area.
6.6.1 Note particular areas of inflammation, excoriation, or swelling, especially
between the
labia in females or the scrotal folds in males.
6.6.2 Also note excessive discharge or secretions from the orifices, and the
presence of odors.
6.7 Wash and dry the perinealgenital area.
6.7.1 For Females
6.7.1.1 Clean the labia majora. Then spread the labia to wash the folds between
the labia
majora and the labia minora.
6.7.1.2 Use separate quarters of the washcloth for each stroke, and wipe from
the pubis to
the rectum. For menstruating women and clients with indwelling catheters,
use
clean wipes, cotton balls, or gauze.
6.7.1.3 Take a clean ball for each stroke.
6.7.1.4 Rinse the area well.
6.7.1.5 Dry the perineum thoroughly.
6.7.2 For Males
6.7.2.1 Wash and dry the penis, using firm strokes.
6.7.2.2 If the client is uncircumcised, retract the prepuce to expose the glans
penis for
cleaning. Replace the foreskin after cleaning the glans penis.
6.7.2.3 Wash and dry the scrotum. The posterior folds of the scrotum may need
to be
cleaned.
6.8 Inspect perineal orifices for intactness.
6.8.1 Inspect particularly around the urethra in clients with indwelling catheters.
6.9 Clean between the buttocks.
6.9.1 Assist the client to turn onto the side facing away from you.
6.9.2 Pay particular attention to the anal area
317 and posterior folds of the scrotum in
males.
6.9.3 Clean the anus with toilet tissue before washing it, if necessary.
6.9.4 Dry the area well.
Republic of
Yemen 48Modern
48
Hospital
318
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Positioning and Mobilizing The Client
Republic of
Yemen 48Modern
Hospital
48
Assistive devices such as overhead trapeze, pull and/or turn sheet, and
5.1.4
transfer or sliding
bar
5.2 Logrolling a Client
5.2.1 Assess:
5.2.1.1 The clients physical abilities
5.2.1.2 Ability to understand instructions
5.2.1.3 Degree of comfort or discomfort when moving. If needed, administer
analgesics or
perform other pain-relief measures.
5.2.1.4 Clients weight
5.2.1.5 Your own strength and ability to move the client
5.2.2 Determine:
5.2.2.1 Assistive devices that will be required
5.2.2.2 Encumbrances to movement, such as an IV or a heavy cast on one leg
5.2.2.3 Medications the client is receiving, as certain medications may hamper
movement
or alertness of the client
5.2.2.4 Assistance required from other health care personnel
5.2.3 Assemble equipment and supplies:
5.2.3.1 Assistive devices such as overhead trapeze, pull and/or turn sheet, and
transfer or
sliding bar
5.3 Turning the Client to Lateral or Prone Position
5.3.1 Determine:
5.3.1.1 Assistive devices that will be required
5.3.1.2 Encumbrances to movement
5.3.1.3 Medications the client is receiving
5.3.1.4 Assistance required from other health care personnel
5.4 Assisting the Client to Sit on the Side of the Bed
5.4.1 Determine:
5.4.1.1 Assistive devices that will be required
5.4.1.2 Encumbrances to movement
5.4.1.3 Medications the client is receiving
5.4.1.4 Assistance required from other health care personnel
5.5 Transferring Client Between Bed and Chair
5.5.1 Before transferring a client, assess the following:
5.5.1.1 The clients body size
5.5.1.2 Ability to follow instructions
5.5.1.3 Activity tolerance
5.5.1.4 Muscle strength
5.5.1.5 Joint mobility
5.5.1.6 Presence of paralysis
5.5.1.7 Level of comfort
5.5.1.8 Presence of orthostatic hypotension
5.5.1.9 The technique with which the client is familiar
5.5.1.10The space in which the transfer is maneuvered
5.5.1.11The number of assistants needed to accomplish the transfer safely
5.5.1.12The skill and strength of the nurse(s)
5.5.2 Implement pain relief measures so that they are effective when the transfer
begins.
5.5.3 Assemble equipment and supplies:
5.5.3.1 Robe or appropriate clothing
5.5.3.2 Slippers or shoes with nonskid soles
320
5.5.3.3 Transfer (walking) belt
5.5.3.4 Chair, commode, wheelchair, or stretcher, as appropriate to client need
5.5.3.5 Sliding board
5.5.4 Remove obstacles from the area used for the transfer.
5.6 Transferring Client Between Bed and Stretcher
5.6.1 Before transferring a client, assess the following:
5.6.1.1 The clients body size
Republic
offollow instructions
5.6.1.2
Ability to
5.6.1.3 Activity
tolerance
Yemen
48Modern
48
5.6.1.4 Level of comfort
Hospital
Republic of
Yemen 48Modern
Hospital
48
5.7.6.2 Tighten your gluteal, abdominal, leg, and arm muscles; rock backward,
shifting
your weight from the forward to the backward foot; and roll the client
onto the side
of the body to face you.
5.7.6.3 Position the client on his side with arms and legs positioned and
supported
properly.
5.7.6.4 To turn a client to the prone position, follow the preceding steps, with
two
exceptions:
5.7.6.4.1 Instead of abducting the far arm, keep the clients arm alongside
the body
for the client to roll over.
5.7.6.4.2 Roll the client completely onto the abdomen. Never pull a client
across the
bed while he is in the prone position.
5.7.6.5
Document
all relevant
information.
Variation: Turning
the Client
to Prone Record:
5.7.6.6.1.1.1
5.7.6.5.1
Time
and
change
of
position moved from and position moved to
Position
5.7.6.5.2 Any signs of pressure areas
5.8 Assisting
Client
on the
Side of the Bed
5.7.6.5.3
Use to
of Sit
support
devices
5.8.1
Explain
to
the
client
what
are going
do, why it is necessary, and how he
5.7.6.6 Ability of client to assistyou
in moving
andto
turning
can
5.7.6.6.1 Response of client to moving and turning
cooperate.
5.8.2 Wash hands and observe other appropriate infection control procedures.
5.8.3 Provide for client privacy.
5.8.4 Position yourself and the client appropriately before performing the move.
5.8.4.1 Assist the client to a lateral position facing you.
5.8.4.2 Raise the head of the bed slowly to its highest position.
5.8.4.3 Position the clients feet and lower legs at the edge of the bed.
5.8.4.4 Stand beside the clients hips, and face the far corner of the bottom of
the bed.
Assume a broad stance, placing the foot nearest the client forward. Lean
your trunk
forward from the hips. Flex your hips, knees, and ankles.
5.8.5 Move the client to a sitting position.
5.8.5.1 Place one arm around the clients shoulders and the other arm beneath
both of the
clients thighs near the knees. Tighten your gluteal, abdominal, leg, and
arm
muscles.
5.8.5.2 Lift the clients thighs slightly.
Variation: Teaching the Client How To Sit on the
5.8.5.4.1.1.1
5.8.5.3 Pivot on the balls of your feet in the desired direction facing the foot of
Side of the Bed Independently
the bed
while pulling the clients feet and legs off the bed.
5.8.1
Instruct
thesupporting
client to: the client until he is well balanced and comfortable.
5.8.5.4
Keep
5.8.1.1
Assess
vital Roll to the side and lift the far leg over the near leg. Grasp the
mattresssigns
edgeas
with
indicated by the clients health status.
the lower arm and push the fist of the upper arm into the mattress.
5.8.1.2 Push up with the arms as the heels and legs slide over the mattress
edge.
5.8.1.3 Maintain the sitting position by pushing both fists into the mattress
behind and to
322
the sides of the buttocks.
5.8.2 Document all relevant information. Record:
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
324
Republic of
Yemen 48Modern
Hospital
48
Republic of
5.11.1 Explain to the client what you are going to do, why it is necessary, and
Hospital
she can
cooperate.
5.11.2 Wash hands and observe other appropriate infection control procedures.
5.11.3 Provide for client privacy.
5.11.4 Prepare the client for ambulation. Apply elastic (antiemboli) stockings, as
required.
5.11.5 Assist the client to sit on the edge of the bed. Assess the client carefully for
signs and
symptoms of orthostatic hypotension. Assist the client to stand by the side of
the bed
until she feels secure.
5.11.6 Ensure client safety while assisting the client to ambulate.
5.11.6.1Encourage the client to ambulate independently if she is able, but walk
beside the
client.
5.11.6.2Remain physically close to the client, in case assistance is needed at any
point.
5.11.6.3Use a transfer or walking belt if the client is slightly weak and unstable.
5.11.6.4Make sure the belt is pulled snugly around the clients waist and
fastened securely.
5.11.6.5Grasp the belt at the clients back, and walk behind and slightly to one
side of the
client
5.11.6.6If it is the clients first time out of bed following surgery, injury, or an
extended
period of immobility, or if the client is quite weak or unstable, have an
assistant
follow you and the client with a wheelchair, in the event that it is needed
quickly.
5.11.6.7If the client is moderately weak and unstable, walk on the clients
weaker side and
interlock your forearm with the clients closest forearm.
5.11.6.8Encourage the client to press her forearm against your hip or waist for
stability, if
desired.
5.11.6.9In addition, have the client wear a transfer or walking belt.
5.11.6.10If the client is very weak and unstable, place your near arm around the
clients
waist, and, with your other arm, support the clients near arm at the elbow.
5.11.6.11Walk on the clients stronger side.
5.11.6.12Again, have the client wear a transfer or walking belt, incase of an
emergency.
5.11.6.13Encourage the client to assume a normal walking stance and gait, as
much as
possible.
5.11.7 Protect the client who begins to fall while ambulating.
5.11.7.1If a client begins to experience the signs and symptoms of orthostatic
hypotension
5.11.7.7Variation: Two Nurses
or extreme weakness, quickly assist the client into a nearby wheelchair or
5.11.8 After the client stands, assume a position with one nurse at either side.
other
5.11.8.1Grasp the inferior aspect of the clients upper arm with your nearest
chair, and help the client to lower her head between her knees.
hand and the
5.11.7.2Stay with the client. When the weakness subsides, assist the client back
clients lower arm or hand with your other hand.
to bed.
5.11.8.2Optional: Place a walking belt around the clients waist.
5.11.7.3 If a chair is not close by, assist the client to a horizontal position on the
5.11.8.3Each nurse grasps the side handle with the near hand and the lower
floor
aspect of the
before fainting occurs.
clients upper arm with the other hand.
5.11.7.4Assume a broad stance with one foot in front of the other.
5.11.8.4Walk in unison with the client, using a smooth, even gait, at the same
5.11.7.5Bring the client backward so that
your body supports the person.
326
speed and
5.11.7.6Allow the client to slide down your leg, and lower her gently to the floor,
with steps the same size as the clients.
making
sure the clients head does not hit any objects.
Republic of
Yemen 48Modern
48
Hospital
5.11.8.5If the client starts to fall and cannot regain strength or balance, slip
your arms
under the clients axillae, grasp the clients hands, and lower the person
gently to
the floor or to a nearby chair.
5.11.9 Document distance and duration of ambulation in the client record.
REFERENCE:
6
6.1 Fundamentals of Nursing concepts, process, and practice
7th Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
327
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
If the deceased is a Muslim, a Muslim nurse of the same gender shall render the
post-
Republic of
mortem care.
Yemen
48Modern
48
5.1.5 Wash hands, wear gloves, apron and mask and follow infection control
measures. Hospital
5.1.6 Disconnect IV tubing, suction, and oxygen. Remove cannula, catheters, drains
and tubes
if present.
5.1.7 Position the deceased in proper body alignment.
5.1.8 Close eyelids.
5.1.4
5.1.9 Put back dentures, if any.
5.1.10 Wash and clean the body with wash cloth removing all dirt, blood stains, and
secretions.
5.1.11 Dry with towel.
5.1.12 Apply proper dressing to open wounds.
5.1.13 Fill up 3 identification tags. Data include the following:
5.1.13.1Patients name and PIN
5.1.13.2Room and bed number
5.1.13.3Treating doctors name
5.1.13.4Name of hospital and city location
5.1.13.5Date and time expired
5.1.13.6Whether patient has a communicable disease
5.1.14 Wrap with plastic shroud following procedures below:
5.1.14.1Place deceased on the shroud sheet with underpad underneath the buttocks
and cover the
genitals with another blue pad.
5.1.14.2Fasten chin strap to keep mouth closed.
5.1.14.3Place hands over abdomen. Secure wrist and ankles with ties.
5.1.14.3.1 Tie together the big toes and ankles to maintain alignment of
extremities.
5.1.14.3.2 Attach ID tag to the big toe.
5.1.14.4Wrap sheet around the body.
5.1.14.5Tie above elbows, at the waist, and below the knees.
5.1.14.6Attach ID tag at head part outside.
5.1.15 Attach ID tag to personal effects.
5.1.16 Document and complete the records.
5.1.17 Notify the Ward Secretary to update charges and discharge from the Computer;
inform
Admission/Discharge Officer and ER Staff for the mortuary key.
5.1.18 Follow up with Treating doctor to fill up the Death Report) for the relatives to
process
government formalities.
5.1.19 Bring the corpse accompanied by relatives to the mortuary.
5.1.20 Record in ER Logbook and ask key from the ER Nurse.
5.1.21 With the help of ER porter, keep the corpse in freezer receptacle and lock. Label
the outside
of Mortuary Freezer.
5.1.22 Advise relatives to settle the bills in Admission/Discharge Office.
5.1.23 Let relatives sign (Form M1056) acknowledging receipt and endorse personal
belongings to
them.
5.1.24 Submit the Death Report to Admission/Discharge Office and surrender Mortuarys
key to
Emergency Room Station.
5.1.25 To collect the body from the morgue, the relatives should sign the consent of
Release of
Dead Body (Form M1050) from Admission/Discharge Office.
5.1.26 ER staff releases the body to the relatives after Admission/Discharge Officer
signs the release
in the mortuary logbook, which indicates that bills are paid.
5.1.27 For foreigners, government formalities are complied before the body is released.
5.1.28 Upon exit, the corpse should pass only
329through the morgue exit.
5.1.29 Aftercare of equipment.
5.2 Care of Amputated Body Parts and Fetus:
5.2.1 Obtain Death Report from Admission/Discharge Office prior to theprocedure.
Republic of
Yemen 48Modern
48
Hospital
5.2.1.1 In case of emergency still birth or abortion (it can be done after.)
5.2.2 Let the Treating Doctor fill the Death Report (Form M5007).
5.2.3 Clean, pack, and label:
5.2.3.1 For Fetus:
5.2.3.1.1 Intra Uterine Fetal Death (IUFD) - keep in the specimen container
with
Formaline. Close tightly and label: fetus identity following mothers
name; treating doctor; date and time of delivery; gender (if identified);
and
weight (if can be weighed).
5.2.3.1.2 Full Term Fetus - wrap first with blue sheet then double wrap with
still
birth shroud. Follow procedures of Post Mortem Care from 5.1.15.1 to
5.1.15.6.
5.2.3.2 For amputated body part:
5.2.3.2.1 Wrap in the shroud pack and apply tag on the outside and in
mortuary
freezer
5.2.3.2.2 For small body parts like finger, place in a specimen container and
label it.
5.2.3.3 Follow procedures on Post Mortem Care from steps 5.1.21. to 5.1.29.
5.3 Care of Infected Dead Body:
5.3.1 Health personnel should follow standard precautions during the care of
infected dead
body. Wash hands before and after dead body contact.
5.3.2 If there is possibility of splash of body fluids, wear eye goggles in addition to
apron,
gloves, and mask.
5.3.2.1 Wear filter mask for TB patient.
5.3.3 Cover all cuts and open lesion on the hand with waterproof dressing.
5.3.4 Double wrap body of patient with shroud pack who had varicella, pnuemonia
plaque,
herpes zoster, hemorrhagic fever, hepatitis, tuberculosis, etc. so that the
outside of
shroud is uncontaminated.
5.3.5 Use red tag and label stating the type of infection patient suffered.
5.3.6 Inform ER staff about the deceased who died or suffered from communicable
disease.
5.3.7 Wrap linen in an orange bag, seal and label Isolation to be treated by
Laundry Staff as
infected and take the necessary precautions.
5.3.8 The room should be fumigated and other equipment be thoroughly cleaned
with phenolic
disinfectant.
5.3.9 Send all use instruments to CSSD for sterilization.
5.3.10 Mortuary room should be well ventilated and provided with facilities for
handwashing
such as skin disinfectants.
330
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Post-Operative Care
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
333
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Post-Operative Teaching: Moving, Leg Exercises, Deep
Breathing and Coughing
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in providing
teaching to
postoperative clients.
1 DEFINITION:
1.1 Post-Operative Teaching - instructions given to the clients that have undergone
surgery to
prevent occurrence of postoperative complications.
2 PURPOSES:
2.1 For prevention of any postoperative complications.
2.2 For early return of clients to his activities of daily living.
3 EQUIPMENTS/SUPPLIES:
3.1 Pillow
3.2 Teaching materials, if appropriate
4 POLICIES:
4.1 Nurses should provide health teachings to all clients undergoing surgery.
4.2 All teachings provided to the client should be documented accordingly.
5 PREPARATION:
5.1 Assess:
5.1.1 Vital signs
5.1.2 Discomfort
5.1.3 Temperature and color of feet and legs
5.1.4 Breath sounds
5.1.5 Presence of dyspnea or cough
5.1.6 Learning needs of the client
5.1.7 Anxiety level of the client
5.1.8 Client experience with previous surgeries and anesthesia
5.2 Determine:
5.2.1 The type of surgery
5.2.2 The time of the surgery
5.2.3 The name of the surgeon
5.2.4 The preoperative orders the agency practices for preoperative care
5.3 Assemble equipment and supplies.
5.4 Check that potential distracters to teaching are not present. Include the family in
the
teaching, if
6
PROCEDURES:
appropriate.
6.1 Explain to the client what you are going to do, why it is necessary, and how he can
cooperate.
6.2 Wash hands and observe other appropriate infection control procedures.
6.3 Provide for client privacy.
6.4 Show the client ways to turn in bed and to get out of bed.
6.4.1 Instruct a client who will have a right abdominal incision or a right-sided chest
incision
to turn to the left side of the bed and sit up as follows:
6.4.2 Flex the knees.
334
6.4.3 Splint the wound by holding the left arm and hand or a small pillow against
the incision.
Republic of
Yemen 48Modern
Hospital
48
6.4.4 Turn to the left while pushing with the right foot and grasping a partial side
rail on the
left side of the bed with the right hand.
6.4.5 Come to a sitting position on the side of the bed by using the right arm and
hand to push
down against the mattress and swinging the feet over the edge of the bed.
6.4.6 Teach a client with left abdominal or left-sided chest incision to perform the
same
procedure but splint with the right arm and turn to the right.
6.4.7 For clients with orthopedic surgery, use special aids, such as a trapeze, to
assist with
movement.
6.5 Teach the client the following three leg exercises:
6.5.1 Alternate dorsiflexion and plantar flexion of the feet.
6.5.2 Flex and extend the knees, and press the backs of the knees into the bed
while
dorsiflexing the feet. Instruct clients who cannot raise their legs to do
isometric exercises
that contract and relax the muscles.
6.5.3 Raise and lower the legs alternately from the surface of the bed.
6.5.4 Flex the knee of the stable leg, and extend the knee of the moving leg.
6.6 Demonstrate deep-breathing (diaphragmatic) exercises as follows:
6.6.1 Place your hands palms down on the border of your rib cage, and inhale slowly
and
evenly through the nose until the greatest chest expansion is achieved
6.6.2 Hold your breath for 2 to 3 seconds.
6.6.3 Then exhale slowly through the mouth.
6.6.4 Continue exhalation until maximum chest contraction has been achieved.
6.7 Help the client perform deep-breathing exercises.
6.7.1 Ask the client to assume a sitting position.
6.7.2 Place the palms of your hands on the border of the clients rib cage to assess
respiratory
depth.
6.7.3 Ask the client to perform deep breathing.
6.8 Instruct the client to cough voluntarily after a few deep inhalations.
6.8.1 Ask the client to inhale deeply, hold the breath for a few seconds, and then
cough once
or twice.
6.8.2 Ensure that the client coughs deeply and does not just clear the throat.
6.9 If the incision will be painful when the client coughs, demonstrate techniques to
splint the
abdomen.
6.9.1 Show the client how to support the incision by placing the palms of the hands
on either
side of the incision site or directly over the incision site, holding the palm of
one hand
over the other.
6.9.2 Show the client how to splint the abdomen with clasped hands and a firmly
rolled pillow
7
held against
the clients abdomen.
REFERENCE:
6.10Inform the client
about
the
expected
frequency
of
these
exercises.
7.1 Fundamentals of Nursing concepts, process, and practice
6.10.1 Instruct the
client to start the exercises as soon after surgery as possible.
7th Edition
6.10.2 Encourage clients
with
abdominal
orErb,
chest
surgery
to carry
out deep
Barbara
Kozier,
Glenora
Audrey
Berman,
Shirlee
Snyder
breathing and
335
coughing at least every 2 hours, taking a minimum of five breaths at each
session.
6.11Document the teaching and all assessments.
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Republic of
Hospital
48
337
Republic of
Yemen 48Modern
Hospital
48
48 MODERN HOSPITAL
Republic of
POLICIES:
Yemen
6.1 Doctors
order 48Modern
of treatment should be documented.
Hospital
339
48
Republic of
Yemen 48Modern
PROCEDURES:
48
Hospital
sequence of
procedure.
7.2 Identify correct patient to prevent errors.
6.2 Should be done for 20-30 minutes before meals or 2 hours after meals and at bed
7.3 Wash hands before and after procedure and wear gloves to prevent crosstime (2-4 x a
contamination.
day).
7.4 Explain the procedure and any adverse effects patient might experience in order to
6.3 Discontinue procedure if tachycardia, palpitation, dyspnea, chest pain or other
allay anxiety
symptoms which
and gain better cooperation.
may indicate hypoxemia.
7.5 Assemble equipment/supplies.
6.4 Keep patient in bed for 1 hour after the procedure.
7.6 Provide privacy.
6.5 Procedure is done under close supervision.
7.7 Assess the condition by auscultating the lungs. Check vital signs as baseline
7
information.
7.8 Determine the time patient had taken last diet/tube feeding.
7.9 Let the patient wear loose fitting gown.
7.10Administer medication that may decrease pain perception as needed/ordered.
7.11Provide tissue and emesis basin to the patient.
7.12Position the patient.
7.12.1 Maintain each position for at least 5-10 minutes and a maximum of 20-30
minutes for
the entire procedure.
7.12.2 Make the patient at ease before the procedure and as comfortable as possible
while he
assumes each position. Patient is positioned so that affected area is near
vertical position
and gravity is used to assist drainage of the specific segment.
7.12.3 Encourage patient to breath slowly through the nose and blow through the
mouth while
assuming position.
7.12.4 Use chest percussion and vibration to loosen bronchial secretion and propel
sputum in
the direction of gravity drainage, if ordered.
7.12.4.1Percussion:
7.12.4.1.1 Instruct the patient to breath slowly and deeply using the
diaphragm to
promote relaxation.
7.12.4.1.2 Keep hands in a cupped shape with fingers flexed and thumb
pressed
tightly against the index finger.
7.12.4.1.3 Percuss each segment for 1-2 minutes by alternating the hands in a
rhythmic manner.
7.12.4.1.4 Listen for a hollow sound on percussion to verify correct
performance of
the technique.
7.12.4.2Vibration:
7.12.4.2.1 Ask the patient to inhale deeply and then exhale through pursed
lips.
7.12.4.2.2 During exhalation firmly press the hand flat against the chest wall.
7.12.4.2.3 Vibrate during 5 exhalation over each chest segment.
7.12.4.2.4 After 3 or 4 vibrations, encourage patient to cough using
diaphragmatic
breathing throughout postural drainage exercise, to be done in
accordance
to patients tolerance.
7.12.5 Observe clinical response of patient and listen to changes in breathing sound.
7.13Suction as required or as ordered.
7.14Assist the patient in a comfortable position and reassess the condition after the
procedure.
340
7.14.1 Advice patient to brush teeth and use mouthwash after the procedure.
7.15Encourage fluid intake to maintain fluid-electrolyte balance and prevent
dehydration.
Republic of
Yemen 48Modern
48
Hospital
7.16Aftercare of equipment.
7.17Document in the Nursing Notes:
7.17.1 Time and date.
7.17.2 Positions maintained and duration of the procedure.
7.17.3 Amount, character, color, and odor of secretion
expectorated.
7.17.4 Patients tolerance to procedure.
7.17.5 Untoward reaction noted during the procedure.
7.18Charge the procedure and supplies used in the Inpatient
Charging Form
341
Republic of
Yemen 48Modern
Hospital
48
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Pre-Operative Care
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the procedure of rendering
preoperative care.
1 DEFINITION:
1.1 Preoperative care is the preparation and assessment of physical, physiological, and
psychological condition of the patient prior to surgery.
2 PURPOSES:
2.1 Physical:
2.1.1 To minimize post-op complications e.g. by teaching deep-breathing exercises,
early
ambulation, following infection control measures.
2.1.2 To assess the physical condition of the patient so that potential problems can be
anticipated and prevented.
2.1.3 To ensure that the patient is on optimum physical condition prior to surgery.
2.1.4 To minimize the risk of surgical wound infection.
2.2 Psychological:
2.2.1 To ensure that patient understands the nature of the surgery to be done.
2.2.2 To teach the patient what to expect post-operatively e.g. about any drain,
catheters, and
so on that may be necessary afterwards.
2.2.3 To assess the area of anxiety that patient may have and discuss them using
nursing
intervention, if appropriate.
2.3 Physiological:
2.3.1 To ensure all necessary investigations (lab, ECG, x-ray) have been done.
2.3.2 To assist in bowel and bladder preparation by the means of
enema/catherization, if
indicated.
2.4 Legal:
2.4.1 To obtain an informed consent from the patient to protect the health team
members, and
the institution against any claim by the patient. Refer to Informed Consent
Policy GW019).
3 EQUIPMENTS/SUPPLIES:
3.1 Razor (disposable, if possible)
3.2 Disposable gloves
3.3 Blue sheet
3.4 Supplies for bathing (Refer to Bathing Procedures)
3.5 Specimen bottles, if needed
3.6 Kidney basin
3.7 Enema kit (Refer to Enema Procedures)
3.8 Clean gown, bedsheet, drawsheet, blanket
3.9 Documentation: Consent form, OR Checklist,
Consent for Valuables
342
Republic of
POLICIES:
Yemen
48Modern
4.1 Ensure
safety by:
4.1.1 Identifying
correct patient.
Hospital
48
343
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
Hospital
48
5.2.3.2 Get verbal consent from the patient. If patient is unconscious inform the
relatives.
5.2.3.3 Assess skin site for rash, abrasion.
5.2.3.4 Take extra caution to avoid cuts and epidermal damage.
5.2.4 Use sterile gauze to swab the operation site with skin disinfectant for 2
minutes.
5.2.5 Let the patient to void immediately before going to Operation Room.
5.2.5.1 Use indwelling catheter, if required as per doctors order. Observe
aseptic
technique.
5.2.6 Take vital signs and give pre-medications as ordered.
5.2.7 Complete the pre-operative checklist. (Form M1003)
5.2.8 Allergies and any positive result for HIV and Hepatitis test should be noted
outside the
patients file and should be verbally endorsed to OR Nurse.
5.2.9 Keep patient covered. Do not expose female patients hair and face.
5.2.10 Raise bedside rails and keep the bed locked to ensure safety during transfer.
5.2.11 The assigned nurse will accompany the patient to Operating Room upon
receiving a call
from OR staff.
5.2.11.1Endorse patient to OR staff along with complete file, X-Ray films,
medication (if
any) and PIN card.
5.2.11.1.1 Prepare post op bed and leave in the corridor outside the Recovery
Room
Area.
SPECIAL CONSIDERATIONS:
5.2.11.1.2
Keep bedside
rails up to prevent
relatives
sitting
or lying
on
6.1 In high
risk operation,
use antimicrobial
soap as
bathing from
agent,
otherwise,
follow
the
bed.
the
procedure
5.2.12
Aftercare of equipment.
above.
5.2.13
Charge
the procedure
and supplies
used in
thehas
Inpatient
Charging
Form. or is
6.2 Special
precautions
are necessary
for patient
who
diabetic
foot, gangrene
a victim of
RTA (Road Traffic Accident) because the skin may become heavily contaminated.
6.2.1 On the day of operation, bath should be given to the patient before sending to
OR. Wash
operation site with anti-microbial soap in 3 separate occasions. If there is no
time, cover
the area with povidine-iodine and leave it for at least 30 minutes.
6.2.2 Subsequent cleaning can be done in the Operation Theatre.
363
345
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Pressure Ulcer Assessment
Republic of
Yemen 48Modern
48
Hospital
4.2.4 Total score is then computed. If Braden Scale is less than 16 (<16), nurse
initiates
appropriate intervention according to pressure ulcer intervention
guidelines.
4.2.5 Section II This specify the exact site and location of the pressure ulcer.
Encircle
the number according to the area affected.
4.2.6 Section III Initial/Weekly Pressure Ulcer Assessment (back of the form)
pressure ulcer
assessment is documented by checking the corresponding item according to the
descriptions weekly.
4.3 Nurses signature is affixed completely.
347
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
6.7 Insert lubricated gloved finger into rectum to check for possible obstructions prior
to insertion of
rectal tube.
6.8 Change gloves if soiled from rectal examination.
6.9 Lubricate end of catheter.
6.10Gently insert catheter into anal canal approximately 10-15 cm. (4-6) while
instructing patient to
breath deeply and slowly to relax anal sphincter.
6.11Immerse other end of the rectal tube into the disposable kidney basin filled with
tap water.
6.12Observe for return flow.
6.13Tape rectal tube into the buttocks and the other end of tube to kidney basin or
attach drainage
bag to end of catheter if rectal tube is not to be removed within 30 minutes.
6.14If desired outcome is obtained, remove the catheter gently. If time limit exceeds
without positive
result, inform the physician.
6.15Aftercare of equipment. Remove gloves and wash hands.
6.16Assist the patient in comfortable position.
6.17Document the following:
6.17.1 Date and time of insertion.
6.17.2 Amount, color, and consistency of any expelled contents.
6.17.3 Assessment of patients abdomen hard, distended, soft, drum-like on
percussion.
6.17.4 Presence of bowel sounds before and after insertion.
6.18Charge the procedure and supplies used.
349
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Removing, Cleaning, and Inserting a Hearing
Aid
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the procedure on removing,
cleaning,
and inserting a hearing aid.
1 DEFINITION:
1.1 Hearing Aid an appliance placed in the external ear/s that aids in hearing.
2 PURPOSES:
2.1 To enhance hearing capabilities of a client having impaired hearing.
3 EQUIPMENTS/SUPPLIES:
3.1 Clients hearing aid
3.2 Soap, water, and towels, or a damp cloth
3.3 Pipe cleaner or toothpick (optional)
3.4 New battery (if needed)
4 POLICIES:
4.1 Infection control policy must be observed.
4.2 Privacy must be observed.
5 PREPARATIONS:
5.1 Assess:
5.1.1 For the presence of inflammation, excessive wax, drainage, or discomfort in the
external
ear
5.2 Determine:
5.2.1 If the client has experienced any problems with the hearing aid and hearing aid
PROCEDURES:
6
practices
6.1 Explain to the client what you are going to do, why it is necessary, and how he can
5.3
Assemble
equipment
and
supplies:
cooperate.
6.2 Wash hands and observe other appropriate infection control procedures.
6.3 Provide for client privacy.
6.4 Remove the hearing aid.
6.4.1 Turn the hearing aid off and lower the volume.
6.4.2 Remove the earmold by rotating it slightly forward and pulling it outward.
6.4.3 If the hearing aid is not to be used for several days, remove the battery.
6.4.4 Store the hearing aid in a safe place, and label with clients name.
6.4.5 Avoid exposure to heat and moisture.
6.5 Clean the earmold.
6.5.1 Detach the earmold if possible.
6.5.2 Disconnect the earmold from the receiver of a body hearing aid, or from the
hearing aid
case of behind the- ear and eyeglasses hearing aids where the tubing meets the
hook of
the case.
6.5.3 Do not remove the earmold if it is glued or secured by a small metal ring.
6.5.4 If the earmold is detachable, soak it in a mild soapy solution. Rinse and dry it
well.
6.5.5 Do not use isopropyl alcohol.
350
6.5.6 If the earmold is not detachable, or is for an in-the-ear aid, wipe the earmold
with a damp
cloth.
Republic of
Yemen 48Modern
48
Hospital
Check that the earmold opening is patent. Blow any excess moisture6.5.7
through
the
351
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
Hospital
48
3 INDICATIONS:
2
PURPOSES:
3.1
For psychiatric patients who are highly combative, agitated and restless.
2.1
To elderly
ensure patients
patientswho
safety
security
respecting his/her rights and dignity and
3.2 For
areand
restless
andwhile
uncooperative.
ensuring
3.3 For confused or disoriented patients.
relation
use of during
restraint.
3.4well-being
For infantsinand
small to
children
treatments and examinations.
2.2
To
limit
movement
of
confused,
disoriented or combative patients from injuring self or
4 CONTRAINDICATIONS:
others.
4.1 For seizure-prone patients because they exaggerate the risk of fracture and trauma.
2.3Presence
To facilitate
examination
and to aidas
initdiagnostic
treatment.
4.2
of wounds
or IV catheters
may causetests
skinand
irritation
and restrict blood
2.4
To
establish
a
patient-focused
process
for
implementation,
application and
flow.
documentation of the
5 POLICIES:
of restraints.
5.2use
Restraints
can only be implemented through a written order from an appropriate
medical
official.
5.2.1 A documented nursing assessment is available prior to notifying the physician
and
recommending restraints.
5.2.2 Orders are to be confined to the type of restraint and the length of time the
restraint will
be used.
5.2.3 Physicians must assess and reassess patients as appropriate and documented
in the
patients file.
5.2.4 Nurses must assess the restrained limb every 30 minutes to check for the
status of the
circulation and the patients responses. It should be documented in the medical
record.
5.3 A patients condition should be monitored, regularly reviewed, and documented
during the
period he is restrained.
5.4 Patients dignity and rights are protected.
5.4.1 Patient should be kept covered when attending to his/her physical needs.
5.5 Underlying principles for applying physical restraints should be observed at all
times.
5.5.1 Restraints should be used only when necessary.
5.5.2 The least restrictive and most effective means of restraint is used.
5.5.3 Restraints should be applied correctly and appropriately.
5.5.4 Restraints should be applied in such a way as to allow immediate release in
cases of
emergency situations.
5.5.5 Restraints should always be applied in a manner that maintains proper body
alignment
and ensures comfort.
5.6 A person who should apply restraint should be competent enough.
5.7 The reason for using restraints should be explained to the patient and family to
prevent
misinterpretation and to ensure cooperation.
5.8 Restraints should be checked frequently to make sure that it is effective. It should
be removed
periodically to prevent skin irritation or impairment or circulation.
5.9 Any restraint that requires attachment to the bed should be secured to the bedsprings
6 PREPARATIONS:
or frame,
Assess:
never the mattress or side6.1
rails.
This allows the side rails to be adjusted without
6.1.1
The behavior indicating the possible need for a
removing the
restraint
restraint or injuring the patients extremity.353
5.10 Any knots that are required should be tied in a manner that permits their quick
release. This is a
safety precaution.
Republic of
Yemen 48Modern
Hospital
48
7 PROCEDURES:
7.1 Determine the need for restraint. If indicated, obtain doctors order which includes
the type of
restraints
to Underlying
be used and
the length
of timebehavior
the restraints will be used.
6.1.2
cause
for assessed
7.2 Explain
reason
for
use
of
restraint
to
the
patient
and
family. And obtain
6.1.3 What other protective measures may be
implemented
before informed
applying
consentafrom
restraint
the patient
familyofbefore
applying
the restraint.
6.1.4or
Status
skin to
which restraint
is to be applied
7.3 Wash6.1.5
hands.
Circulatory status distal to restraints and of extremities
7.4 Provide
forEffectiveness
client privacy,ofifother
indicated.
6.1.6
available safety precautions
7.5 To apply
restraint,
consider
the
6.2 Assemble equipment and following:
supplies:
7.5.1 Belt
Restraint
(Safety
Belt)
6.2.1
Appropriate
type
and size of restraint
7.5.1.1 Determine that the safety belt is in good order. If a Velcro safety belt is to be
used,
make sure that both pieces of Velcro are intact.
7.5.1.2 If the belt has a long portion and a shorter portion, place the long portion of
the belt
behind (under) the bedridden client and secure it to the movable part of the bed
frame.
7.5.1.3 Place the shorter portion of the belt around the clients waist, over the gown.
7.5.1.4 There should be a fingers width between the belt and the client; or
7.5.1.5 Attach the belt around the clients waist, and fasten it at the back of the
chair; or
7.5.1.6 If the belt is attached to a stretcher, secure the belt firmly over the clients
hips or
abdomen.
7.5.2 Jacket Restraint
7.5.2.1 Place vest on client, with opening at the front or the back, depending on the
type.
7.5.2.2 Pull the tie on the end of the vest flap across the chest, and place it through
the slit in
the opposite side of the chest.
7.5.2.3 Repeat for the other tie.
7.5.2.4 Use a half-bow knot to secure each tie around the movable bed frame, or
behind the
chair to a chair leg.
7.5.2.5 Fasten the ties together behind the chair using a square (reef) knot.
7.5.2.6 Ensure that the client is positioned appropriately to enable maximum chest
expansion
for breathing.
7.5.3 Mitt Restraint
7.5.3.1 Apply the commercial thumbless mitt to the hand to be restrained.
7.5.3.2 Make sure the fingers can be slightly flexed and are not caught under the
hand.
7.5.3.3 Follow the manufacturers directions or securing the mitt.
7.5.3.4 If a mitt is to be worn for several days, remove it at least every 24 hours.
7.5.3.5 Wash and exercise the clients hand, then reapply the mitt.
7.5.3.6 Check agency practices about recommended intervals for removal.
7.5.3.7 Assess the clients circulation to the hands shortly after the mitt is applied
and at
regular intervals.
7.5.4 Wrist or Ankle Restraint
7.5.4.1 Pad bony prominences on the wrist or ankle, if needed to prevent skin
breakdown.
7.5.4.2 Apply the padded portion of the restraint around the ankle or wrist.
7.5.4.3 Pull the tie of the restraint through the slit in the wrist portion or through
the buckle.
7.5.4.4 Using a half-bow or a square knot,
354 as appropriate, attach the other end of the
restraint
to the movable portion of the bed frame.
7.5.4.5 Remove restraint for at least 15 minutes every 2 hours.
Republic of
Yemen 48Modern
48
Hospital
355
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: SGH Cocktail
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure discusses about the components and
indications of
SGH cocktail.
1 DEFINITION:
1.1 SGH Cocktail - an in-house preparation of mixture using more than 2 drugs
incorporated to IV
fluids mainly NSS, given via infusion for orthopedic cases.
2 PURPOSE:
2.1 To relieve pain and inflammation.
3 CONTRAINDICATION:
3.1 Depending on the disease condition and doctors order (e.g. diabetic, hypertension).
4 EQUIPMENTS/SUPPLIES:
4.1 NSS and other medications
4.2 IV cannula (different sizes)
4.3 IV tubing
4.4 Tourniquet
4.5 Transparent dressing - IV 3000
4.6 Blue pad
4.7 Disposable gloves
4.8 Razor
4.9 Syringes and needles
4.10IV Pole
4.11Adhesive tape
4.12Small sharp container
4.13Sterile gauze
4.14Band aid
4.15Alcohol pad
4.16Sterile H2O
5
TYPES AND COMPONENTS:
5.1 SGH Cocktail 1
5.1.1 NSS 500ml.
5.1.2 Tilcotil 20mg
5.1.3 Lasix 10mg
5.1.4 Solu Cortef 100mg
5.1.5 Becozyme 2ml
5.2 SGH Cocktail 2
5.2.1 NSS 500ml.
5.2.2 Lasix 10mg
5.2.3 Solu Cortef 50mg
5.2.4 Becozyme 2ml
5.2.5 Tilcotil 20mg.
5.3 SGH Cocktail 3
5.3.1 NSS 500ml
5.3.2 Tilcotil 20mg
356
Republic of
Yemen 48Modern
48
Hospital
357
Republic of
Yemen 48Modern
Hospital
48
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Applies to: General Ward and Specialty Units
Title: Cleaning Mercury Spills
CONTENTS: This General Ward policy and procedure deals with the guidelines on how safely
clean
mercury spills
1 DEFINITION:
1.1 Liquid Mercury Spills also known as elemental or metallic mercury, forms a droplet
that can
accumulate in the tiniest of spaces and then emit vapors into the air.
1.1.1 Mercury vapor in the air is odorless, colorless, and very toxic.
1.1.2 Most mercury exposures occur by breathing vapors, by direct skin contact or by
eating food
or drinking water contaminated with mercury.
1.1.3 Health problems caused by mercury depend on how much has entered your body,
how it
entered your body, how long you have been exposed to it, and how your body
responds to
the mercury.
2 PURPOSES:
2.1 To prevent occurrence of serious health complications brought about by exposure to
mercury.
3 POLICIES:
3.1 All mercury spills, regardless of quantity, should be treated seriously.
3.2 Observe strictly the precautions in cleaning mercury spills:
3.2.1 Never use a vacuum cleaner to clean up mercury. The vacuum will put mercury
into the air
and increase exposure. The vacuum appliance will be contaminated and have to be
thrown
away.
3.2.2 Never use a broom to clean up mercury. It will break the mercury into smaller
droplets and
spread them.
3.2.3 Never pour mercury down a drain. It may lodge in the plumbing and cause future
problems
during plumbing repairs. If discharged, it can cause pollution of the septic tank or
sewage
treatment plant.
3.2.4 Never wash mercury-contaminated items in a washing machine. Mercury may
contaminate
the machine and/or pollute sewage.
3.2.5 Never walk around if your shoes might be contaminated with mercury.
Contaminated
clothing can also spread mercury around.
3.3 Mercury spills should be reported to the local authority for proper disposal.
4 EQUIPMENTS:
4.1 4 to 5 ziplock-type bags
4.2 trash bags (2 to 6 mm thick)
4.3 rubber or latex gloves
4.4 paper towels
4.5 cardboard or squeegee
4.6 eyedropper
358
4.7 duct tape, or shaving cream & small paint brush
4.8 flashlight
4.9 powdered sulfur (optional)
Republic of
PREPARATIONS:
Yemen
48Modern
5.1 Remove
everyone
from the area where cleanup will take place.
5.2 Shut door of
impacted area.
Hospital
359
48
PROCEDURES:
Republic of
6.1 Spills: Less than or equal to the amount in a thermometer
Yemen 48Modern
48
6.1.1 Put on rubber or latex gloves.
Hospital
6.1.2 If there
are any broken pieces of glass or sharp objects, pick them up with
care.
Place all
broken objects on a paper towel. Fold the paper towel and place in a zip lock bag.
Secure
the bag and label it.
5.3 Turn off ventilation system.
6.1.3 Locate visible mercury beads. Use a squeegee or cardboard to gather mercury
5.4 Mercury can be cleaned up easily from the following surfaces: wood, linoleum, tile
beads. Use
and any other
slow sweeping motions to keep mercury from becoming uncontrollable. Take a
like surfaces.
flashlight,
5.5 If a spill occurs on carpet, curtains, upholstery or other like surfaces, these
hold it at a low angle close to the floor in a darkened room and look for additional
contaminated items
glistening beads of mercury that may be sticking to the surface or in small
should be thrown away.
cracked areas of
5.6 Only cut and remove the affected portion of the contaminated carpet for disposal.
the surface. Note: Mercury can move surprising distances on hard-flat surfaces,
6
so be sure
to inspect the entire room when "searching."
6.1.4 Use the eyedropper to collect or draw up the mercury beads. Slowly and
carefully squeeze
mercury onto a damp paper towel. Place the paper towel in a zip lock bag and
secure. Make
sure to label the bag.
6.1.5 After you remove larger beads, put shaving cream on top of small paint brush
and gently
"dot" the affected area to pick up smaller hard-to-see beads. Alternatively, use
duct tape to
collect smaller hard-to-see beads. Place the paint brush or duct tape in a zip lock
bag and
secure. Make sure to label the bag.
6.1.6 OPTIONAL STEP: It is OPTIONAL to use commercially available powdered sulfur to
absorb the beads that are too small to see. The sulfur does two things: (1) it
makes the
mercury easier to see since there may be a color change from yellow to brown
and (2) it
binds the mercury so that it can be easily removed and suppresses the vapor of
any missing
mercury.
6.1.6.1 Note: Powdered sulfur may stain fabrics a dark color. When using powdered
sulfur, do
not breathe in the powder as it can be moderately toxic. Additionally, users
should
read and understand product information before use.
6.1.7 Place all materials used with the cleanup, including gloves, in a trash bag. Place
all
mercury beads and objects into the trash bag. Secure trash bag and label.
6.1.8 Contact the local Ministry of Health Department, municipal waste authority or
the local fire
department for proper disposal in accordance with the laws.
6.1.9 Remember to keep the area well-ventilated to the outside (i.e., windows open
and fans
running) for at least 24 hours after your successful cleanup.
6.2 Spills: More than the amount in a thermometer
6.2.1Isolate the area.
6.2.2 Turn down temperature.
6.2.3 Open windows.
6.2.4 Don't let anyone walk through the mercury.
6.2.5 Don't vacuum.
6.2.6 Contact the local Ministry of Health.
6.2.7
6.3 Spills: Greater than One Pound (Two Tablespoons)
360
6.3.1 Any time one pound or more of mercury is released to the environment, it is
mandatory to
call the authority at once Ministry of Health or the Fire Department.
Republic of
Yemen 48Modern
48
Hospital
7 REFERENCE:
7.1 Environmental Protection Agency homepage; //
www.EPA.com
361
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Sitz Bath
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines procedures in
sitz bath
administration.
1 DEFINITION:
1.1 Sitz Bath - a method of immersing the perineal area in warm water with or without
medicated
solution, as indicated.
2 PURPOSES:
2.1 To relieve discomfort.
2.2 To promote wound healing.
2.3 To increase circulation and reduce inflammation.
2.4 To relax local muscles.
2.5 To facilitate easy removal of anal pack.
3 INDICATIONS:
3.1 Rectal surgery/episiotomy during childbirth.
3.2 Painful hemorrhoids/vaginal inflammation.
4 CONTRAINDICATION:
4.1 Non-ambulatory, debilitated patients.
5 EQUIPMENTS/SUPPLIES:
5.1 Sitz basin
5.2 Solution or medication
5.3 Mat bath
5.4 Towels
5.5 Patients gown
5.6 Dressing and ointment as ordered.
5.7 Disposable gloves
5.8 Thermometer
5.9 Sphygmomanometer and Stethoscope
6 POLICIES:
6.1 Obtain Obtain physicians order. Identify correct client.
6.2 Follow standard precautions.
6.3 Sitz bath should not be more than 15-20 minutes, as indicated.
7
PROCEDURES:
6.4 Check water temperature according to patients tolerance.
7.1 Check doctors order and assess patients condition.
7.2 Explain the procedure and wash hands.
7.3 Prepare all necessary items needed.
7.4 Check vital signs, instructs the patient to void.
7.5 Provide privacy. Collect water in the sitz bath basin. Check the temperature. It should
not be too hot
or too cold.
7.6 Wear gloves. Instruct and assist patient to sit on the basin slowly to immerse the
perineal area and to
hold on for 10-20 minutes.
7.7 Provide safety measures.
363
7.8 Drape to avoid chills that may cause vasoconstriction.
Republic of
Yemen 48Modern
48
Hospital
7.9 Stay with patient for a while to assess general condition or reaction.
7.10When the prescribed time is finished, ask the patient to use the safety rail for
standing.
7.11Assist back to the bed, redress the wound, if needed.
7.12Reassess patients general condition.
7.13Aftercare of equipment.
7.14Remove gloves and wash hands.
7.15Document: time, duration, wound condition before and after, vital signs, tolerance
and any
complications.
7.16Charge the procedure and supplies used.
364
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Skin Test
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the procedures in performing
skin test.
1 DEFINITION:
1.1 Medication a substance used to promote health, to prevent, to diagnose, to alleviate
or cure
diseases.
1.2 Medication Preparation one of the nursing functions of setting the medicines ready for
administration. The process involves accurate dosage, calculation, measurement and
proper handling
of medicines. Medication preparation includes skin testing to certain drugs.
1.3 Skin Test a method for determining induced sensitivity by applying an antigen
(allergen) or
inoculating it into the skin, induced sensitivity (allergy) to the specific antigen is
indicated by an
inflammatory reaction of one of two general kinds.
1.4 Results of Skin Test result of hypersensitivity reaction either :
1.4.1 Positive Result/Response itching and marked increase in the size of the original
bleb. A
wheal greater than 5mm or more with significant flair 10mm or more or with
pseudopodia.
1.4.2 Negative Result/Response no increase in the size of the original bleb or no
greater than
the control site.
1.5 Ambiguous Result/Response a wheal reaction slightly larger than the original bleb with
or
without accompanying erythematous flare and larger than the control site.
2 PURPOSE:
2.1 To ensure client safety in the administration of medication.
2.2 To determine the sensitivity for certain medication.
2.3 To reduce the incidence and severity of hypersensitive reaction.
3 EQUIPMENTS/SUPPLIES:
3.1 Prescribed medicine
3.2 Medication tray
3.3 Tuberculine syringe
3.4 Sterile gauze
3.5 Alcohol swabs
3.6 Underpads
3.7 Saline solution or sterile water
3.8 Sharp disposal container
3.9 Stethoscope
3.10 Sphygmomanometer
3.11Thermometer
POLICIES:
4.1 Preparation
365
Republic of
4.1.1 Aseptic technique and proper procedure in handling and preparation of medication.
48
4.1.2Yemen
Medicines 48Modern
should be prepared in the medication preparation area properly
lighted.
4.2 Anaphylactic
tray should be available at bedside.
Hospital
366
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
5.4.4.3 Forearm site should be 3-4 finger width below ante cubital fossa and one
hand width
above the wrist on inner aspect of forearm.
5.4.4.4 Locate an area of skin on the inner volar surface of the forearm.
5.4.5 Use antiseptic swab in a circular motion to clean the site.
5.4.6 While holding the swab with non dominant hand, pull cap from needle.
5.4.7 With non dominant hand, stretch the skin over the site with forefinger and
thumb.
5.4.8 Insert needle slowly at 5-15 degrees angle, bevel up, until resistance is
felt.Advance to no
more than 1/8 inch below the skin. The middle tip should be seen through the
skin.
5.4.9 Do not aspirate, slowly inject the medication until resistance will be felt. Note a
small bleb,
like a mosquito bite forming under the skin pressure.
5.4.10 Withdraw needle while applying antiseptic swab.
5.4.11 Do not massage the site.
5.4.12 Draw a circle around the parameter of injection site using black ink.
5.4.13 Dispose syringe with needle in the sharp container.
5.4.14 After 30 minutes, inform the physician to evaluate the result.
5.5 Assist client to a comfortable position.
5.6 Observe closely for adverse reaction as skin test is administered and for several
times there after.
5.7 Wash hands.
5.8 Charge and dispose the supplies used.
5.9 If client is for admission, document the skin test in the nurses notes.
368
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
369
Republic of
48
370
Republic of
Yemen 48Modern
48
Hospital
6.6.1.1 Let the patient pass stool in bedpan. Request patient to avoid voiding so as
not to
small
it.
371
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the procedures in performing
Title: Suctioning
suction.
1 DEFINITION:
1.1 Suctioning - the aspiration of secretions by a catheter connected to suction machine
with an
application of a negative pressure to create vacuum to enable secretions to move from
an area of
higher pressure (airway) to an area of lower pressure (suction bottle).
1.1.1 Oropharyngeal and Nasopharyngeal
Is used when the patient is able to cough effectively but is unable to clear secretions by
expectorating or swallowing.
1.1.1 Orotracheal and Nasotracheal
Is necessary when the client with pulmonary secretions is unable to cough and does not
have an
artificial airway. This technique is similar as above, but the catheter tip is moved
further in to
suction the trachea.
1.1.1 Suctioning through an Artificial Airway
An artificial airway is an oral airway or an endotracheal, nasotracheal or tracheostomy
tube.
Indications for an artificial airway include decreased level of consciousness, airway
obstruction,
mechanical ventilation and removal of tracheal secretions.
2 PURPOSES:
2.1 To provide a patent airway by keeping it clear of excessive secretions
2.2 To obtain sputum specimen for diagnostic purposes.
2.3 To prevent infection that may result from the accumulation of secretions in the
respiratory tract.
2.4 To provide rest and comfort.
3 INDICATIONS:
3.1 Inability to cough and expectorate effectively (infants and comatose patients).
3.2 Inability to swallow.
3.3 Light bubbling or rattling breath sounds that indicates the accumulation of secretions.
3.4 When patient shows any signs and symptoms of hypoxia.
3.5 Labored respirations.
3.6 Increased peak inspiratory pressure in patient on mechanical ventilation.
4 EQUIPMENTS/SUPPLIES:
4.1 Sterile gloves
4.2 NSS
4.3 Sterile suction catheter
4.4 Suction machine
4.5 Kidney basin
4.6 Mask
4.7 Kleenex/Tissue paper
4.8 Materials needed for oral care and tracheostomy care
4.9 Stethoscope
372
4.10 Oxygen if necessary
4.11Underpad
4.12Pulse Oximeter
Republic of
Yemen 48Modern
Hospital
48
5
POLICIES:
5.1 Infection control policy should be followed.
5.2 Proper assessment of patients condition should be done before and after suctioning.
Monitor the
following:
5.2.1 Rate depth and rhythm of respiration to evaluate airway.
5.2.2 Oxygen saturation to determine oxygen level and adequate air exchange.
5.3 Encourage coughing and deep breathing to decrease need for suctioning.
5.4 Everytime suctioning is done, a sterile suction catheter should be used.
5.5 Suctioning should be done 10-15 seconds only.
6
PREPARATIONS:
6.1 Assess:
6.1.1 Client for the presence of congestion on auscultation of the thorax
PROCEDURES:
6.1.2 Note
the clients
ability orindicating
inability to
remove the
secretions
coughing
7.1 Assess
for signs
and symptoms
presence
of upper
airwaythrough
secretions;
6.2 Determine:
gurgling
6.2.1 If the client
has been
suctioninpreviously;
if so, review
the documentation
respirations,
restlessness,
vomitus
mouth, drooling.
Auscultate
breath sounds.of the
procedure
7.2
Wash hands.
6.2.2 Assemble
equipment
supplies.
7.3 Assemble
all equipments
toand
be used.
7
7.4 Explain the procedure to the patient, (if patient is conscious).
7.5 Provide privacy.
7.6 Place patient in a comfortable working position. Lower siderails closer to you. Place
the patient in
semi-fowlers position if conscious, and unconscious patient should be placed in lateral
position
facing you.
7.7 Place blue sheet across patients chest.
7.8 Turn suction to appropriate pressure:
7.8.1 Wall unit
Adult : 100 - 120 mmHg
Child : 95 - 110 mmHg
Infant : 50 - 95 mmHg
7.8.1 Portable unit
Adult : 10 - 15 mmHg
Child : 5 - 10 mmHg
Infant : 2 - 5 mmHg
7.9 Administer oxygen as ordered (Refer to oxygen inhalation therapy procedure)
7.10Open sterile suction package. Set-up sterile container touching only the outside
surface and pour
sterile saline solution.
7.11Wear sterile gloves and mask.
7.12The dominant hand will handle the catheter and must remain sterile, while the nondominant hand
is considered clean rather than sterile.
7.13Using dominant hand, pick-up the sterile catheter and connect to suction tubing that
is held with
non-dominant hand or unsterile hand.
7.14Moisten the catheter by dipping into the container of sterile saline. Occlude Y-tube to
check
suction.
7.15Suctioning technique:
7.15.1 Nasopharyngeal or Oropharyngeal Cavities:
7.15.1.1Prepare the client.
7.15.1.1.1 Position a conscious person
373who has a functional gag reflex in the
semiFowlers position, with the head turned to one side for oral suctioning or
with
Republic of
Yemen 48Modern
Hospital
48
7.15.1.8.2 Attach the suction tubing to the sputum trap air vent.
7.15.1.8.3 Suction the clients nasopharynx or oropharynx. The sputum trap
will collect
the mucus during suctioning.
7.15.1.8.4 Remove the catheter from the client.
7.15.1.8.5 Disconnect the sputum trap tubing from the suction catheter.
7.15.1.8.6 Remove the suction tubing from the trap air vent.
7.15.1.8.7 Connect the tubing of the sputum trap to the air vent. Connect the
suction
catheter to the tubing.
7.15.1.8.8 Flush the catheter to remove secretions from the tubing.
7.15.1.9Promote client comfort.
7.15.1.9.1 Offer to assist the client with oral or nasal hygiene Assist the client
to a
position that facilitates breathing.
7.15.1.10Dispose of equipment and ensure availability for the next suction.
7.15.1.10.1Dispose of the catheter, gloves, water, and waste container.
7.15.1.10.2 Wrap the catheter around your sterile gloved hand and hold the
catheter as the
glove is removed over it for disposal.
7.15.1.10.3 Rinse the suction tubing as needed by inserting the end of the
tubing
into the or Nasotracheal
7.15.1
Orotracheal
used
water container.
Empty and
theorsuction
collection
container
7.15.1.1The
catheter
is passed through
therinse
mouth
nose and
move further
in to
as
suction
the
needed or indicated by protocol.
trachea.
7.15.1.10.4 procedure
Change theas
suction
tubing and and
container
daily.
7.15.1.2Same
in oropharyngeal
nasopharyngeal
suctioning.
Ensure that supplies are available for the next suctioning.
7.15.27.15.1.10.5
Artificial Airway
7.15.1.11Assess
theaeffectiveness
ofor
suctioning.
7.15.2.1Suctioning
Tracheostomy
Endotracheal Tube
7.15.1.11.1Auscultate
the
clients
breath
o ensure they
are clear
7.15.2.1.1 Prepare the equipment. Attachsounds
the resuscitation
apparatus
toof
the
secretions.
oxygen
7.15.1.11.2Observe
skin color, dyspnea, and level of anxiety.
source.
7.15.1.12Document
relevant
Record
the100
procedure:
7.15.2.1.1.1Adjust
thedata.
oxygen
flow to
percent flush. Open the sterile
7.15.1.12.1The
amount, consistency, color, and odor of sputum
supplies
in
7.15.1.12.2The
clientsfor
breathing
status before and after the procedure
readiness
use.
7.15.2.1.1.2Place the sterile towel, if used, across the clients chest below
the
tracheostomy.
7.15.2.1.1.3Turn on the suction, and set the pressure in accordance with
agency
policy.
7.15.2.1.1.4Put on goggles, mask, and gown, if necessary.
7.15.2.1.1.5Put on sterile gloves.
7.15.2.1.1.6Holding the catheter in the dominant hand and the connector in
the
nondominant hand, attach the suction catheter to the suction tubing.
7.15.2.1.2 Flush and lubricate the catheter. Using the dominant hand, place the
catheter
tip in the sterile saline solution.
7.15.2.1.2.1Using the thumb of the nondominant hand, occlude the thumb
control,
and suction a small amount of the sterile solution through the
catheter.
7.15.2.1.3 If the client does not have copious
375 secretions, hyperventilate the
lungs with a
resuscitation bag before suctioning. Summon an assistant, if one is
available,
Republic of
Yemen 48Modern
Hospital
48
the
the
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Total Parenteral Nutrition
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in
administering total
parenteral nutrition.
1 DEFINITION:
1.1 Total Parenteral Nutrition - the parenteral administration of hypertonic solutions
thereby
achieving anabolism, through central vein.
1.1.1 Composition of total parenteral solutions:
1.1.1.1 Energy:
1.1.1.1.1 Various combinations of dextrose, fat emulsion or both provide calories.
1.1.1.1.2 Most adults require approximately 1500 calories per day post
operatively to
prevent catabolism of body proteins but persons with hypermetabolic
condition require more than 2000 calories.
1.1.1.2 Dextrose:
1.1.1.2.1 Dextrose solutions range from 10 to 70 percent.
1.1.1.2.2 Hypertonic dextrose solutions used in TPN may necessitate the use of
insulin
to prevent hyperglycemia.
1.1.1.3 Lipid emulsions:
1.1.1.3.1 Lipid emulsions are isotonic and contain 10 or 20 percent of safflower or
soybean oil, egg yolk phospholipids (as emulsifier) and glycerin.
1.1.1.3.2 It can be given via Piggyback with amino acid and dextrose solutions
or all 3
can be mixed in the same bag (Total Nutrient Admixture).
1.1.1.3.3 When TPN continues for more than 2 to 3 weeks, lipid emulsions are
necessary to prevent essential fatty acid deficiency.
1.1.1.3.4 Using both dextrose and lipids improved glucose tolerance and less
fluid
retention.
1.1.1.3.5 It should be refrigerated to prevent aggregation of fat particles.
1.1.1.4 Protein:
1.1.1.4.1 Contain both essential and non-essential amino acids.
1.1.1.4.2 Used principally for protein repletion and are not relied on for calories.
1.1.1.5 Vitamins and minerals.
2 PURPOSES:
2.1 To meet patients high energy requirement.
2.2 To promote cell growth and repletion.
3 INDICATIONS:
3.1 Severe burns
3.2 Acute pancreatitis
3.3 Inflammatory bowel disease
3.4 Ulcerative colitis
3.5 Acute renal failure
3.6 Mild to moderate hepatic failure
3.7 Cardiac disease or surgery
377
Republic of
CONTRAINDICATIONS:
48Modern
48
4.1 The Yemen
following are
contraindicated when using central venous line for hyperalimentation.
Hospital
378
Republic of
Yemen 48Modern
Hospital
48
4.1.1
Infusion of blood or blood products.
4.1.2
Bolus infusion of drugs.
4.1.3
Simultaneous administration of IV solutions.
4.1.4
Measurement of central venous pressure.
4.1.5
Aspiration of blood for routine laboratory tests.
4.1.6
Addition of medication to an intravenous hyperalimentation solution
container.
5
EQUIPMENTS/SUPPLIES:
5.1 Infusion pump
5.2 Infusion tubing
5.3 Sterile gloves
5.4 Alcohol spray 70%
5.5 Sterile gloves 10 x 10
5.6 Transparent dressing
5.7 Dressing set
5.8 Face masks
5.9 Scissors
6 POLICIES:
6.1 Doctors order must be obtained.
6.2 7 Rights in giving medication should be followed.
PROCEDURES:
6.3 It should
done under aseptic technique.
7.1 Preparation
ofbe
equipment:
6.4 Nurses
must
aware of the solution
complication
and s
provide
7.1.1
Compare
the be
contents
with of
theTPN
doctor
order. proper intervention,
if
any Check
of the the solution for cloudiness, turbidity, particles, and container for cracks. If
7.1.2
complication occurs.
any,
6.5return
TPN solution
should
in Pharmacy.
the solution
to be
theprepared
Pharmacy.
7.1.3 Using aseptic technique, insert the pump tubing into the post of the solution. 7
7.1.4 Prime the tubing and remove air.
7.2 Essential steps:
7.2.1 If patient has no central line, arrange for Central Line Insertion to be done in ICU.
If patient
has central line, take vital signs as baseline.
7.2.2 Explain the procedure to the patient.
7.2.3 Wash hands, wear disposable gloves and mask.
7.2.4 Place the patient in supine position with the head turned away from the catheter
insertion
site.
7.2.5 Remove the dressing carefully, pulling the tape gently from the skin to minimize
trauma.
Inspect the site for signs of infection and the catheter for leakage or other
mechanical
problems.
7.2.6 Remove gloves and put on sterile gloves. Cleanse the insertion site with alcohol
70%.
Work in a circular motion, moving from the insertion site outward to the edge of
the
adhesive border to avoid introducing contaminants from the uncleaned area.
7.2.7 Working in a circular motion as before, cleanse the insertion site and the
catheter for 2
minutes with the povidone-iodine solution.
7.2.8 Instruct the patient to perform Valsava maneuver or to hold his breath on deep
inspiration as
the IV tubing is changed.
7.2.9 Ensure that the junction of the catheter tubing is secured, remove the
contaminated gloves
and put on a sterile pan.
379
7.2.10 Continue to cleanse the skin with povidone-iodine solution for 3 minutes.
7.2.11 Using a sterile swab or sponge, apply anti-microbial ointment to the stem of the
insertion
Republic of
Yemen 48Modern
Hospital
48
site and to the hub of the catheter at the catheter tubing junction, being careful
not to loosen
the connection.
7.2.12 Apply sterile dressing, tape securely, and occlusively to the skin.
7.2.13 Write on the tape the date and time dressing was changed.
7.2.14 Remove gloves, wash hands.
7.2.15 Begin infusion at a slow rate (usually 10ml/hour). Then, as ordered, increase
the adults
infusion rate.
7.2.16 Check the infusion pumps volume meter and the time tape every 30 minutes
or more
frequently, if necessary.
7.2.17 Record vital signs every 4 hours.
7.2.18 Assist the patient in a comfortable position.
7.2.19 Aftercare of the equipment.
7.2.20 Documentation:
SPECIAL
CONSIDERATIONS:
7.2.20.1Record
the time and date of dressing and solution changes.
8.1
If
the
patient
develops
fever,
discontinue
the site.
TPN solution and replace it with dextrose
7.2.20.2The
condition
of the
catheter
insertion
10%
in
water
7.2.20.3Type of solution infused.
after informing the
doctor. Change
the IV tubing and dressing and notify the doctor who
7.2.20.4Patients
tolerance,
vital signs.
might
7.2.20.5Note for patients progress and response.
8
order for fungal
and abnormal,
bacterial cultures
solution,
tubing, and blood.
7.2.20.6Note
for any
adversefor
or altered
responses.
8.2
Observe
the
patient
for
signs
of
thrombosis
or
thrombophlebitis
such
as
erythema
and
7.2.21 Charge for the supplies and equipment used.
edema at the
catheter insertion site, ipsilateral swelling of the arm, neck or face, pain along the
course of the vein
and other systemic manifestation.
8.3 Be alert for swelling at the catheter insertion site, indicating extravasation of the TPN
solution,
which can cause necrosis.
8.4 Observe for signs of air embolism such as:
8.4.1 dyspnea
8.4.2 apprehension
8.4.3 chest pain
8.4.4 tachycardia
8.4.5 hypotension
8.4.6 cyanosis
8.4.7 seizures and loss of consciousness
8.4.8 cardiopulmonary arrest
8.5 TPN can cause many complications, nursing intervention for more prevalent
complications are
presented.
8.5.1 Sepsis:
8.5.1.1 Monitor for sudden elevation of fever and glucose.
8.5.1.2 Use aseptic technique when hanging solution and preparing tubing to
prevent bacterial
contamination.
8.5.2 Hyperglycemia and hypoglycemia:
8.5.2.1 Monitor flow rate hourly.
8.5.2.2 Monitor closely blood glucose levels of person at risk of developing blood
glucose
problems (early phase injury; diabetes mellitus, pancreatic disease, sepsis,
surgery, use
380
of B-blockers, phenytoin, steroids, epinephrine, thiazide diuretics.
8.5.3 Lipid overload
1.1.1.1 Give initial fat solution slowly.
Republic of
Yemen 48Modern
48
Hospital
381
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Tracheostomy Care
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in doing
tracheostomy
care.
1 DEFINITION:
1.1 Tracheostomy Care - is the method of cleaning the tracheostomy tube and keeping the
site clean
and dry, thus preventing skin irritation and infection.
2 PURPOSES:
2.1 To ensure airway patency.
2.2 To maintain mucus membrane and skin integrity.
2.3 To prevent infection.
3 EQUIPMENTS/SUPPLIES:
3.1 Sterile gloves
3.2 Antiseptic solution
3.3 NSS 1000cc
3.4 Cotton tip applicators
3.5 Gauze 10 x 10
3.6 Tracheostomy ties
3.7 Underpad
3.8 Kidney basin (2) sterile
3.9 Zinc oxide cream
3.10Mask and goggles
3.11Hydrogen peroxide
3.12Adhesive tape
3.13Scissors
3.14Sterile Forceps
4 POLICIES:
4.1 Policy on infection control must be observed.
4.2 Cleaning of the Fresh Stoma should be performed every 8 hours or more frequently as
necessary.
4.3 Tracheostomy ties should be changed every 24 hours or as necessary.
5 PREPARATIONS:
5.1 Assess:
5.1.1 Respiratory status, including ease of breathing, rate, rhythm, depth, and lung
sounds
5.1.2 Pulse rate
5.1.3 Character and amount of secretions from tracheostomy site
5.1.4 Presence of drainage on tracheostomy dressing or ties
PROCEDURES:
6
5.1.5 Appearance
incision
6.1 Explain
to the clientof
what
you are going to do, why it is necessary, and how he can
5.2 Assemble equipment and supplies.
cooperate.
6.1.1 Provide for a means of communication, such as eye blinking or raising a finger, to
indicate
pain or distress.
382
6.2 Wash hands and observe other appropriate infection control procedures.
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
8
REFERENCE:
8.1 Fundamentals of Nursing concepts, process, and practice
7th Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
385
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Urinary Catheter (Indwelling) Care
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in the care of
urinary
(indwelling) catheter.
1 DEFINITION:
1.1 Management of indwelling catheter is a special nursing care provided to patients with
urinary
catheter for hygienic and medical reasons i.e.:
1.1.1 Care of indwelling catheter.
1.1.2 Irrigation of indwelling catheter.
1.1.3 Emptying a catheter bag.
2 PURPOSES:
2.1 To prevent infection.
2.2 To restore or maintain patency of catheter.
2.3 To prevent urinary tract obstruction by flushing out small blood clots formed after
prostate or bladder
surgery.
2.4 It creates a mild tamponade that prevents venous hemorrhage.
2.5 To treat an irritated, inflamed, or infected bladder lining.
2.6 To instill medicine for therapeutic purposes.
3 EQUIPMENTS/SUPPLIES:
3.1 Antibacterial solution
3.2 Sterile gauze
3.3 Disposable/sterile gloves
3.4 Sterile kidney basin
3.5 Sterile irrigating solution
3.6 Wash cloth
3.7 Bedpan
3.8 Blue pads
3.9 Prescribed antibiotic cream (as ordered)
3.1020-50ml. Syringe
3.11Alcohol swab
POLICIES:
4
3.12Medication for irrigation (optional)
4.1 Follow infection control measures.
4.1.1 Urinary catheters shall be used only when absolutely necessary and for a short
period of time
as possible, the need for the indwelling catheter shall be reassessed every 72
hours in an
acute care, and monthly in long-term care.
4.2 Only trained personnel shall insert urinary catheters.
4.3 Aseptic technique shall be used in urinary catheter insertion and care.
4.4 All urinary catheters shall be properly secured or anchored to prevent movement and
urethral
traction.
4.5 Care of indwelling catheter shall be done every shift and as necessary.
386type used.
4.6 Catheter should be changed depending on the
4.6.1 Silicon Catheter - up to 3 months
PROCEDURES:
Republic of
5.1 Verify physicians order.
Yemen 48Modern
48
5.2 Provide privacy. Explain procedure to the patient.
Hospital at bedside.
Republic of
Yemen 48Modern
48
Hospital
388
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Urinary Catheterization
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in doing urinary
catheterization.
1 DEFINITION:
1.1 Urinary Catheterization - an introduction of a special rubber or plastic tube into the
bladder via the
urethra to drain
1.2 Types: urine, obtain a specimen, or instill fluids using strict aseptic technique.
1.2.1 Indwelling - remains in place until the patient is able to void completely and
voluntarily.
1.2.2 Intermittent - a straight single use catheter is introduced long enough to drain the
bladder
(5-10 minutes).
2 PURPOSES:
2.1 To relieve acute or chronic urinary retention and incontinence.
2.2 For pre and post operative urinary drainage.
2.3 To obtain urine specimen for analysis and culture.
2.4 To empty contents of bladder prior to instillation, irrigation, and delivery.
2.5 To provide a means of accurately recording output in critically ill or comatose patients.
2.6 To prevent skin breakdown in comatose patients who are incontinent or severely
disoriented.
3 INDICATIONS:
3.1 Indwelling
3.1.1 Obstruction to urine outflow like prostate enlargement and urethral stricture.
3.1.2 For patient undergoing surgical repair of the urethra and surrounding structures
(transurethral resection).
3.1.3 For urethral obstruction from blood clots due to bladder tumor and surgical repair
of urethra.
3.1.4 To determine amount of residual urine after voiding.
3.2 Intermittent
3.2.1 Immediate relief of acute bladder distention as follows:
3.2.1.1 Patient unable to void 8-12 hours after surgery.
3.2.1.2 Acute retention after trauma to the urethra.
3.2.1.3 Patients unable to void as a result of the effects of sedatives or analgesics.
EQUIPMENTS/SUPPLIES:
3.2.2 For long-term
management of patient with incompetent bladder such as:
4
4.1cord
Sterile
catheter of appropriate size. An extra catheter should also
3.2.2.1 Spinal
injuries.
be at hand.
3.2.2.2 Progressive
neuromuscular degeneration.
4.2 Catheterization kit or individual sterile items:
4.2.1 12 pair sterile gloves
4.2.2 Waterproof drape(s)
4.2.3 Antiseptic solution
4.2.4 Cleansing balls
4.2.5 Forceps
4.2.6 Water-soluble lubricant
389
Republic of
Yemen 48Modern
Hospital
48
one side of
the labia majora in an antero-posterior direction.
7.14.2.4Use a new ball for the opposite side. Repeat for the labia minora.
7.14.2.5Use the last ball to cleanse directly over the meatus.
7.14.3 Male
7.14.3.1Use your nondominant hand to grasp the penis just below the glans.
7.14.3.2If necessary, retract the foreskin.
7.14.3.3Hold the penis firmly upright, with slight tension.
7.14.3.4Pick up a cleansing ball with the forceps in your dominant hand and wipe
from the
center of the meatus in a circular motion around the glans.
7.14.3.5Use a new ball and repeat three more times.
7.15Insert the catheter.
7.15.1 Grasp the catheter firmly 23 inches from the tip.
7.15.2 Ask the client to take a slow deep breath, and insert the catheter as the client
exhales.
7.15.3 Advance the catheter 2 inches further after the urine begins to flow through it.
7.15.4 If the catheter accidentally contacts the labia or slips into the vagina, it is
considered
contaminated, and a new, sterile catheter must be used.
7.15.5 The contaminated catheter may be left in the vagina until the new catheter is
inserted to help
avoid mistaking the vaginal opening for the urethral meatus.
7.16Hold the catheter with the nondominant hand.
7.16.1 In males, lay the penis down onto the drape, being careful that the catheter
does not pull out.
7.17For an indwelling catheter, inflate the retention balloon with the designated volume.
7.17.1 Without releasing the catheter, hold the inflation valve between two fingers of
your
nondominant hand while you attach the syringe (if not left attached earlier when
testing the
balloon) and inflate with your dominant hand.
7.17.2 If the client complains of discomfort, immediately withdraw the instilled fluid,
advance the
catheter further, and attempt to inflate the balloon again.
7.17.3 Pull gently on the catheter until resistance is felt, to insure that the balloon has
inflated and to
place it in the trigone of the bladder.
7.18Collect a urine specimen if needed.
7.18.1 Allow 2030 ml to flow into the bottle without touching the catheter to the
bottle.
7.18.2 Allow the straight catheter to continue draining.
7.18.3 If necessary, attach the drainage end of an indwelling catheter to the collecting
tubing and
bag.
7.19Examine and measure the urine. In some cases, only 7501000 ml of urine are to be
drained from
the bladder at one time.
7.20Remove the straight catheter when urine flow stops.
7.20.1 For an indwelling catheter, secure the catheter tubing to the inner thigh for
females, or the
upper thigh/abdomen for males with enough slack to allow usual movement.
7.20.2 Also secure the collecting tubing to the bed linens and hang the bag below the
level of the
bladder. No tubing should fall below the top of the bag.
7.21Wipe the perineal area of any remaining antiseptic or lubricant. Return the client to a
comfortable
391
position.
7.22Discard all used supplies in appropriate receptacles and wash your hands.
7.23Document the catheterization procedure, including catheter size and results, in the
client record.
Republic of
Yemen 48Modern
48
Hospital
SPECIAL CONSIDERATIONS:
8
8.1 Urine to be drained should not be more than 750cc at one time as it may cause
hypotension, bladder
atony.
8.2 Identify patients at high risk for UTI like older adults, debilitated, malnourished,
chronically ill,
immuno-suppressed, and diabetic patients.
8.3 Prevent infection in catheterized patient by:
8.3.1 Clamp drainage tube when the urine bag is raised above the level of patients
bladder.
8.3.2 Ensure free flow of urine by preventing kinked/twisted tubing or allowing pools of
Empty
the urine bag at least every 4 hours and as needed.
REFERENCE:
8.3.3 Never change the
catheter unless there is a leakage, blockage, encrustation or9
9.1 Fundamentals of Nursing concepts, process, and practice
less than one
7th Edition
month.
Barbara
Kozier,
Glenora
Erb, Audrey
Berman, Shirlee Snyder
8.3.4 Never irrigate the
catheter
routinely
unless
ordered.
392
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Urine Specimen Collection
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in collecting
urine
specimen.
1 DEFINITION:
1.1 Part of the physical examination or at various times during hospitalization that
permits laboratory
screening for urinary and systemic pathologies.
1.1.1 Method
1.1.1.1 Routine urinalysis specimen
1.1.1.2 Clean catch or midstream specimen
1.1.1.3 Indwelling urinary catheter
1.1.1.4 U-bag collection
2 PURPOSES:
2.1 To provide a tentative diagnosis.
2.2 To indicate the need for further studies.
2.3 To monitor the progression of a disorder (e.g. Diabetes Mellitus)
3 EQUIPMENTS/SUPPLIES:
3.1 Catheterization set (if patient is unable to void freely)
3.2 Perineal care set
3.3 Sterile/clean specimen bottle
3.4 Bed pan/Urinal
3.5 Underpad
3.6 Disposable gloves
4 POLICIES:
4.1 Doctors order must be obtained.
4.2 Ensure that proper method of collection and purpose is well understood by the
patient.
4.3 Observe infection control policy in collecting urine specimen.
5
PREPARATIONS:
4.4 Specimen
should be properly labeled with name, PIN, date and time.
5.1
Assess: collected should be sent immediately to laboratory.
4.5 Urine
specimen
5.1.1 Clients ability to provide the specimen
5.1.2 Color, odor, and consistency of the urine
5.1.3 For the presence of clinical signs of urinary tract infection
5.2 Assemble equipment and supplies:
5.2.1 Disposable gloves
5.2.2 Antiseptic towelette, such as povidone-iodine
5.2.3 Sterile cotton balls or 2 x 2 gauze pads
5.2.4 Sterile specimen container
5.2.5 Specimen identification label
5.3 In addition, the nurse needs to obtain:
5.3.1 Completed laboratory requisition form
5.3.2 Urine receptacle, if the client is not ambulatory
5.3.3 Basin of warm water, soap, washcloth, and towel for the
nonambulatory client
393
PROCEDURES:
6.1 Check the doctors order.
6.2 Send the request through computer after charging.
6.3 Explain to the client what you are going to do, why it is necessary, and how he or she
Republic of
can
cooperate.
Yemen 48Modern
48
6.4 Wash hands and observe other appropriate infection control procedures.
Hospital
Republic of
Yemen 48Modern
48
Hospital
6.13.2.2Boys - Apply and fix the collection bag to the base of the penis.
6.13.3 A diaper is placed over the bag and should be checked often and remove it as
soon as
urine is available.
6.13.4 Transfer the collected urine from the collection bag to the labeled specimen
container and
cap tightly.
6.13.5 Remove gloves and wash hands.
6.13.6 Send specimen to the laboratory as soon as collected.
6.13.7 Document the date and time specimen is collected, amount, color, clarity and
odor.
6.13.8 Variation: Collecting a Specimen from a Foley (Retention) Catheter or
Drainage
Tube
6.14Put on disposable gloves.
6.15If there is no urine in the catheter, clamp the drainage tubing for about 30 minutes.
6.16Wipe the area where the needle will be inserted with a disinfectant swab.
6.17Insert the needle at a 30- to 45-degree angle.
6.18Unclamp the catheter.
6.19Withdraw the required amount of urine.
6.20Transfer the urine to the specimen container.
6.21Without recapping the needle, discard the syringe and needle in an appropriate
sharps container.
6.22Cap the container.
6.23Remove gloves and discard appropriately.
6.24Label
the container, and send the urine to the laboratory immediately.
SPECIAL
CONSIDERATIONS:
7
6.25Record
of the specimen
and
any
pertinent
of theform.
urine on
7.1 If patientcollection
has menstruation,
it should
be
noted
in the observations
laboratory request
the For
appropriate
7.2
female patients, if she feels defecating instruct to void first so that feces do not
records.
contaminate the
6.26Note
that this procedure can be followed if needle-less port systems are being used.
specimen.
8
REFERENCE:
8.1 Fundamentals of Nursing concepts, process, and practice 7 th Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
395
Republic of
Yemen 48Modern
48
Hospital
396
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Urinary Catheter Removal
Republic of
Yemen 48Modern
48
Hospital
399
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Issued Effective: Replaces:
Manual: General Nursing Departmental Manual
Title: Urine Test for Sugar and KetonesDue for Review:Page 1 of 2
CONTENTS: This General Ward policy and procedure deals with the guidelines in testing
urine for sugar
and ketones.
1 DEFINITION:
1.1 Urine Test for Sugar and Ketones - a test that permits fast monitoring of urine glucose
and
ketone levels. It provides reliable screening for diabetes.
2 PURPOSES:
2.1 To monitor urine glucose and ketone level in the diabetic client.
2.2 To regulate insulin therapy.
3 EQUIPMENTS/SUPPLIES:
3.1 Urine specimen container
3.2 Multistix strips
3.3 Disposable gloves
3.4 Multistix reference color chart
4 POLICIES:
4.1 Obtain doctors order.
4.2 Identify correct client.
4.3 Follow infection control policy in collecting and handling of urine specimen.
5 PROCEDURES:
5.1 Check the doctors order.
5.2 Explain the procedure to patient. Wash hands and wear gloves.
5.3 Provide privacy and give health-teachings on how to test his/her urine properly.
5.4 Check the expiry date on the container of the strip before use and close tightly after
removing the
strip.
5.5 For collection of urine sample:
5.5.1 A second voided specimen is collected after giving a glass of water to drink, if
possible.
5.5.2 For patient in foley catheter - follow procedure for urine collection.
5.6 With available specimen, dip the multistix strip in the urine and remove immediately.
Then tap off
the excess urine from the strip.
5.7 Hold the strip horizontally to avoid mixing reagents from adjacent test area on the
strip. Allow
time interval before interpreting results.
5.7.1 ketones = 40 seconds.
5.7.2 glucose = 30 seconds.
5.8 Compare the color result of the strip against standard color chart.
5.9 Discard the urine specimen and strip used. (If patients Input and Output is being
monitored,
measure the amount of urine discarded.)
5.10Remove gloves and wash hands thoroughly.
5.11Document the following:
5.11.1 Date and time
5.11.2 Result of the test in the Diabetic Worksheet
(Form M1026)
400
5.11.3 Health teachings given to patient
5.12Relay result to the physician concerned.
5.13Charge the procedure and supplies used in the Computer Charging Form.
Republic of
Yemen 48Modern
48
Hospital
6
SPECIAL CONSIDERATIONS:
6.1 For patient who are unable to pass urine inform the doctor. Catheterization might be
performed for
urgent test.
6.2 Patient should be able to test his/her urine properly before being discharged from
the hospital.
401
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Issued Effective:Replaces:
Title: Vaginal IrrigationDue for Review:Page 1 of 2
CONTENTS: This General Ward policy and procedure deals with the guidelines in performing
vaginal
irrigation.
1 DEFINITION:
1.1 Vaginal irrigation is a therapeutic measure of instilling fluid into the vaginal cavity.
2 PURPOSES:
2.1 To remove odor or foul discharge.
2.2 To disinfect vagina preoperatively.
2.3 To administer antiseptic drug.
2.4 To stop bleeding.
2.5 To relieve pain and inflammation.
3 CONTRAINDICATIONS:
3.1 During pregnancy
3.2 4-6 weeks after miscarriage or post partum
3.3 Untreated venereal disease
4 EQUIPMENTS/SUPPLIES:
4.1 Disposable gloves, underpad
4.2 Wash cloth/cotton balls
4.3 Bed pan
4.4 Bath towel
4.5 Basin with warm water
4.6 Antiseptic solution
4.7 Pick up forceps
4.8 OB pads + diapers
4.9 Lubricant + Irrigating vaginal nozzle
4.10Connecting tubes with clamps
4.11Prescribed solution
4.12IV Pole
4.13Container to mix solution
5 POLICIES:
5.1 Written order should be obtained prior to procedure.
5.2 Infection control measures should be observed.
5.3 Cultural and religious beliefs must be considered.
PROCEDURES:
6
6.1 Check the physicians order.
6.2 Follow procedures on Perineal Care.
6.3 Hang the prepared solution to the IV pole.
6.4 Lubricate nozzle tip.
6.5 Open clamp to allow some solution to flow through the tubing.
6.6 Insert the nozzle tip gently into the vagina (2 to 2.5 depth) at approximately 45 o
angle following the
vaginal curvature.
6.7 Open clamp to allow the solution to flow into the vagina. Gently rotate the nozzle tip
to ensure that
402
fluid reaches all areas of vagina.
Republic of
Yemen 48Modern
48
Hospital
6.8 When irrigating container is emptied, close clamp and remove the nozzle
from vagina.
6.9 Assist patient into sitting position on the bedpan for return flow.
6.10Offer toilet tissue to dry the perineum with an instruction to wipe from
front to back.
6.11Remove the bedpan and offer perineal pad.
6.12Aftercare of equipment.
6.13Remove gloves and wash hands.
6.14Record the procedure and observations made.
6.15Charge all supplies used.
403
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Issued Effective:Replaces:
Title: Vital Signs TakingDue for Review:Page 1 of 10
CONTENTS: This General Ward policy and procedure deals with the guidelines in taking vital
signs.
1 DEFINITION:
1.1 Vital signs - are indexes that reflect body physiological functions. They represent
cardinal signs
to illness or disease condition. Vital signs includes:
1.1.1 Temperature is a measurement of heat expressed in degrees Fahrenheit ( o F) or
Centigrade (o C).
MethodDuration
oOral- 37 C3 minutes
oRectal - 37.5 C1 minute
oAxilla - 36.5 C5 minutes
oTympanic- 37.5 CAccording to calibration
1.1.2 Pulse is defined as the alternate expansion and contraction of an artery as the
wave of blood
is forced through it by the contraction of the left ventricle.
1.1.3 Respiration is the exchange of oxygen and carbon dioxide into the body. It
consists of a
process of inhalation and exhalation.
1.1.4 Blood Pressure is the force exerted by the blood against the walls of the vessels,
usually
expressed in millimeter of mercury (mmHg).
3
EQUIPMENTS/SUPPLIES:
2 PURPOSES:
3.12.1
Temperature
To monitor fluctuations or deviations from normal.
3.1.1
2.2 To Thermometer
determine the effect of medicines affecting vital signs.
3.1.2
Thermometer
sheath
cover
2.3
Used
as an indicator
for or
pre
and post-operative management.
3.1.3 Water-soluble lubricant for a rectal temperature
3.1.4 Disposable gloves
3.1.5 Towel for axillary temperature
3.1.6 Tissues/wipes
3.2 Peripheral Pulse
3.2.1 Watch with a second hand or indicator.
3.2.2 If using Doppler ultrasound stethoscope (DUS), obtain the transducer probe, the
stethoscope headset, transmission gel, and tissues/wipes
3.3 Apical Pulse
3.3.1 Watch with a second hand or indicator
3.3.2 Stethoscope
3.3.3 Antiseptic wipes
3.3.4 If using DUS, the transducer probe, obtain the stethoscope headset,
transmission gel, and
tissues/wipes
3.4 Apical-Radial Pulse
3.4.1 Watch with a second hand or indicator
3.4.2 Stethoscope
404
Republic of
Yemen 48Modern
Hospital
48
4
POLICIES:
4.1 Upon admission, vital signs should be taken immediately.
4.2 Vital signs are taken.
4.2.1 Routine - every 12 hours (5am-5pm).
4.2.2 Pre and post invasive/surgical procedure. (Refer to post-operative care GW-095).
4.2.3 Every 15 minutes or hourly as ordered for unstable vital signs depending upon
patients
condition.
4.2.4 As necessary (p.r.n.) - when patient reports non-specific symptoms.
4.2.5 Before and after administering medications that affect cardiovascular,
respiratory, and
temperature changes.
4.3 Handwashing before and after the procedure.
4.4 Proper recording on:
PROCEDURES:
4.4.1 Graphic and Treatment Record (Form M1042) - routine vital signs monitoring.
5.14.4.2
Explain
the procedure.
Ensure
that
patient
is comfortable.
Intensive
Vital Signs
Sheet
(Form
M1023)
- for monitoring critically ill patients.
5.2
equipment
and supplies
at bedside.
4.5 Assemble
Observe infection
control
measures.
5
5.3
hands
before and
afterdepending
the procedure.
4.6 Wash
Determine
accepted
method
on patients condition.
5.4 Assess:
5.4.1 Clinical signs of fever
5.4.2 Clinical signs of hypothermia
5.4.3 Site most appropriate for measurement
5.4.4 Factors that may alter core body temperature
5.5 Take body temperature as follows:
5.5.1 Mercurial:
5.5.1.1 Rinse the thermometer in tap water and dry it using a gauze or clean
alcohol swab
from the bulb upward.
5.5.1.2 Grasp the thermometer firmly with the thumb and forefinger. With strong
wrist
movement, shake the thermometer until the mercury line reaches 36 oC (95oF).
5.5.1.3 Read the thermometer by holding it horizontally at eye level, and rotate it
between the
fingers until the mercury line can be seen clearly.
5.5.1.4 Insert the plastic sheet in the mercurial thermometer.
5.5.2 Methods:
5.5.2.1 Oral:
5.5.2.1.1 Place the mercurial bulb of the thermometer under the tongue in
posterior
sublingual pocket lateral to the center of lower jaw.
5.5.2.1.2 Instruct the patient not to bite the thermometer rather close his/her
lips.
5.5.2.1.3 Leave the thermometer for 3 minutes.
5.5.2.2 Axilla:
5.5.2.2.1 Expose the axilla, and place the bulb of the thermometer into the
center.
5.5.2.2.2 Bring the patients arm down close to his/her body and place the
forearm over
405
his/her chest.
4.1.1.1.1. Leave the thermometer for 5 minutes.
4.1.1.2. Rectal:
Republic of
Yemen 48Modern
Hospital
4.1.1.2.1. Position the patient to Sims with upper knee flexed and
expose
the anal area.
4.1.1.2.2. Wash hands and wear gloves.
4.1.1.2.3. Lubricate the tip of thermometer and insert to the anus
approximately 3.8cm. (11/2 inches) in adult, 2.5cm (1 inch) in
children, and 1.25cm (1/2 inch) in infant.
4.1.1.2.4. Hold the thermometer in place for 1 minute.
4.1.1.2.5. Remove the thermometer and the plastic sheet.
4.1.1.2.6. Wipe it with alcohol swab from upward to mercury bulb
using
firm twisting motion.
4.1.1.2.7. Read the thermometer to the nearest tenth and inform
patient of
reading.
4.1.1.2.8. Wash the thermometer with soap and water. Rinse in cool
water,
dry and return to the container.
4.1.1.2.9. Remove gloves and wash hands.
4.1.1.3.Electronic:
4.1.1.3.1. Insert the probe into the disposable probe cover.
4.1.1.3.2. Methods:
4.1.1.3.2.1.Oral (Blue):
4.1.1.3.2.1.1. Place the tip of the thermometer under the
tongue.
4.1.1.3.2.1.2. Instruct the patient to close his lips and not to
bite the probe.
4.1.1.3.2.2.Axilla (Blue)
4.1.1.3.2.2.1. Place the tip of the thermometer at the center
of
the axilla.
4.1.1.3.2.2.2. Bring the patients arm down, close to his/her
body and place forearm over the chest.
4.1.1.3.2.3.Rectal (Red)
4.1.1.3.2.3.1. Wash hands, put on gloves.
4.1.1.3.2.3.2. Lubricate the tip of the probe cover.
4.1.1.3.2.3.3. Insert to anus approximately 3.8cm (11/2
inches)
in adult, 2.5cm (1 inch) in children, and 1.25cm
(1/2 inch) in infant.
4.1.1.3.2.3.4. Wait for the audible alarm to occur.
Temperature appears in digital display.
4.1.1.3.2.3.5. Remove the probe and inform patient of
reading.
4.1.1.3.2.3.6. Push ejection button on probe to discard
plastic
cover into appropriate container.
4.1.1.3.2.3.7. Insert probe to storage of recording unit.
4.1.1.3.2.3.8. Remove gloves and wash hands.
4.1.1.3.2.4.Tympanic:
4.1.1.3.2.4.1. Assist patient in comfortable position with
head
turned to side, (away from the nurse).
4.1.1.3.2.4.2. Remove thermometer from its charging base.
Note the equivalent setting on display. Ensure
tympanic mode is selected by pressing mode
button.
406
4.1.1.3.2.4.3. Slide disposable plastic cover over otoscopelike tip until it locks in place.
4.1.1.3.2.4.4. Follow manufacturers instruction for tympanic
48
Republic of
Yemen 48Modern
48
Hospital
an
probe positioning.
4.1.1.3.2.4.4.1.Pull ear pinna upward and back for
adult.
4.1.1.3.2.4.4.2.Downward and back for a child.
4.1.1.3.2.4.4.3.Place probe tip in ear canal and ear
opening.
4.1.1.3.2.4.5. Press and release scan button. Remove
probe
tip from ear as soon as triple bleep is heard
and
display flashes DONE.
4.1.1.3.2.4.6. Note the temperature reading in the
digital
display screen, and inform the patient.
4.1.1.3.2.4.7. Press blue release eject button to discard
the
used probe cover.
4.1.1.3.2.4.8. Press MODE button at the back of
thermometer
until it displays SCAN.
4.1.1.3.2.4.9. Press SCAN and replace back the
thermometer
to its charging base.
4.1.1.3.2.4.10. After 15 seconds it will be ready for next
use.
4.1.1.3.2.4.11. Aftercare of the genius tympanic
thermometer.
4.1.1.3.2.4.11.1.For base unit/main body, use water
and
mild detergent or less than 10% bleach
solution.
4.1.1.3.2.4.11.2.The digital display screen and base
door should be wiped with cloth dampen
with mild detergent or less than 10%
bleach solution. Do not use alcohol on
any of the clear plastic part.
4.1.1.3.2.4.11.3.Wipe using a lint-free cloth, if
remain
4.2. Take Pulse Rate:
soiled, slightly
dampen
swabssite.
4.2.1.
Locate cotton
the possible
with isopropanol.
With
the
lens
4.2.1.1.Temporal pointing
artery
down, gently clean
with a swab carotid artery
4.2.1.2.Common
followed by a lint-free
cloth.
4.2.1.3.Brachial
artery
4.1.1.3.2.4.11.4.Do not use
excessive
force.
4.2.1.4.Radial
artery (most commonly accessible
4.1.1.3.2.4.11.5.Return
site) thermometer to its base
unit and
4.2.1.5.Femoral artery
allow 45 minutes
drying time prior
to
4.2.1.6.Popliteal
artery
using the thermometer.
4.2.1.7.Posterior tibial artery
4.1.1.3.2.4.11.6.Return the
thermometer to
base
4.2.1.8.Dorsalis
pedis
artery
unit
4.2.2.
Peripheral Pulse
4.2.2.1.Assess:and keep in place for proper storage
4.2.2.1.1. Clinical signs of cardiovascular alterations, other than pulse
rate,
407
Republic of
Yemen 48Modern
Hospital
48
rhythm, or volume
4.2.2.1.2. Factors that may alter pulse rate
4.2.2.1.3. Site most appropriate for assessment
4.2.2.2.Palpate and count the pulse.
4.2.2.2.1. Place two or three middle fingertips lightly and squarely
over the
pulse point.
4.2.2.2.2. Count for 15 seconds and multiply by 4. Record the pulse in
beats
per minute on your worksheet. If taking a client's pulse for the
first
time, when obtaining baseline data, or if the pulse is irregular,
count for a full minute.
4.2.2.2.3. An irregular pulse also requires taking the apical pulse. Is
irregular, count for a full minute.
4.2.2.3.Assess the pulse rhythm and volume.
4.2.2.4.Document
the Using
pulse rate,
rhythm,
and volume
and your (DUS)
actions in
4.2.2.5.Variation:
a Doppler
Ultrasound
Stethoscope
the client4.2.2.5.1. If used, plug the stethoscope headset into one of the two
record.
output
light
to
aqueous
solutions.
4.2.3. Apical Pulse
4.2.3.1.Assess:
4.2.3.1.1. Clinical signs of cardiovascular alterations, other than pulse
rate,
rhythm, or volume
4.2.3.1.2. Factors that may alter pulse rate
4.2.3.2.Locate the apical impulse.
4.2.3.2.1. Palpate the angle of Louis, located just below the
suprasternal
notch and felt as a prominence.
4.2.3.2.2. Slide your index finger just to the left of the client's sternum,
and
palpate the second intercostal space.
4.2.3.2.3. Place your middle or ring finger in the third intercostal space,
4.2.3.3.1.
Use antiseptic wipes to clean the earpieces and diaphragm
and
of the
continue palpating downward until you locate the fifth
stethoscope.
intercostal
4.2.3.3.2. Warm space.
the diaphragm of the stethoscope by holding it in
the palm 4.2.3.2.4. Move your index finger laterally along the fifth intercostal
space of the hand for a moment.
408
4.2.3.3.3. Inserttowards
the earpieces
of the
stethoscope
into impulse
your ears
the MCL.
Normally,
the apical
isin
palpable at or
the
just medial to the MCL.
4.2.3.3.Auscultate and count heartbeats.
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
Hospital
48
4.3.3. Observe
the depth, rhythm, and character of respirations.
4.4.Take
Blood Pressure:
4.3.3.1.Observe
the respirations for depth by watching the movement of the
4.4.1. Assess:
chest. 4.4.1.1.Signs and symptoms of hypertension
4.3.3.2.Observe
the respirations
regular or irregular rhythm.
4.4.1.2.Signs and
symptoms offor
hypotension
4.3.3.3.Observe
the
character
of
respirationsthe
sound they produce and
4.4.1.3.Factors affecting blood pressure
the4.4.2.
effortPosition the client appropriately.
they require.
4.4.2.1.The
adult client should be sitting unless otherwise specified.
4.3.4. Document
thefeet
respiratory
rate,
and character on the
4.4.2.2.Both
should be
flatdepth,
on the rhythm,
floor.
appropriate
4.4.2.3.The elbow should be slightly flexed with the palm of the hand facing
up andrecord.
the forearm supported at heart level.
4.4.2.4.Expose the upper arm.
4.4.3. Wrap the deflated cuff evenly around the upper arm. Locate the brachial
artery.
4.4.3.1.Apply the center of the bladder directly over the artery.
4.4.3.2.For an adult, place the lower border of the cuff approximately 2.5 cm
(1 inch)
above the antecubital space.
4.4.4. If this is the client's initial examination, perform a preliminary palpatory
determination of systolic pressure.
4.4.4.1.Palpate the brachial artery with the fingertips.
4.4.4.2.Close the valve on the pump by turning the knob clockwise.
4.4.4.3.Pump up the cuff until you no longer feel the brachial pulse. At that
pressure,
the blood cannot flow through the artery.
4.4.4.4.Note the pressure on the sphygmomanometer at which pulse is no
longer felt.
4.4.4.5.Release the pressure completely in the cuff, and wait one to two
minutes
before making further measurements.
4.4.5. Position the stethoscope appropriately.
4.4.5.1.Cleanse the earpieces with alcohol or recommended disinfectant.
4.4.5.2.Insert the ear attachments of the stethoscope in your ears so that
they tilt
slightly forward.
4.4.6. Ensure that the stethoscope hangs freely from the ears to the diaphragm.
4.4.6.1.Place the bell side of the amplifier of the stethoscope over the brachial
pulse.
4.4.6.2.Hold the diaphragm with the thumb and index finger.
4.4.7. Auscultate the client's blood pressure.
4.4.7.1.Pump up the cuff until the sphygmomanometer reads 30 mm Hg above
the
point where the brachial pulse disappeared.
4.4.7.2.Release the valve on the cuff carefully so that the pressure decreases
at the
rate of 23 mm Hg per second.
4.4.7.3.As the pressure falls, identify the manometer reading at each of the
five
phases, if possible.
4.4.7.4.Deflate the cuff rapidly and completely.
4.4.7.5.Wait one to two minutes before making further determinations.
4.4.8. Repeat the above steps once or twice as necessary to confirm the accuracy
of the
reading.
410
4.4.8.1.If this is the clients initial examination, repeat the procedure on the
clients
other arm.
Republic of
Yemen 48Modern
Hospital
48
pressure while
the client is in a supine position with the knee slightly flexed.
4.4.10.2.1. Slight flexing of the knee will facilitate placing the
stethoscope on
the popliteal space. Expose the thigh, taking care not to
expose the
client unduly.
4.4.10.2.2. Locate the popliteal artery.
4.4.10.2.3. Wrap the cuff evenly around the midthigh, with the
compression
bladder over the posterior aspect of the thigh and the bottom
edge
above the knee.
4.4.10.2.4. If this is the client's initial examination, perform a
preliminary
palpatory determination of systolic pressure by palpating the
4.4.11. Variation:
Using
an Electronic Indirect Blood Pressure Monitoring Device
popliteal
artery.
4.4.11.1.Place
the blood
cuff on the
extremity
according
4.4.10.2.5.
In adults,
the pressure
systolic pressure
in the
popliteal
artery isto the
manufacturers
guidelines.
usually 20
4.4.11.1.1.
Turn
on the
blood
switch.artery because of
30 mm Hg
higher
than
thatpressure
in the brachial
4.4.11.1.2.
If
appropriate,
set
the
device
for the desired number of
use of
minutes
a larger bladder; the diastolic pressure is usually the same.
between blood pressure determinations.
4.4.11.1.3. When the device has determined the blood pressure reading,
note
the digital results.
4.4.11.2.Remove the cuff.
4.4.11.3.Wipe the cuff with an approved disinfectant.
4.4.11.4.Document and report pertinent assessment data.
4.5.Report immediately to the treating doctor any abnormality noted.
4.6.Aftercare of equipment.
4.7.Record vital signs taken in the:
4.7.1. Graphic and Treatment Record (Form M1042) as routine.
4.7.2. Intensive Vital Signs Sheet (Form M1023) as indicated (for seriously ill
6
SPECIAL CONSIDERATIONS:
patients).
6.1the
Temperature:
4.8.Charge
supplies used.
6.1.1 Oral temperature is not allowed:
6.1.1.1 If patient is unconscious, disoriented, seizure-prone or extremely
weak.
6.1.1.2 For young children.
6.1.1.3 For infants with oral/nasal impairment and mouth breather.
6.1.1.4 For patients who have injuries, inflammation or operations of
the mouth.
411
6.1.1.5 Patients suffering from frequent
attacks of cough.
Republic of
Yemen 48Modern
48
Hospital
6.1.1.6 Oral temperature should not be taken immediately after patient has taken
hot or cold
drinks. Temperature is taken after 30 minutes of food intake or strenuous
activity.
6.1.2 Rectal temperature is contraindicated:
6.1.2.1 For newborn with imperforated anus.
6.1.2.2 Patients who had rectal surgery or inflammation of the rectum.
6.1.2.3 Patients who are have diarrhea.
6.1.2.4 Patients who are on treatment such as bowel wash and enema.
6.1.3 Ensure that probe lens is clean at all times as it alters the recording. Cleanse it
with lintfree cloth.
6.2 Blood Pressure:
6.2.1 It should not be taken on the site of AV fistula.
6.2.2 Breast or axillary surgery (affected site).
6.2.3 Injured or diseased limbs.
6.3 Vital signs must be recorded also in the nurses notes aside from Intensive Vital Signs
and Graphic
Sheet Form for the following conditions:
6.3.1 Admission
6.3.2 Trans-in (including special areas)
6.3.3 If abnormal, followed by nursing measures done
6.3.4 Post-partum and post-op conditions upon receiving in the floor
6.4 For Newborn:
6.5 Method of temperature taking is through axilla only except during admission
wherein rectal
thermometerREFERENCE:
is used to assess the patency of the anus.
7
7.1 Fundamentals of Nursing concepts, process, and practice
7th Edition
Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder
412
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Wound Dressing
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines on how to do
wound
dressing.
1 DEFINITION:
1.1 Wound dressing - is a procedure done under aseptic technique where a material is
applied to the
surface of a wound to provide and maintain an environment in which healing can take
place at
maximum rate.
1.2 Types of Dressing :
1.2.1 Dry-to-dry dressing used primarily for wound closing by primary intention.
1.2.2 Wet-to-dry dressing used for untidy or infected wounds that must be debrided
and closed
by secondary intention.
1.2.3 Wet-to-wet dressing used on clean open wound or on granulating surfaces.
2 PURPOSES:
2.1 To prevent, eliminate, and control infection.
2.2 To absorb drainage or secretion.
2.3 To provide physical, psychological and aesthetic comfort.
2.4 To protect the wound from further injury.
2.5 To protect the skin surrounding the wound.
2.6 To maintain moist wound and environment.
2.7 To remove necrotic tissue.
2.8 To promote hemostasis as in pressure dressings.
3 INDICATIONS:
3.1 Surgical incision.
3.2 Insertion of central line or other invasive procedure.
3.3 Wounds with drain.
4 EQUIPMENTS:
4.1 Refer to dressing trolley contents
5 POLICIES:
5.1 Hospital Infection Control Policy is observed.
5.2 Privacy should be maintained.
5.3 Dressing should be done by the physician assisted by a nurse.
5.4 Wound culture, if needed, should be taken prior to dressing.
5.5 Dressing trolley should be checked for completeness of items at the start of each shift.
5.6 Solutions, ointment and spray should be labeled as to date of opening.
6
PROCEDURES:
5.7 During wound dressing, the
upper level of trolley should be kept free and the surface
6.1 Wash hands.
should be
6.2 Take the dressing trolley to the clients room.
disinfected before and after.
6.3 Provide
privacy
and explain
theused.
procedure.
5.8 Counting/Checking of dressing
instruments
before
and after
6.4
Wear
disposable
gloves
and
protective
apparel, if
5.9 All items must be charged.
indicated.
413
Republic of
Yemen 48Modern
48
Hospital
414
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Central Venous Catheter Insertion
Republic of
Yemen 48Modern
Hospital
48
4 POLICIES:
4.1 There should be a written order for the procedure.
4.2 Infection control policy must be followed:
4.2.1 Central catheter line should be changed within 7-10 days.
4.2.2 Daily dressing should be done under aseptic technique.
4.2.3 Date of insertion should be written.
4.3 Consent should be obtained.
4.4 Strict aseptic technique should be followed throughout the
procedure.
5 PROCEDURES:
5.1 Verify doctors order.
5.2 Identify correct patient by checking his/her ID band and asking his/her name.
5.3 Wash hands.
5.4 Assemble equipments and supplies needed.
5.5 Provide privacy; explain the procedure to the patient.
5.6 Place the patient in appropriate position with blue pad under the site of insertion.
5.6.1 Antecubital vein - in supine position with arm extended and secured by an
armboard.
5.6.2 Jugular/subclavian vein - in Trendelenburg position unless contraindicated. Place a
small
log towel under the shoulder.
5.6.3 Femoral vein - in supine position with leg straight.
5.7 Wash hands again. Wear disposable gloves.
5.8 Attach to cardiac monitor. Check for vital signs. Monitor continuously all throughout the
procedure.
5.9 Prepare the site and expose. Prepare the CVP scale. Attach to the medifix, one tube
goes to the
patient, another tube to the NSS and the side tube to be connected to the CVP scale.
5.10Assist the physician in inserting the central venous line.
5.11Check for the patency of the catheter by heparin flush.
5.12Flush the 3-way stopcock with NSS and attach to the catheter of secalon and cavafix.
Assist the
doctor in suturing the catheter using silk 3-0. Apply steristrip in cavafix catheter.
5.13Apply mepore dressing after the doctor has secured the catheter. Write the date of
insertion on
mepore dressing. Watch for bleeding on the site.
5.14Assist the patient in a comfortable position.
5.15Dispose used items.
5.16Remove gloves, wash hands.
5.17Obtain Chest X-ray as ordered. Follow-up and inform the doctor.
5.18Document the following:
5.18.1 vital signs
5.18.2 site of insertion
5.18.3 time and date of insertion
6 SPECIAL
5.18.4CONSIDERATIONS:
type of catheter used
6.15.18.5
A CVP tolerance
line is potential
source of septicemia that the health care team must be aware of.
to procedure
Strict5.18.6 any unusual occurrences or observations
infection control
precautions
should
be observed.
5.19Charge
procedure
and supplies
used
6.1.1 Hand-washing proper employing correct technique should be implemented at all
times.
6.2 Observation for following complications should be made:
6.2.1 From catheter insertion:
6.2.1.1 pneumothorax, hemothorax
6.2.1.2 fluid overload
6.2.1.3 air embolism, thrombosis
416
6.2.1.4 dysrhythmias
Republic of
Yemen 48Modern
48
Hospital
6.2.1.5 hematoma
6.2.1.6 cardiac tamponade
6.2.2 From indwelling catheter:
6.2.2.1 infection
6.2.2.2 air embolism
6.3 Ensure that all connections are tight to avoid blood loss or air embolism.
6.4 Always maintain patency of the catheter when used for intermittent therapy, the
catheter should be
flushed after each use with appropriate flushing solution.
6.5 Insertion site should be checked regularly for local inflammation or phlebitis. Dressing
should be
changed daily under aseptic technique and must be labeled always to show date when
catheter was
inserted.
6.6 Send the catheter tip for bacteriologic culture when needed after removal.
6.7 Avoid BP measurement taking on the involved arm
417
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Central Venous Line Removal
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the procedures of removing
central
venous line.
1 DEFINITION:
1.1 Removal of Central Line - a method of withdrawing the central venous catheter under
strict aseptic
technique.
2 PURPOSES:
2.1 Completion of therapy
2.2 Onset of complications
2.3 A leaking or damaged catheter
3 EQUIPMENTS/SUPPLIES:
3.1 Sterile gloves
3.2 Alcohol spray
3.3 Sterile gauze
3.4 Blue sheet
3.5 Mepore
3.6 Surgical blade
3.7 Orange bag
3.8 Sharp container
3.9 Disposable gloves
3.10Sterile specimen container (if needed)
4 POLICIES:
4.1 Doctors order must be obtained.
4.2 Must be done under strict aseptic technique.
5
4.3 Compression
of the site for 10 minutes must be done or as needed.
PROCEDURES:
5.1 Verify physicians order.
5.2 Prepare the needed equipments and supplies.
5.3 Identify the correct patient.
5.4 Provide privacy. Explain the procedure.
5.5 Assist the patient in supine position.
5.6 Wash hands. Wear disposable gloves.
5.7 Assist the doctor in removing the central line.
5.8 Apply pressure to the site for a minimum of 10 minutes or until bleeding
stops.
5.9 Inspect the site for the following:
5.9.1 Signs of infection
5.9.2 Bleeding and hematoma
5.9.3 Discoloration of the skin
5.9.4 Peripheral pulse
5.9.5 Sensation and temperature of the extremity
5.10Cleanse the area of insertion site with alcohol spray and apply
418
transparent dressing.
Republic of
Yemen 48Modern
48
Hospital
5.11If infection is suspected, keep catheter tip in sterile container and send to laboratory
for culture and
sensitivity test as ordered.
5.12Dispose supplies and catheter to appropriate container.
5.13Remove gloves. Wash hands.
5.14Document the following:
5.14.1 Date and time of removal
5.14.2 Condition of the site
5.14.3 Observations made
5.14.4 If catheter tip is sent for culture and sensitivity test
5.15Charge the used supplies.
Filename: central_venous_line_removal
419
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
5.16Keep the manometer in upright position hanging from the IV pole to prevent air
bubbles from
entering the fluid column or to the patient and to prevent contamination of manometer.
5.17Assist patient in comfortable position.
5.18Remove gloves and wash hands.
5.19Document the CVP reading date and time and notify the physician.
5.20Charge all supplies used.
SPECIAL CONSIDERATIONS:
6
6.1 If the patient is connected to ventilator and receiving positive end expiratory pressure
(PE EP),
expect high CVP readings.
6.1.1 Normal range of CVP
6.1.1.1 2-6 mm of Hg
6.1.1.2 6-12 cm of H2O
6.1.2 Accepted range of CVP for patient on ventilator is normal range of CVP + PE EP
rate 1
6.2 Avoid taking CVP measurements when the patient is sitting-up. Since it will cause
false low results.
6.3 Patient with Chronic Obstructive Pulmonary Disease (COPD) usually has a high CVP.
6.4 A low CVP is an indicator of hypovolemia generally calling for an increase in IV fluid.
6.5 A high CVP can be caused by hypervolemia or by poor cardiac function.
6.6 Any variation on the measurement should be informed to the physician at once.
421
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Applies to: General Ward and Specialty Units
Manual: General Nursing Departmental Manual
CONTENTS: This General Ward policy and procedure serves as a guideline procedure during
implantation
Title:
Chemotherapy: Implanted Venous Access
of venous access device to be used during
chemotherapy.
Device
1 DEFINITIONS:
1.1 Venous Access Device (VAD) - an implanted catheter or device that remains in place for
an
extended period of time (weeks, months or even years). It maybe tunneled or
implanted.
2 PURPOSES:
2.1 For administering
2.1.1 blood or blood products
2.1.2 chemotherapy
2.1.3 fluid replacement therapy
2.2 For blood sampling
3 INDICATIONS:
3.1 Limited peripheral venous access due to extensive previous IV therapy, surgery and/or
previous
tissue damage.
3.1.1 Long term therapy.
4 CONTRAINDICATIONS:
4.1 obesity
4.2 chest wall disease
4.3 superior vena cava abnormalities
5 EQUIPMENTS/SUPPLIES:
5.1 Sterile gloves
5.2 90o sterile Huber needle with winged infusion set attached.
5.3 NSS 10cc
5.4 Sterile 10cc syringe (2)
5.5 Clinipad dressing set
5.6 Sterile drape, steri strip
5.7 Opsite dressing
5.8 Heparin 10 IU/1ml - 5ml vial
5.9 Heparin 100 IU/1ml - 5ml vial
5.10Xylocaine gel 2%, mask
6 POLICIES:
6.1 Obtain doctors order
6.2 When VAD is used for intermittent usage, it must be flushed well before and after
therapy with NSS
and then heparinized using heparin 10 IU/ml + 5ml NSS every 8 hours to maintain
patency.
6.3 When VAD is deaccessed and is not to be used for a period of time, it must be flushed
with heparin
100 IU/5ml NSS every 4 weeks to maintain patency. Maintain positive pressure while
flushing to
avoid reflux of blood in the portal septum as it may block the catheter.
6.4 Only non-coring needles (Huber) are to be used when accessing the port with
appropriate gauge and
length according to patients size.
6.5 Strict aseptic technique should be maintained.
422
6.6 Huber needle and dressing should be changed every 7 days and as necessary if there
is any drainage
from the porta site. A swab must be taken for C/S and notify physician.
Republic of
Yemen 48Modern
Hospital
48
7 PROCEDURES:
7.1 Verify doctors order.
7.2 Review the prescribed order for blood sampling or medication administration.
7.3 Gather supplies needed.
7.4 Wash hands.
7.5 Identify the correct patient and explain the procedure.
7.6 Place patient in slightly elevated supine position.
7.7 Wear disposable gloves.
7.8 Expose skin and palpate port septum and assess for any signs and symptoms of
infection or
swelling.
7.9 Prime needle and extension set with NSS.
7.10Remove disposable gloves and put on sterile gloves.
7.11Observing sterile technique, clean the inlet septum injection site with betadine using
an outward
circular motion, extending prepped over beyond peripheral of the port and allow to dry.
Then prep
with alcohol swab and allow the area to dry.
7.12Apply sterile drape over prepped porta site, palpate the port site to locate the septum.
7.13Stabilize port and firmly insert needle at a right angle to the skin, through the skin and
septum until
needle touches the back of the port.
7.14Aspirate blood to verify needle placement and function of port.
7.15Obtain blood samples as ordered. Aspirate 4-5ml of blood then discard it, and withdraw
the desired
amount of blood for analysis.
7.16Flush the line with normal saline to clear blood and establish patency of the line.
Observe for
swelling or complain of pain.
7.17Proceed with medication administration as ordered.
7.18For continuous infusion, connect and regulate flow rate.
7.19If needle will be left in place, secure needle with sterile dressing.
7.20For intermittent infusion, use heparin locked and clamped extension set and remove
straight needle
for heparin plug and leaving tube needle in place within septum.
7.21If needle will be removed, flush needle with heparin solution to establish heparin lock,
maintaining
positive pressure at the end of heparin instillation. Positive pressure maybe created by
clamping the
tubing while instilling the last ml of heparin solution
7.22Remove needle by stabilizing the port. Press down on the port with 2 fingers and
remove Huber
needle with a firm and straight motion.
7.23Apply pressure and dressing to insertion site.
7.24Dispose all supplies used.
7.25Remove gloves and wash hands.
7.26Document the following:
7.26.1 Function of VAD
7.26.2 Medications administered
7.26.3 Blood samples drawn
7.26.4 Patient response to procedure
7.26.5 Any unusual observations
423
7.27Charge all supplies used.
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Chemotherapy: Management of Cytotoxic
Extravasation
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure serves as a guideline in the management
of
cytotoxic extravasation.
1 DEFINITIONS:
1.1 Extravasation - leakage of a vesicant drug from the vein into the subcutaneous tissue
that may
result in pain, necrosis or sloughing of tissues.
2 PURPOSES:
2.1 To prevent damage to underlying tissues, tendons, and nerves that may lead to joint
contracture.
2.2 To avoid chronic damage to skin and underlying tissues that can only be healed by
surgical
intervention.
3 EQUIPMENTS/SUPPLIES:
3.1 Long sleeved impervious closed gown
3.2 Non-sterile powderless gloves
3.3 1cc syringe (5)
3.4 Heparin lock
3.5 Sterile needle
3.6 2 x 2 gauze
3.7 Alcohol swabs
3.8 Necessary equipment for antidote administration
3.9 Compresses (hot or cold dependent upon drug extravasation)
4 POLICIES:
4.1 All antidote therapy requires a physicians order.
4.2 Patient and family should be educated regarding the signs and symptoms of
extravasation and the
need for immediate follow-up. These s/s include:
4.2.1 blisters
4.2.2 pain
4.2.3 ulceration
4.2.4 necrosis
4.2.5 swelling
4.2.6 erythema
4.3 Once extravasation is discovered, an incident report should be made immediately.
4.4 When venous access is a problem, those patients still needing therapy with vesicant
agent
should
PROCEDURES:
5
haveinfusion
central immediately.
line such as hickman line or infusoport.
5.1 Stop
Chemotherapy
should not
be given
to a recent
venipuncture
orhandling
extravasation
5.24.5
Withdraw
chemotherapy
syringe
and needle
fromsite
the of
port
utilizing safe
might occur and
precautions
where
vein and
was alcohol
recentlyprep
penetrated.
place
2 x the
2 gauze
swab between skin and IV cannula.
Site should
monitored
every 24-48
hours following
extravasation
and usually
5.34.6
Discontinue
IVbe
tubing
from cannula
and attach
syringe directly
to IV cannula
and till
resolution.
attempt
to gently
aspirate 3-5cc of drug or blood from the site. 424
5.4 IV cannula is maintained till physicians decision is made regarding antidote
administration.
Republic of
Yemen 48Modern
48
Hospital
5.5 Elevate extremities for 48 hours and apply hot or cold compress, avoid applying
direct manual
pressure to the site. Compresses should be applied for 20 minutes every 4-6 hours for
24 hours as
ordered.
5.6 Administer antidote as ordered by physician, inject appropriate amount of antidote
SQ in divided
doses into the extravasated site using on needle technique then discontinue IV
cannula. If no
antidote is ordered, IV cannula maybe removed immediately.
5.7 Mark the area of erythema and swelling.
5.8 Documentation should be done at the time extravasation was noted. The following
should be
documented:
5.8.1 Date and time of occurrence
5.8.2 Type and gauge of venous access device inserted on the site.
5.8.3 Number and location of venipuncture attempts
5.8.4 Drug being administered, sequence and technique.
5.8.5 Amount of drug given (to estimate amount of drug extravasated).
5.8.6 Description of extravasation site.
5.8.7 Patients complaints, statement and nursing management.
5.8.8 Physician notification and implementation.
5.8.9 Patient
education.
SPECIAL
CONSIDERATIONS:
6
5.9
Assess
patient
for
pain
and
medicate
as
ordered.
6.1 Cold compress is indicated for extravasation caused by antibiotic, antitumor,
5.10Write an
incident
alkylating
agents
and report.
425
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Chemotherapy: Management of Cytotoxic
Spills
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure serves as a guideline and safety
measures in the
management of cytotoxic spills.
1 DEFINITIONS:
1.1 Cytotoxic Spill a dripping of cytotoxic agents during chemotherapy preparations.
2 PURPOSES:
2.1 To reduce potential risk associated with exposure to cytotoxic agents.
3 EQUIPMENTS/SUPPLIES:
3.1 Chemo spill kit containing:
3.1.1 Long sleeved impervious gown
3.1.2 2 pairs of chemo-approved gloves
3.1.3 Aerosol mask, goggles, absorbent towels, spills control pillows, cytotoxic plastic
bag (2),
scoop and brush
3.2 Chemo spill caution sign
3.3 One blue absorbent pad
3.4 Sharps container with lid or rigid chemo container
4 POLICIES:
4.1 Chemo spill kits are kept on all units where chemotherapy is routinely administered.
4.2 If cytotoxic agents come in contact with skin, the area must be washed with copious
amount of
soap and water for minimum of 5 minutes.
4.3 If the affected areas are the mucous membranes and eyes flush with copious amount of
PROCEDURES:
water or
5.1 Secure the area by alerting other staff a chemo spill has occurred. Instruct the family,
isotonic eyewash for at least 5 minutes.
sitters and
4.4 If linen is involved in the spill, dispose in water resistant isolation bag and place in
5
patient to move away from spill area. Put a chemo spill sign.
double orange
5.2 Obtain chemo spill kit.
cytotoxic plastic bag.
5.3 Put on protective apparel. Two pairs of chemo gloves are to be worn, one with cuffs
4.5 Initial clean up (drugs, excretion) is a nursing responsibility, and housekeeping will
under gown
perform the
cuffs, and one pair over the gown cuffs.
second clean up.
5.4 Place one orange plastic bag inside the other to provide double thickness. Turn the
tops of the bags
outward to form cuff.
5.5 Carefully pick-up any broken glass and place inside sharp container or chemo
container.
5.6 Using absorbent paper towels, begin cleaning the spill outside and moving towards
inside.
Continue until area is dry.
5.7 Place soiled paper towels and other contaminated items into the double orange
plastic bag.
5.8 Cover the spill area with blue absorbent pad.
5.9 Remove outer pair of gloves and place inside the double orange plastic bag. Remove
gown and
other protective apparel and place in another426
double orange plastic bag, remove
remaining inner
pair of gloves last.
5.10Place hands on outside of double orange plastic bag under cuff, close and tie bag.
Republic of
Yemen 48Modern
48
Hospital
427
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Chemotherapy: Preparation and Administration of
Cytotoxic Drugs
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure serves as a guideline in the preparation
and
administration of cytotoxic drugs.
1 DEFINITIONS:
1.1 Chemotherapy - the use of anti-neoplastic drugs to promote tumor destruction by
interfering with
cellular function and reproduction. It includes the use of various chemotherapy agents
and
hormones. (Chemotherapy may be combined with surgery or radiation therapy or
both)
1.2 Cytotoxic Drugs and agent capable of specific destructive action on certain cells;
usually used
in reference to kill anti-neoplastic drugs that selectively kill dividing cells.
2 PURPOSES:
2.1 To destroy as many tumor cells as possible with minimal effect on healthy cells.
2.2 To treat systemic disease rather than lesions that are localized and amenable to
surgery or
radiation.
2.3 To cure, control and palliation.
2.4 To reduce tumor size pre operatively to destroy any remaining tumor cells post
operatively.
2.5 To treat some forms of leukemia.
3 CONTRAINDICATIONS:
3.1 Abnormal hepatic & kidney profile
3.2 Fever due to infection
3.3 Intolerance to chemotherapy
3.4 Uncooperative patient
3.5 Bone marrow suppression
3.5.1 Neutropenic patient low WBC <500/mm3
3.5.2 Thrombocytopenia low platelet count <10,000 mm3
3.5.3 Anemia
4 EQUIPMENTS/SUPPLIES:
4.1 Biological Safety cabinet
4.2 Infusion pump
4.3 IV pole
4.4 Goggles, hepa filtered mask/dust mist, blue pads
4.5 Non-sterile powder less gloves
4.6 Long sleeve impervious chemo gowns
4.7 Plastic emesis basin
POLICIES:
5
4.8 IV set alcohol swab, sterile gauze 2x2
5.1 Physicians order should be written.
4.9 IV 3000 transparent dressing, cannula of different sizes
5.2 Consent for the procedure should be
4.10Syringes & needles of different sizes
obtained.
4.11IVF & medications as ordered
428
4.12Chemo precaution sign for patients door
4.13Nonprolleak plastic container for syrine/needle.
Republic of
Yemen 48Modern
Hospital
48
touching it.
6.1.1.7.3 Tablet or capsule in the strip should be cut by using scissors and
place in the
medication cap (open only at the time of administering). Break scored
tablets Republic of
only.48Modern
Yemen
48
6.1.1.7.4 When giving liquid medicine. Shake bottle well.
Hospital
6.1.1.7.5 Remove cork, unscrew cap from bottle and pour medicine with label
toward
your hand palm in front of the patient when administering.
6.1.1.7.6 Hold medicine glass at eye level pointing thumbnail on the line
indicating
the desired dose.
6.1.1.7.7 If excess drug is poured, discard it in double orange plastic bag.
Never return
to the bottle.
6.1.1.7.8 After preparing the medicine, remove gloves, gown, goggles and
mask and
dispose properly.
6.1.1.7.9 Wash hands and wear new pair of gloves.
6.1.1.7.10 Take the prepared medicine in the medication tray with the
medication card
to patients bedside.
6.1.1.7.11 Explain the purpose, action and the common expected side effects
of each
medication.
6.1.1.7.12 Ensure that 5 rights of medication administration are observed.
6.1.1.8 Place patient in sitting position (if not contraindicated).
6.1.1.9 Place a napkin or towel under the chin of the patient. Administer drug
either with the
use of spoon or medication glass.
6.1.1.10Stay with the patient until he/she swallows the medicine.
6.1.1.11If the only way to administer the drug is through NGT because of certain
conditions
(See in Special Consideration), the tablet should be crushed, capsule should
be
opened and dissolve with 20 to 30cc of water.
6.1.1.12Dispose used supplies in double orange plastic bag including gloves.
6.1.1.13Wash hands.
6.1.1.14Observe if the patient tolerated the medicine. If vomiting noted within 60
minutes,
inform the physician.
6.1.1.15Document the following:
6.1.1.15.1 Date and time medication given.
6.1.1.15.2 If medication was tolerated or not.
6.1.1.15.3 Vital signs.
6.1.1.15.4 Any unusual observation and intervention made.
6.1.1.16Charge supplies used.
6.1.2 Intravenous Push
6.1.2.1 Verify doctors order and review patients laboratory results.
6.1.2.2 Identify correct patient.
6.1.2.3 Assess patients general condition and check vital signs.
6.1.2.4 Assess IV site, patency, and placement of cannula including blood return.
6.1.2.5 Assemble equipment/supplies needed.
6.1.2.6 Wash hands; wear mask, gown, goggles and gloves.
6.1.2.7 Verify the dosage of drugs based on BSA (Body Surface Area).
6.1.2.8 In aspirating medicine from the ampoule/vial, observe the following steps.
6.1.2.8.1 Tap gently the top of ampoule if the medicine is trap on the neck of
the
ampoule.
6.1.2.8.2 Place a small gauze and alcohol swab around the neck of ampoule
and snap
off the top in an outward motion.
6.1.2.8.3 Keep the gauze and the alcohol swab while aspirating the
430
medication.
6.1.2.9 Place a piece of gauze around the tip of needle while expelling air after
preparing the
medicine.
6.1.2.10Remove gloves, mask, goggles and gown and dispose to double orange
plastic bag.
Wash hands and wear new gloves.
6.1.2.11Place
Republic
the prepared
of
injectable medicine in the tray together with the
medication card,
Yemen
48Modern
48
and take to patients bedside.
Hospital
6.1.2.12Explain
the purpose, action and the common expected side effects of
each
medication. Assist patient to comfortable position. Administer premeds prior
to
administration of chemo agent.
6.1.2.13Ensure that the 5 rights of medication administration is observed.
6.1.2.14Vigorously cleanse with alcohol swab the IV port of flush tubing nearest
to IV site.
Allow to dry.
6.1.2.15Insert needle to the IV port and wrap with 2x2 gauze around the port and
hub of
needle.
6.1.2.16Check for blood return prior to injecting medication and every after each
2-3cc of
medicine has been pushed. Inject the drug slowly.
6.1.2.17Ask patient, periodically if he/she is experiencing any discomfort through
out the
procedure.
6.1.2.18After the medicine is administered, pinch the tubing between IV port and
cannula.
Gently aspirate 2-3cc of flushing solution into the empty syringe. Release
pinched
tubing, slowly inject flushing solution. Repeat 3-6 times.
6.1.2.19Slowly withdraw needle from IV port keeping 2x2 gauze in place.
6.1.2.20Discard syringe with needle in the sharp container.
6.1.2.21Dispose used supplies in double orange plastic bag including gloves.
6.1.2.22Wash hands.
6.1.2.23Observe for immediate side effects such as nausea and vomiting and
monitor the
severity and inform the doctor.
6.1.2.24Document the following:
6.1.2.24.1 Date and time medication given.
6.1.2.24.2 Vital signs.
6.1.2.24.3 Any unusual observation made.
6.1.2.24.4 Intake and output if ordered.
6.1.2.25Charge the procedure and supplies used.
6.1.3 Continuous Infusion
6.1.3.1 Verify doctors order and review patients laboratory results.
6.1.3.2 Identify correct patient.
6.1.3.3 Assess patient general condition and check vital signs.
6.1.3.4 Assess IV site, patency, placement of cannula including blood return.
6.1.3.5 Assemble equipments/supplies needed.
6.1.3.6 Wash hands, wear mask, gown, goggles and gloves.
6.1.3.7 Verify the dosage of drugs based on BSA (Body Surface Area).
6.1.3.8 In aspirating medicine from ampoule or vial, cover the neck with alcohol
swab and
gauze.
6.1.3.9 Incorporate the aspirated cytotoxic drugs to the IV solution, and label
with the
following:
6.1.3.9.1 Cytotoxic agent incorporated.
6.1.3.9.2 Date and time infusion started and to be consumed.
6.1.3.9.3 Flow rate.
6.1.3.10Prime IV line with NSS and connect to prepared IV fluid incorporated with
cytotoxic agents.
6.1.3.11Medicines available in dark vials should be protected from light by means
of
covering the infusion bottle and tubings
431 with black plastic.
6.1.3.12Remove gloves, mask, gown and goggles and dispose to double orange
plastic bag.
Wash hands and wear new pair of gloves.
Republic of
Yemen 48Modern
Hospital
48
Republic of
7.1.5.1 Hospital
Discuss taste changes and changes in food preferences.
7.1.5.2 Ask about daily food intake and normal eating patterns.
7.1.5.3 Evaluate if there are any changes in daily eating patterns.
7.1.6 Hematopoietic System
7.1.6.1 Neutropenia - absolute granulocyte count less than 500/mm 3
7.1.6.1.1 Determine if patient has productive cough or shortness of breath.
7.1.6.1.2 Monitor for an elevation of temp. > 38.3oC (> 101oF).
7.1.6.2 Thrombocytopenia - Platelet count less than 50,000/mm 3 (mild risk) <
20,000/mm3
(severe risk)
7.1.6.2.1 Assess skin and oral mucous membranes for petechiae
7.1.6.2.2 Determine if patient has episodes of bleeding (including nose,
urinary, rectal
or hemophysis).
7.1.6.2.3 Observe for signs and symptoms of intracranial bleeding such as
changes in
level of responsiveness somnolence, coma.
7.1.6.3 Anemia
7.1.6.3.1 Ascertain if patient has experienced dyspnea upon exertion.
7.1.7 Respiratory and Cardiovascular System
7.1.7.1 Signs and symptoms of congestive heart failure and/or irregular apical or
radial
pulses.
7.1.7.2 Assess for pulmonary fibrosis evidenced by a dry, non-productive cough
with
increasing dyspnea.
7.1.8 Neuromuscular System
7.1.8.1 Determine the presence of paresthesias or difficulty with fine motor
activities such as
zipping pants, tying shoes or buttoning a shirt.
7.1.8.2 Evaluate patients for weakness, ataxia or slapping gait.
7.1.9 Genito Urinary System
7.1.9.1 Evaluate any changes in order, color or clarity of urine sample.
7.1.9.2 Observe for hematuria, urinary frequency, oliguria or anemia.
7.1.10 Sexuality, Body Image and Self Esteem.
7.1.10.1Discuss body image changes and the impact on the individuals life
7.1.10.2Discuss risks to reproductive potential and the patients emotion.
7.2 Nursing Intervention
7.2.1 Discuss the method of administration, expected side effects and the overall
goal of
chemotherapy.
7.2.2 Instruct patient to report any discomfort, pain or burning during administration
of IV
chemotherapy.
7.2.3 Avoid infections by observing the following:
7.2.3.1 Avoid performing invasive procedures as much as possible (e.g. rectal
temp, enemas,
insertion of indwelling catheter).
7.2.3.2 Stress importance of strict hand washing.
7.2.3.3 Check for reduction in the number of leukocytes and differential count.
7.2.3.4 Reinforce good personal hygiene.
7.2.3.5 Instruct patient about signs and symptoms of infection including:
7.2.3.5.1 Mouth lesions, swelling or redness.
7.2.3.5.2 Redness, pain or tenderness or hemorrhoids at rectum.
7.2.3.5.3 Any changes on bowel habits.
7.2.3.5.4 Any areas of redness, swelling indication or pain in the surface of the
skin.
7.2.3.5.5 Any pain or burning when urinating
or odor from urine.
433
7.2.3.5.6 Any cough or shortness of breath.
7.2.3.5.7 If patient develop fever, administer antibodies within 1 hour per
hospital
Republic of
Yemen 48Modern
Hospital
48
policy.
7.2.4 Avoid bleeding due to thrombocytopenia
7.2.4.1 Avoid invasive procedure when platelet count < 100,000 mm 3, including
IM
injections, enemas, suppositories and indwelling catheter insertion.
7.2.4.2 Avoid aspirin containing products.
7.2.4.3 Monitor and test all urine, stools and emesis for blood.
7.2.4.4 Minimize nausea and vomiting by:
7.2.4.4.1 Administering anti emetics on scheduled basis prior and during 24
hour
period of chemotherapy as prescribed.
7.2.4.4.2 Monitoring I & O including emesis.
7.2.4.4.3 Encouraging patient to eat bland highly nutritious foods (high
protein and
high carbohydrate).
7.2.4.4.4 Offering soda crackers and ice chips to relieve nausea.
7.2.4.4.5 Discouraging smoking and use of alcoholic beverages since these
irritate
mucous membrane.
7.2.4.5 Promote Oral Comfort
7.2.4.5.1 If No White Patches Are Present:
7.2.4.5.1.1 Encourage prophylactic oral hygiene after meals and at night,
more
frequently if needed.
7.2.4.5.1.2 Use soft toothbrush.
7.2.4.5.1.3 Avoid spicy and hot foods.
7.2.4.5.1.4 Assess need for oral antifungal or antibacterial agents.
7.2.4.5.1.5 Avoid commercial mouthwash that may irritate sensitive
tissues.
7.2.4.5.2 If oral cavity erythematous or white patches are present:
7.2.4.5.2.1 Monitor weight and encourage bland finger foods - less painful.
7.2.4.5.2.2 Increase frequency of oral care.
SPECIAL CONSIDERATIONS:
8
7.2.4.5.2.3 Use normal saline mouth rinses
8.1 7.2.4.6
Risks toReassure
personnel
involved
in
the
reconstitution
and
administration
of
cytotoxic
patient that hair will usually grow back.
drugs
fall into
7.2.4.7
Discourage use of hair coloring during treatment period.
two categories:
8.1.1 Local effects caused by direct contact with the skin, eyes and mucous
membranes include
the following:
8.1.1.1 Dermatitis
8.1.1.2 Inflammation of mucous membranes
8.1.1.3 Excessive Lacrimation
8.1.1.4 Pigmentation
8.1.1.5 Blistering
8.1.1.6 Other miscellaneous, allergic reaction
8.1.2 Systemic effects include the following:
8.1.2.1 Lightheadedness
8.1.2.2 Dizziness
8.1.2.3 Nausea
8.1.2.4 Headache
8.1.2.5 Alopecia
8.1.2.6 Coughing
8.1.2.7 Pruritus
8.1.2.8 General malaise
8.2 Safety measures in handling Cytotoxic Anticancer Drugs.
434the following:
8.2.1 Personal safety to minimize exposure to
negative
pressure technique.
8.2.1.1.3 Wrap gauze or alcohol pads around the neck of ampules when
opening to
decrease droplet contamination.
8.2.1.1.4 Wrap gauze or alcohol pads around injection sites when removing
syringes
or needles from IV injection ports.
8.2.1.1.5 Do not dispose materials by clipping needles or removing needles
from
syringes.
8.2.1.2 Via Skin Contact
8.2.1.2.1 Wash hands before and after the procedure.
8.2.1.2.2 Double gloving and change frequently.
8.2.1.2.3 Wear gown with long sleeves.
8.2.1.2.4 Label all syringes and IV tubing containing chemotherapeutic agents
as
hazardous material.
8.2.1.2.5 Place an absorbent pad directly under the injection site to absorb
accidental
spillage.
8.2.1.2.6 If any contact with the skin occurs, immediately wash the area
thoroughly
with soap and water.
8.2.1.2.7 If eye contact is made, immediately flush the eye with water and
seek
medical attention.
8.2.1.3 Via Ingestion
8.2.1.3.1 Do not eat, drink, chew gum or smoke while preparing or handling
chemotherapy.
8.2.1.3.2 Keep all food and drinks away from preparation area.
8.2.1.3.3 Wash hands before and after handling chemotherapy.
8.2.1.3.4 Avoid hand to mouth or hand to eye contact while handling
chemotherapeutic agents or body fluids of the person receiving
chemotherapy.
8.2.2 Safe disposal of Antineoplastic Agents
8.2.2.1 Discard gloves and gown into a leak proof container, which should be
marked as
contaminated or hazardous waste.
8.2.2.2 Use puncture and leak proof containers for non-capped, non-clipped
needles and
other sharp or breakable objects.
8.2.3 Safe handling of body fluids and excreta
8.2.3.1 Wear gloves for disposing excreta.
8.2.3.2 Wear gloves and gowns for handling soiled linens.
8.2.4 Oral
8.2.4.1 Do not use a medication that has an unpleasant taste, (i.e. Prednisone)
teach patient
how to swallow.
8.2.4.2 Enteric-coated tablets should never be crushed.
8.2.4.3 Mix crushed tablets in a small amount of juice or food with a strong taste
(i.e. peanut
butter, maple syrup, fruit flavored syrup or jelly) and the patient must take
all of the
mixture to receive full dose.
8.2.4.4 Oral medications that are irritating to gastrointestinal mucosa
(prednisone) should be
435
given with milk or food. Administer antacid
as ordered.
8.2.4.5 With single daily doses, administer all tablets at one time to achieve
maximum blood
level.
8.2.4.6 Prevent or minimize vomiting by administering anti-emetic prior to
Republic of
Yemen 48Modern
48
Hospital
436
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Chest Tube Insertion and Management
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure serves as a guideline in the insertion
and
management of chest tube.
1 DEFINITION:
1.1 Chest Tube Insertion - the insertion of one or more flexible tubes into the pleural or
mediastinal
space following an aseptic technique.
1.2 Types of Drainage System:
1.2.1 One - Bottle System -water seal and collection of drainage occurs in the same
bottle used
for simple pneumothorax.
1.2.2 Two - Bottle System - water seal and collection of drainage are in separate
bottles. The
first bottle directly attached to the patient serves as a collection container for the
fluid.
The second bottle serves as a water seal container as in the one-bottle system.
1.2.3 Three - Bottle System - water seal, collection of drainage, and suction control are
in
separate bottles. This is indicated when significant amounts of drainage are
expected and
the patient requires suction to the chest tubes.
1.2.4 Pleur Evac - same as the three-bottle system but incorporated into a single,
easily
movable unit.
2 PURPOSES:
2.1 To re-expand a collapsed lung by restoring negative intrapleural pressure.
2.2 To measure drainage from the intrapleural space.
2.3 To re-establish an adequate ventilation-perfusion ratio.
2.4 To restore normal cardio-respiratory function after surgery, trauma or medical
conditions by
establishing negative pressure in the pleural cavity.
2.5 To allow sclerosing agents to be placed in the pleural cavity for the treatment of
malignant
EQUIPMENTS/SUPPLIES:
4
effusions.
4.1 Drainage bottle set according to type of drainage
2.6 To evacuate blood, air or fluid
collections.
system
3 INDICATIONS:
4.2 Suturing set
3.1 Hemothorax or pleural effusion
4.3 Trocar (different sizes)
3.2 After cardiothoracic surgery
4.4 Sterile and disposable gloves
3.3 Emphyema
4.5 Antiseptic solution
3.4 Pneumothorax
4.6 Disposable scalpel size 11
4.7 2% Xylocaine
4.8 Syringe with needles
4.9 Underpad, alcohol swab
4.10Sterile gauze 10 x 10
4.11Adhesive tape, mepore
437
Republic of
Yemen 48Modern
Hospital
48
4.12Silk 3-0
4.13Puncture towel
4.14Normal saline 500ml
4.15Suction tubings
4.16Sterile specimen container
4.17Clamp (2 forceps)
4.18Milker
4.19Spirometer
4.20Y connector (for two chest tubes on the same
side)
POLICIES:
5
5.1 Obtain doctors order.
5.2 Identify correct client.
5.3 Consent must be signed prior to the procedure.
5.4 Infection control policy must be strictly followed.
5.5 Nurses should be knowledgeable of the principle of close
drainage system.
5.6 Procedure should be done under strict aseptic technique.
5.7 Keep the patency of the tubing throughout the procedure.
PROCEDURES:
5.8 Observe and monitor for the oscillation of fluid frequently.
6.1 Verify physicians order.
6.2 Check the following:
6
6.2.1 Identity of the client.
6.2.2 Consent
6.3 Explain the procedure. Provide privacy.
6.4 Wash hands and wear gloves.
6.5 Prepare the needed equipments and supplies.
6.6 Assemble the drainage system and fill with sterile water or normal saline according
to the system.
6.7 Take and record vital signs as baseline. Assess clients general condition.
6.8 Position the client according to doctors order.
6.9 Carry out physicians order prior to the procedure such as use of analgesics.
6.10Assist the physician during the procedure and continuously monitor the vital signs,
oxygen
saturation until procedure is completed. Check for respiratory pattern and general
condition.
6.11After the tube is inserted, clamp and connect to the drainage system and attach to
the bed below
chest level.
6.12Assist in suturing and apply dressing.
6.13Remove the sterile drape from the client.
6.14Place client in semi-sitting position, and make client comfortable.
6.15Instruct the client to take a deep breath, hold and slowly exhale to assist drainage
of the pleural
space and lung re-expansion.
6.16After care of equipments should be done.
6.17Remove gloves and wash hands.
6.18Send the request for portable chest X-ray.
6.19Immediate care:
6.19.1 Mark the original fluid level with tape outside the bottle.
6.19.2 Check and mark the drainage every 15 minutes for the first 4 hours and every
hour
thereafter.
6.19.3 Check vital signs every 15 minutes for 1 hour, then every hour for 2 hours or
as
necessary.
438
6.19.4 Inform physician if the following is observed:
6.19.4.1If the drainage is more than 100ml/hr.
6.19.4.2Change in vital signs.
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Chest Tube Removal
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure serves as a guideline in the removal of
chest tube.
1 DEFINITION:
1.1 Removal of Chest Tube - is an aseptic procedure of withdrawing a chest tube from the
pleural/mediastinal space without introducing air or infectious microorganism
2 PURPOSES:
2.1 To regain and establish normal lung function
2.2 To establish normal pattern of respiration.
3 INDICATIONS:
3.1 Once the lung has re-expanded (confirmed by chest X-ray) and with minimal drainage.
3.2 The risk of fluid collection in mediastinum post-cardiac surgery.
4 CONTRAINDICATIONS:
4.1 When the X-ray shows incomplete lung expansion.
4.2 When clamping the tube induces respiratory distress.
5 EQUIPMENTS/SUPPLIES:
5.1 Clamp
5.2 Dressing tray
5.3 Surgical gloves
5.4 Surgical blade
5.5 Underpad
5.6 Antiseptic solution
5.7 Sterile gauze
5.8 Mepore
5.9 Analgesic (PRN)
5.10Syringe with needle g. 22 as needed
5.11Disposable gloves
5.12Orange bag
5.13Stethoscope and sphygmomanometer
5.14Thermometer
6 POLICIES:
6.1 Doctors order must be obtained.
6.2 Proper identification of patient is a must.
6.3 Follow infection control policy.
6.4 Chest x-ray before and after insertion must be obtained.
PROCEDURES:
7
7.1 Verify doctors order.
7.2 Identify the correct patient.
7.3 Provide privacy, explain the procedure.
7.4 Assemble equipments.
7.5 Assess the depth and quality of patients respiration and obtain
baseline vital signs.
7.6 Wash hands. Give analgesic as ordered prior to removal of chest tube.
7.7 Keep the patient on semi-fowlers position or on his unaffected side.
440
Republic of
Yemen 48Modern
48
Hospital
441
Republic of
Yemen 48Modern
48
Hospital
DIAGNOSTIC
PROCEDURES
442
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Abdominal and Pelvic Ultrasonography
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in performing
abdominal
and pelvic ultrasonography.
1 DEFINITION:
1.1 Abdominal Ultrasonography a noninvasive test focuses high frequency sound waves
over an
abdominal organ to obtain an image of the structure as displayed on the oscilloscope.
1.2 Pelvic Ultrasonography a noninvasive test that uses high frequency sound waves to
form
images of the interior pelvic cavity as displayed on the oscilloscope.
2 PURPOSES:
2.1 Abdominal Ultrasonography
2.1.1 To detect small abdominal masses, fluid-filled cysts, gallstones, dilated bile
ducts, ascites
and vascular abnormalities.
2.2 Pelvic Ultrasonography
2.2.1 To detect uterine, tubal, organ and pelvic cavity pathology.
2.2.2 To measure organ size.
2.2.3 To evaluate pregnancy.
3 POLICIES:
3.1 Doctors order should be obtained.
3.2 Identify correct client.
PROCEDURES:
4
3.3 Patient should be properly prepared for the procedure.
4.1 Check doctors order.
3.4 The patient should be aware of the purpose of the procedure.
4.2 Fill-up laboratory Form M3019 and give to ward secretary for charging.
4.3 Enter X-Ray request through computer on line.
4.4 Explain the procedure to the patient to allay anxiety.
4.5 Ask appointment from the X-Ray Department.
4.6 Prepare the patient according to the type of procedure to be done:
4.6.1 Abdominal Ultrasonography
4.6.1.1 Keep patient NPO (Nothing Per Orem) for at least 6 hours.
4.6.2 Pelvic Ultrasonography
4.6.2.1 Instruct patient to increase oral fluid intake to keep bladder full as soon as
possible.
If patient has an on-going IVF, give rapid infusion as ordered.
4.6.2.2 Clamp indwelling catheter if present.
4.6.2.3 If there is an urge to urinate, instruct patient to inform the nurse.
4.6.3 Abdominal and Pelvic Ultrasonography
4.6.3.1 Keep patient NPO (Nothing Per Orem) except water. Once bladder is full,
instruct to
inform the nurse.
4.7 Confirm appointment from X-Ray if patient is for abdominal ultrasonography and
send to X-Ray
Department according to the time schedule given. If for pelvic or combined
ultrasonography, once
443
patient feels the urge to urinate, inform X-Ray Department.
4.8 Send patient to X-Ray Department per wheelchair or stretcher depending on his/her
condition.
Republic of
Yemen 48Modern
48
Hospital
4.9 Endorse patient to X-Ray Department staff and inform to call the nursing unit once
procedure is
completed.
4.10As soon as the patient arrives in the unit, call the pantry to serve the prescribed
diet previously
ordered.
5
SPECIAL CONSIDERATIONS:
5.1 The chief advantage of the abdominal ultrasonography is the spatial reproduction of
masses in
transverse and longitudinal directions. This is useful in studying the liver, spleen,
pancreas,
gallbladder and retroperitoneal tissue. However, this procedure is cannot be used
when a structure
to be examined lies behind bony tissues. Also gas in the abdomen or air in he lungs
presents a
problem, as ultrasound is not well transmitted through gas or air.
5.2 Transvaginal approach for pelvic ultrsonography will be performed, inform the
patient that a
vaginal probe will be inserted to obtain more accurate measurements from internal
organs.
5.3 During the third trimester of pregnancy, a full bladder is no longer necessary for
pelvic
ultrasonography.
444
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Abdominal Paracentesis
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in performing
abdominal
paracentesis.
1 DEFINITION:
1.1 Abdominal Paracentesis - aspiration of fluid from the peritoneal space through a
needle (trocar
or cannula) inserted in the abdominal wall, under sterile condition. This procedure is
performed
for therapeutic and diagnostic purposes.
2 PURPOSES:
2.1 To determine the cause of ascites.
2.2 To relieve pressure cause by ascites that can lead to respiratory distress.
2.3 To diagnose intra-abdominal bleeding following trauma.
2.4 To provide peritoneal fluid specimen for laboratory analysis.
3 CONTRAINDICATIONS:
3.1 Peritonitis
3.2 Hypovolemia
3.3 Platelet count below 100,000 units
4 EQUIPMENTS/SUPPLIES:
4.1 cannula g. 14, 16
4.2 sterile and disposable gloves
4.3 sterile gauze
4.4 blue pads
4.5 syringe 50ml, 5ml
4.6 needle g. 23
4.7 IV tubing
4.8 specimen container
4.9 drainage bag or bottle
4.10betadine solution
4.11sharp disposal container
4.12forceps
4.13mask (optional)
4.14plaster (durapore)
4.15xylocaine 2% or per doctors order
4.16sterile drape
4.17razor (optional)
4.18measuring tape
4.19sphygmomanometer
4.20stethoscope
4.21thermometer
POLICIES:
5.1 Obtain doctors order.
445
Republic of
Hospital
446
48
Republic of
Yemen 48Modern
Hospital
48
5.4 Measurement of abdominal girth and weight is taken before and after
procedure.
PROCEDURES:
6
6.1 Verify doctors order.
6.2 Identify the correct patient. Explain the procedure to the patient and check if
consent is signed.
6.3 Assess patients allergic reaction to local anesthesia.
6.4 Instruct the patient to void as completely as possible.
6.5 Measure the patients. abdominal girth and weight.
6.6 Check vital signs and assess patients general condition.
6.7 Assist patient in comfortable position (as ordered by doctor.)
6.8 Wash hands and wear gloves.
6.9 Assemble all equipments and prepare for the procedure.
6.10Place BP cuff on one of the patients arm to monitor BP during the procedure.
6.11Assist the doctor and anticipate his needs during the procedure.
6.12Monitor vital signs at least every 15 minutes and observe for signs of pallor or
sweating during
the drainage procedure.
6.13When the procedure is completed, assist the patient in comfortable position.
6.14Monitor the patients vital signs, urine output, dressing and drainage every 15
minutes or as
ordered, and record.
6.15Measure abdominal girth and weight (if condition allows).
6.16Label the specimen with patients complete data and send to laboratory with
charged request form
through computer.
6.17Dispose used items properly.
6.18Remove gloves and wash hands.
6.19Document the following:
6.19.1 time the procedure was done.
6.19.2 site of puncture.
6.19.3 laboratory analysis ordered.
6.19.4 patients response to procedure.
6.19.5 pressure dressing on assessment of drainage.
6.19.6 amount, consistency, color and opacity of fluid drained.
6.20Charge all supplies used and procedure.
6.21Follow
up results of laboratory analysis and notify physician.
SPECIAL
CONSIDERATIONS:
7
7.1 Explain to patient that he/she will experience only minimal discomfort during the
procedure.
7.2 If patient shows any signs of hypovolemic shock, reduce the vertical distance
between needle and
collection bag to slow drainage rate. If necessary, stop the drainage and notify
physician.
7.3 If patient is on continuous drainage, verify to the physician the amount of fluid to be
collected
prior to termination of procedure.
7.4 Instruct patient to report any changes in his/her condition (e.g. shortness of breath,
dizziness and
increase perspiration).
447
7.5 Reposition the patient to facilitate the flow of peritoneal fluid if the drainage stop,
as ordered by
the doctor.
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Angiography
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in performing
angiography procedure.
DEFINITION:
1
1.1 Angiography - a procedure wherein a contrast medium is injected into the vascular
system (to
outline the heart and the vessels) accompanied by cineangiograms (rapidly changing
films or
movies on an intensified fluoroscopic screen) which record the passage of contrast
medium
through the vascular tree.
1.2 Types of Angiography:
1.2.1 Selective angiocardiography contrast medium is injected through a catheter
directly into
one of the heart chambers, coronary arteries, or greater vessel.
1.2.2 Aortography form of angiography that outlines the lumen of the aorta and
major arteries
PURPOSES:
2
arising
from it.
2.1 To provide
information
regarding coronary anatomy, structural abnormalities
1.2.3 Coronary
(occlusions,
defects,Arteriography (most common form of selective angiocardiograophy).
1.2.1
Peripheral
Arteriography
fistulae) or abnormal
heart valve function.
2.2 To serve as an evaluation tool before coronary artery surgery or myocardial
revascularization and
3
after surgery to evaluate graft patency.
2.3 To determine arterial patency of extremities.
EQUIPMENTS/SUPPLIES:
3.1 Stethoscope with BP apparatus
3.2 IVAC machine
3.3 Blue sheet
3.4 Razor
3.5 Disposable gloves
3.6 Fucidin ointment
4
3.7 Tensoplast dressing
3.8 Sandbag 1kg.
POLICIES:
4.1 Doctors order should be obtained.
4.2 Obtain written consent from the patient.
PROCEDURES:
5
4.3 Have appointment from X-ray department/Cathlab prior to procedure.
5.1 Obtain doctors order.
5.2 Secure consent as witnessed by the treating doctor.
5.3 Explain the procedure to the patient.
5.4 Preparatory phase:
5.4.1 Let the doctor fill-up X-ray request form (Form M3015).
5.4.2 Give the X-ray request to the ward secretary to charge the procedure and send
request
through computer online to X-ray department. If patient is for coronary
448
angiography, send
Republic of
Yemen 48Modern
48
Hospital
449
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Barium Enema
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines during
Barium enema
procedure.
1 DEFINITION:
1.1 Barium Enema - a procedure in which a barium mixture is introduced in the large
intestine via
rectal catheter for fluoroscopic visualization of the entire colon (large intestine).
2 PURPOSES:
2.1 To demonstrate the presence of polyps, tumors, and other lesions of large intestine.
2.2 To reveal any abnormal anatomy or malfunction of the bowels.
2.3 To aid in diagnosis of colorectal cancer and inflammatory disease.
2.4 To attempt to reduce non-strangulated ileocolic intussusception in children.
3 CONTRAINDICATIONS:
3.1 Tachycardia
3.2 Ulcerative colitis
3.3 Suspected perforation or obstruction
3.4 Toxic megacolon
4 EQUIPMENTS/SUPPLIES:
4.1 Disposable gloves
4.2 Blue pad
4.3 Fleet enema
4.4 Thermometer
4.5 Sphygmomanometer and Stethoscope
5 POLICIES:
5.1 Obtain doctors order.
5.2 Appointment must be obtained a day before the procedure.
5.3 Patient must sign consent form for diagnostic procedure. Ensure that patient is well
informed of
the purpose of the procedure.
5.4
Physical and psychological preparation is a must.
PROCEDURES:
6
5.5
Provide privacy.
6.1 Preparatory
Phase:
6.1.1 Check for doctors order.
6.1.2 Send request to X-Ray Dept. after charging through computer.
6.1.3 Take appointment from X-Ray Department.
6.1.4 Inform and explain procedure to the patient.
6.1.5 One day prior to examination:
6.1.5.1 Instruct patient to take only fluids (e.g. water or juice but not milk) about
2-3 liters.
6.1.5.2 Take vital signs before and after giving enema.
6.1.5.3 Fleet Enema at 12:00 midnight.
6.1.6 Keep patient nothing by mouth on the day of procedure.
6.1.7 Give fleet enema 2 hours prior to appointment time.
6.1.8 Prepare patient and transport to Radiology Department via wheelchair or
stretcher with
450
safety straps depending on patients condition after proper documentation.
Republic of
Yemen 48Modern
48
Hospital
6.1.8.1 For female patient, keep hair and face fully covered.
6.1.9 Endorse patient to X-Ray Technician.
6.1.10 Request X-Ray Technician to inform the ward when procedure is finished.
6.2 Post Procedure Phase:
6.2.1 Receive patient from X-Ray Department with complete endorsement including
special
instructions relating to patients condition.
6.2.2 Take note of the time patient was received from the X-ray department,
patients
condition and tolerance to the procedure.
6.2.3 Transport patient back to the room. Transfer to the bed, if in
wheelchair/stretcher.
6.2.4 Assess patients condition. Take vital signs.
6.2.5 Instruct patient to resume diet and take more fluids.
6.2.6 Administer the prescribed cathartic or cleansing enema to promote elimination
of barium,
in order to prevent impaction and bowel obstruction.
6.2.7 Explain to patient that the barium will lighten color of stool.
6.2.8 Document:
6.2.8.1 Time received
6.2.8.2 Tolerance to the procedure
6.2.8.3 Objective/subjective
observations
SPECIAL CONSIDERATIONS:
7
6.2.8.4 Vital signs 7.1 If barium is not eliminated within 2-3 days notify the
6.2.9 Charge the procedure
and supplies used.
physician.
451
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Barium Meal / Barium Swallow
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in performing
barium
meal/barium swallow.
1 DEFINITION:
1.1 Barium Meal/Barium Swallow is a radiographic study of the gastro-intestinal tract and
associated organs by administering a contrast medium. The procedure is safe and
consists of
giving a radiopaque substance called barium to drink. It flows through the upper GI
and
monitored by series of x-rays taken at varying intervals. It is takes 10-30 minutes.
2 PURPOSES:
2.1 Evaluates patients ability to swallow.
2.2 Reveals any abnormalities of the pharynx or esophagus.
2.3 Helps to diagnose hiatal hernia, diverticula and varices.
2.4 To detect strictures, ulcers, tumors, polyps, and motility disorders (esophagus,
stomach and
duodenum).
3 INDICATIONS:
3.1 Patient suffering from dysphagia.
3.2 Gastroesophageal reflux.
3.3 To rule out a tumor of esophagus, stomach or duodenum.
4 CONTRAINDICATIONS:
4.1 Pregnancy
4.2 Intestinal obstruction
4.3 Patient with suspected gastrointestinal perforation (water soluble contrast media
should be used
safely)
5 EQUIPMENTS/SUPPLIES:
5.1 IVAC thermometer with probe cover
5.2 BP apparatus
6 POLICIES:
6.1 Obtain doctors order.
6.2 Ensure patient is well informed of procedure and its purpose.
6.3 Consent for Diagnostic Procedure (Form M1141) must be signed by the patient and
PROCEDURES:
7
witnessed by
7.1 Preparatory Phase:
treating doctor.
7.1.1 Verify doctors order.
6.4 Appointment must be obtained day before the procedure.
7.1.2 Explain the procedure to the patient.
6.5 Follow safety measures during transfer.
7.1.3 Enter the request through the computer after charging.
7.1.4 Get appointment from X-Ray Department.
7.1.5 Keep patient Nothing Per Orem (NPO) after midnight.
7.1.6 Assess patients condition. Take and record vital signs.
7.1.7 Verify and confirm from X-Ray Dept. the patients appointment
time.
452
Republic of
Yemen 48Modern
48
Hospital
453
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Bronchoscopy
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines during
bronchoscopy
procedure.
1 DEFINITION:
1.1 Bronchoscopy is the direct inspection and examination of the larynx, trachea and
bronchi through
either a flexible fiberoptic or rigid bronchoscope.
1.1.1 Diagnostic Bronchoscopy
1.1.2 Therapeutic Bronchoscopy
2 PURPOSES:
2.1 Diagnostic
2.1.1 To examine tissues or collect secretions.
2.1.2 To determine the location and extent of the pathologic process.
2.1.3 To obtain a tissue sample for diagnosis.
2.1.4 To determine if a tumor can be resected surgically.
2.1.5 To locate the source of hemoptysis.
2.2 Therapeutic
2.2.1 To remove foreign bodies from the tracheobronchial tree.
2.2.2 To remove secretions obstructing the tracheobronchial tree when the patient
cannot clear
them.
2.2.3 To treat Post-op atelectasis.
2.2.4 To destroy and excise lesions.
3 CONTRAINDICATIONS:
3.1 Recent Myocardial Infraction
3.2 Cerebral Hemorrhage (less than 6 weeks)
3.3 O2 saturation less than 90% with oxygen
4 EQUIPMENTS/SUPPLIES:
4.1 BP apparatus
4.2 IVAC machine with probe cover
4.3 Syringes and needle
4.4 Alcohol pads
4.5 Band-aid
4.6 Small sharp container
4.7 Pulse Oximeter
5 POLICIES:
5.1 Obtain doctors order.
5.2 Secure written consent.
PROCEDURES:
6
5.3 Observe fall precautions.
6.1 Preparatory phase
5.4 Ensure that patient is NPO for 6-12 hours6.1.1
to prevent
aspiration
when reflexes are
Verify doctors
order.
blocked.
6.1.2 Identify the correct patient.
6.1.3 Explain the procedure to the
patient.
454
Republic of
Yemen 48Modern
48
Hospital
455
Republic of
Yemen 48Modern
48
Hospital
456
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Colonoscopy
457
Republic of
Yemen 48Modern
48
Hospital
6.4 Results of laboratory and radiologic investigations should be made available prior to
the
procedure.
PROCEDURES:
7
7.1 Verify doctors order.
7.2 Explain the procedure to the patient.
7.3 Assess patients condition and review current treatment (i.e. anti-coagulant should
be hold before
the test as per doctors order).
7.4 A Day Prior to Procedure:
7.4.1 Mix 3 sachets of cololyte in 3 liters of water.
7.4.2 Instruct patient to fast (NPO) after lunch except water or juice.
7.4.3 Instruct patient to start drinking the prepared solution 3 hours after lunch.
7.4.4 Ensure that patient consumes the whole amount of prepared solution within 3-5
hours.
7.4.5 Administer fleet enema at 12:00 midnight and 6:00 a.m.
7.5 On the day of the procedure:
7.5.1 Confirm time of appointment from Endoscopy nurse.
7.5.2 Allow patient to take some juice or water but not food or milk.
7.5.3 Take and record vital signs prior to procedure.
7.5.4 Insert IV cannula, if there is any premeds to be given.
7.5.5 Coordinate with Endoscopy nurse before sending the patient.
7.5.6 Transport the patient to Endoscopy Unit per stretcher along with file and X-ray
results,
PIN card. Observe fall precautions, apply safety straps.
7.5.7 Document the following:
7.5.7.1 mode of transfer
7.5.7.2 condition of patient
7.5.7.3 date and time of procedure
7.5.7.4 patients tolerance to bowel preparation
7.6 Post procedure phase:
7.6.1 Prepare the room where patient is admitted:
7.6.2 Keep the following ready:
7.6.2.1 oxygen with accessories
7.6.2.2 IV stand
7.6.2.3 blue sheet
7.6.2.4 kidney basin
7.6.2.5 disposable gloves
7.6.3 Receive patient with complete endorsement from the nurse of Endoscopy unit.
7.6.4 Assess patients condition after the procedure.
7.6.5 Transfer patient to bed. Place in comfortable position. Put siderails up.
7.6.6 Monitor vital signs and record.
7.6.7 Observe for signs of perforation, pain, abdominal rigidity, distention,
respiratory distress
and inform the doctor, if any.
7.6.8 Resume diet per doctors order and instruct patient to increase fluid intake.
7.6.9 Document the specific procedure performed, patients tolerance to procedure,
and
REFERENCES:
8
observations
made.
8.1 Rex DK Colonoscopy . Gastrointest Endosc Clin North AM 2000;10:
7.6.10 Charge
the procedure and supplies used in the Inpatient Charging Form.
135-60
8.2 Sivak MV Jr, ed. Gastrointerologic endoscopy, 2nd edn. Philadelphia:
WB Saunders, 1995
8.3 Waye JD, Rex DK., Williams CB. Colonoscopy . Oxford: Blackwell
Publishing 2003
458
Republic of
Yemen 48Modern
48
Hospital
459
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Endoscopic Retrogade Cholangiopancreatography
(ERCP)
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines during ERCP
procedure.
1 DEFINITION:
1.1 Endoscopic Retrograde Cholangiopancreatography (ERCP) is the technique of
visualization
of the biliary and pancreatic duct systems underfluoroscope, which involves injection
of radio
opaque fluid into the biliary systems through the catheter.
2 PURPOSES:
2.1 To determine intra-hepatic or extra-hepatic obstructive jaundice.
2.2 To visualize the biliary tree when the bilirubin level is greater than 3.5mg /dl.
2.3 Helpful to provide mapping of the duct systems before surgical operation.
2.4 Prominent in the therapy of known established pancreato-biliary disease.
2.5 Diagnostic approach to suspected biliary tract/pancreatic diseases with symptoms of
jaundice,
abdominal pain and laboratory tests.
2.6 Must be done before endoscopic papillotomy, biliary/pancreatic drainage or dilatation
of duct
stricture.
3 INDICATIONS:
3.1 Biliary stone, benign stricture, cyst and malignant tumors
3.2 Chronic pancreatitis
3.3 Obstructive jaundice
3.4 Pre and post cholecystectomy
4 CONTRAINDICATIONS:
4.1 Acute cardio-respiratory disease.
4.2 Stricture or obstruction of esophagus or doudenum.
4.3 Acute recent attack of pancreatitis (within 3 weeks) because of risk of inducing
another attack.
4.4 Acute cholangitis.
4.5 Severe upper gastro-intestinal bleeding.
4.6 Patients with esophageal diverticula, and with pancreatic pseudocyst.
4.7 Patient with glaucoma.
4.8 Uncooperative patient.
5 EQUIPMENTS/SUPPLIES:
5.1 IVAC Thermometer with probe cover
5.2 Sphygmomanometer and Stethoscope
5.3 Syringes
5.4 Needles
5.5 IV cannula
5.6 Alcohol swab
5.7 Tourniquet
5.8 IV 3000 transparent dressing
5.9 Band aid
460
5.10Disposable gloves
5.11Underpad
5.12Distilled water
Republic of
Yemen 48Modern
Hospital
48
POLICIES:
6
6.1 Obtain physicians order.
6.2 Identify correct client.
6.3 Obtain a written consent and explain procedure to the client.
6.4 Proper assessment of clients condition prior and after the procedure.
6.5 X-ray request should be send to radiology, endoscopy and anaesthesia
department.
PROCEDURES:
7
7.1 Preparatory Phase:
7.1.1 Check doctors order.
7.1.2 Send the request to Endoscopy, X-Ray Dept., and Anesthesia.
7.1.3 Explain the preparation to be done and carry out doctors order.
7.1.4 Instruct patient to keep fasting from 12:00 midnight.
7.1.5 Inform Anesthesiologist for premeds evaluation. Carry out order, if any.
7.2 Day of the Procedure:
7.2.1 Follow up for the results of laboratory investigations and x-rays to be sent with
patient.
7.2.2 Ensure that Consent for Diagnostic Procedure (Form M1141) is signed.
7.2.3 Insert cannula if not present, and administer prescribed antibiotic as ordered.
7.2.4 Check patients preparation against OR Checklist.
7.2.5 Take and record vital signs before sending for procedure.
7.2.6 Coordinate with Endoscopy nurse before sending the patient.
7.2.7 Send patient by stretcher or bed together with x-rays, lab results, file and PIN
card to XRay Department. Observe safety precautions.
7.2.8 Endorse patient and documents to Endoscopy Nurse.
7.2.9 Request Endoscopy Nurse to notify the ward by telephone once the procedure
is done.
7.3 Follow Up Phase:
7.3.1 Receive the patient and file from X-Ray Department with complete endorsement
from
Endoscopy Nurse.
7.3.2 Check patients condition upon receiving from X-Ray Department.
7.3.3 Check the file for doctors order and instructions.
7.3.4 Take patient back to the room and transfer back to the bed with side rails up.
7.3.5 Check and monitor vital signs. Notify the physician of any deviation.
7.3.6 Instruct patient or relative to maintain Nothing Per Orem (NPO) according to
doctors
order.
7.3.7 Observe for signs and symptoms of complication that may arise such as:
7.3.7.1 Bleeding
7.3.7.2 Fever
7.3.7.3 Mild to severe epigastric pain
7.3.7.4 Dysphagia, nausea, and vomiting
7.4 Notify the physician if any of the symptoms above arise.
7.5 Document the following:
7.5.1 Time came back to the ward.
7.5.2 Condition of the patient.
7.5.3 Pertinent observations.
461
7.5.4 Tolerance to the procedure.
7.5.5 Vital signs taken.
7.6 Charge the procedure done as endorsed by the Endoscopy Nurse in Form M5091.
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Intravenous Pyelography (IVP)
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines during IVP
procedure.
1 DEFINITION:
1.1 Intravenous Pyelography - a non-invasive procedure that provides visualization of
renal
parenchyma and pelvis, and outline the ureters,bladder, and urethra by injecting
intravenous
radiopaque dye into the vascular system.
2 PURPOSES:
2.1 It is conducted as part of initial assessment of any suspected urologic problem,
especially lesion in
kidneys and ureters.
2.2 To provide a rough estimate of renal function.
2.3 To reveal the position, shape, and dimensions of the kidney, anatomic peculiarities of
the urinary
system and ureters.
2.4 To assess congenital absence or malposition of kidneys.
3 CONTRAINDICATIONS:
3.1 A client who is sensitive to iodine compounds.
3.2 History of allergy, serious kidney damages, cardiac arrythmias and liver diseases.
3.3 A severely dehydrated patient, unless appropriate measures have been taken.
4 EQUIPMENTS/SUPPLIES:
4.1 Alcohol pads
4.2 IV 3000 - transparent dressing
4.3 IV cannula gauge 18 or 20
4.4 Blue pads
4.5 Disposable gloves
4.6 Medications (as ordered i.e.):
4.6.1 Disflatyl
4.6.2 Castor oil
4.7 Fleet enema
5 POLICIES:
5.1 Obtain doctors order.
PROCEDURES:
6
Proper
assessment
6.15.2
Check
doctors
order. and history-taking especially when patient is sensitive to iodine
compound
6.2
Identify correct patient.
prior to
procedure.
6.3 Explain
the
procedure to the patient.
an informed
Consent
for
Diagnostic
Procedure
(Form
M1141).
6.45.3
LetObtain
the doctor
fill up the
request
form.
Send request
through
computer.
6.5 Seek appointment from X-Ray Department and confirm the time.
6.6 Preparatory and post-procedure phase.
6.6.1 Preparatory Phase:
6.6.1.1 A day before the procedure, give 3 tablets of Disflatyl to be chewed every
3 hours
from 3:00 p.m. of the day preceding the examination.
6.6.1.2 Give 60cc Castor oil at 6:00 p.m.
462
Republic of
Yemen 48Modern
48
Hospital
6.6.1.3 Keep patient Nothing Per Orem (NPO) starting from 12:00 midnight.
6.6.1.4 Give fleet enema at 12:00 midnight and 6:00am.
6.6.1.5 Let patient void before the procedure.
6.6.1.6 Insert cannula choosing the big veins.
6.6.1.7 Check vital signs before sending to X-Ray Department.
6.6.1.8 Inform X-Ray Department before sending patient.
6.6.1.9 Transfer patient to stretcher or wheelchair (per patients condition). Put
safety straps.
6.6.1.10Document the following:
6.6.1.10.1 condition of patient
6.6.1.10.2 mode of transfer
6.6.1.10.3 patients tolerance to the preparation
6.6.1.11Send the patient and endorse to X-Ray Department personnel.
6.6.1.12Charge the supplies used in the Inpatient Charging Form.
6.6.2 Post Procedure Phase:
6.6.2.1 Receive the patient from X-Ray Department and transfer back to the bed
in
comfortable position.
6.6.2.2 Assess patients condition when received.
6.6.2.3 Check vital signs and cannula site.
6.6.2.4 Instruct patient to take meal.
6.6.2.5 Inform the Pantry Staff to serve the food.
6.6.2.6 Observe and inform the physician for any reaction to the contrast medium
such as
rash, nausea, and hives.
6.6.2.7 Document the following:
6.6.2.7.1 time the patient came back to the ward
6.6.2.7.2 patients condition
6.6.2.7.3 mode of transfer
6.6.2.7.4 any untoward observation or manifestation
SPECIAL CONSIDERATIONS:
7.5 Elderly, debilitated or young patient may not tolerate the dehydration and
compromises may need
to be made.
463
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Kidney, Ureter, Bladder
464
Republic of
Yemen 48Modern
Policy No.
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Lithotripsy Procedure (ESWL)
IPP-NR-118
465
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
467
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Liver Biopsy
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in assisting
during liver
biopsy procedure.
1 DEFINITION:
1.1 Liver Biopsy the sampling of liver tissue by needle aspiration for the purpose of
histologic
study. The procedure can be performed by either transthoracic (intercostals) or
transabdominal
(subcostal) methods.
2 PURPOSES:
2.1 To determine anatomic changes in liver tissue.
2.2 To facilitate the diagnosis of most hepatic disorders.
3 EQUIPMENTS/SUPPLIES:
3.1 IVAC machine with probe cover
3.2 BP apparatus with stethoscope
4 POLICIES:
4.1 Written consent should be obtained.
5 PROCEDURES:
4.2 Doctors order should be obtained.
5.1
doctors
4.3Verify
Identify
correctorder.
client.
5.2
Identify
the
patient.
4.4 Ensure thatcorrect
all results
of laboratory investigations that has been ordered are
5.3 Explain
procedure to the patient.
complete
andthe
reported.
5.4
for signed
consent.
4.5Check
Thorough
assessment
of patients condition.
5.5 Send X-ray request Form M3019 to X-ray department through computer online after
charging.
5.6 If the procedure is to be done under anesthesia, send OR request through computer
online or
manual request (if urgent) properly filled-up by the treating doctor and send to
anesthesiologist.
Keep patient on NPO at least 6-8 hours.
5.7 Follow-up for the results of laboratory investigation that has been ordered if available.
5.8 Communicate with X-ray department about the schedule time of the procedure.
5.9 Take and record vital signs before sending patient to X-ray/OR department.
5.10Counter check for the signed consent. Provide emotional support.
5.11Send patient to X-ray/OR department per stretcher/bed together with the complete
file and PIN
card. Observe safety precautions.
5.12Endorsed to X-ray/OR department staff.
5.13Post procedure phase:
5.13.1 Received patient from X-ray/OR department with complete endorsement from Xray/RR
staff.
5.13.2 Assess patients condition.
5.13.3 Check the file for doctors order and specific instructions.
5.13.4 Transfer back the patient to ward, put on safety straps/side rails-up.
5.13.5 Transfer the patient in bed, turn him/her
468 onto his right side, place a pillow under
his costal
margin, and instruct to remain in this position, recumbent and immobile for
several hours.
Republic of
Yemen 48Modern
48
Hospital
5.13.6 Monitor vital signs every 10-20 minutes intervals or as ordered by the
physician until
stability verified. Notify the doctor for any deviation.
5.13.7 Checked frequently the biopsy site for signs of bleeding.
5.13.8 Maintain pressure dressing on biopsy site.
5.13.9 Document the following:
5.13.9.1Date and time the procedure is finished
5.13.9.2Condition of patient
5.13.9.3Pertinent observations
5.13.9.4Tolerance to the procedure
5.13.9.5Vital signs before and after the procedure.
5.14Charge the supplies used.
6 SPECIAL CONSIDERATIONS:
6.1 Be alert and report promptly any increase in pulse rate, decrease in BP, any complain
of pain, or
manifestation of apprehensions. These signs may indicate the presence of and the
progress of
hepatic bleeding, severe hemorrhage, or bile peritonitis, the most frequent
complications of liver
biopsy.
469
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
470
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Myelogram
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in assisting
during
myelogram procedure.
1 DEFINITION:
1.1 Myelogram - a radiography of spinal cord, nerve roots and spinal canal after injecting
a
radiopaque substance into the spinal subarachnoid space through a spinal puncture.
2 PURPOSES:
2.1 For diagnostic evaluation of neurologic disease.
2.2 To detect any distortion of spinal cord.
2.3 To detect tumor or cyst in the dorsal sac, herniated intervertebral discs, or other
lesion.
3 EQUIPMENTS/SUPPLIES:
3.1 BP apparatus
3.2 IVAC thermometer
4 POLICIES:
4.1 Obtain doctors order.
4.2 Obtain written consent from the patient.
4.3 Have appointment from X-Ray Department prior to procedure.
PROCEDURES:
5
4.4 Follow safety measures during transfer.
5.1 Preparatory Phase:
5.1.1 Let the doctor fill up X-Ray Request Form M3015.
5.1.2 Give the X-Ray Request (Form M3015) to the Ward Secretary to charge the
procedure
and send request through computer online to X-Ray Department.
5.1.3 Let patient (or relative) sign the consent, witnessed by the Treating Doctor.
5.1.4 Explain the procedure to the patient.
5.1.5 Keep patient on Nothing Per Orem (NPO) 6 hours prior to procedure.
5.1.6 Check vital signs of patient before sending to X-Ray Department.
5.1.7 Confirm appointment from X-Ray Department.
5.1.8 Transfer patient to stretcher. Put on safety straps and side rails.
5.1.9 Send patient to X-Ray Department along with the file.
5.1.10 Endorse to X-Ray personnel responsible for the procedure.
5.1.11 Remind X-Ray personnel to call the ward once procedure is finished.
5.2 Post-Procedure Phase:
5.2.1 Receive the patient and file with complete endorsement from the X-Ray Staff.
5.2.2 Check post myelogram order.
5.2.3 Transport patient to the ward.
5.2.4 Transfer to bed and position the patient by elevating the head of the bed at 3045 o for 4-6
hours or as recommended by the doctor.
5.2.5 Monitor vital signs.
5.2.6 Encourage the patient to have fluid intake for rehydration and replacement of
cerebrospinal fluid and to decrease the incidence of post lumbar headache.
5.2.7 Watch for any untoward signs of headache, fever, stiff neck, and inform the
472
doctor
immediately.
Republic of
Yemen 48Modern
48
Hospital
473
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
Hospital
48
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Renal Biopsy
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in assisting
during renal
biopsy procedure.
1 DEFINITION:
1.1 Renal Biopsy Needle biopsy of the kidney is performed by percutaneous needle
biopsy through
renal tissue. The procedure can be performed by either percutaneous (closed) or
surgical (open)
methods.
2 PURPOSES:
2.1 To determine the nature, extent and diagnosis of renal disease.
2.2 To obtain specimens for electron and immunoflourescent microscopy particularly for
glomerular
disease.
3 EQUIPMENTS/SUPPLIES:
3.1 IVAC machine with plastic cover
3.2 Stethoscope and sphygmomanometer
3.3 Sand bag
4 POLICIES:
4.1 Doctors order should be obtained.
4.2 Written consent should be signed.
PROCEDURES:
4.3 Thorough assessment of patients condition after the procedure should be strictly
5
5.1
Verify doctors order.
observed.
5.2 4.4
Explain
thefor
procedure
to the patient.
Ensure
the completeness
of all investigations that has been ordered and if
5.3
Let
the
patient
sign
the
consent form as witness by the doctor.
reported.
5.4 4.5
Send
X-raythat
request
Form M3019
toinformed
X-ray department
through
computer
online.
Ensure
the patient
is well
of the purpose
of the
procedure.
5.5 If the procedure is to be done under anesthesia send OR request through computer
online or
manual request (if urgent) properly filled-up by treating doctor.
5.6 Keep patient on nothing per orem (NPO) at least 6-8 hours.
5.7 Day of the procedure:
5.7.1 Follow-up for the laboratory results that has been ordered, if complete and
available such
as prothrombin time, platelet count, type and crossmatch blood for possible
blood
transfusion.
5.7.2 Maintain patient on NPO. Countercheck for signed consent.
5.7.3 Confirm with X-ray/OR department about the schedule of the procedure (if
under
sedation).
5.7.4 Take and record vital signs before sending the patient to X-ray/OR department.
5.7.5 Provide emotional support.
5.7.6 Send patient to X-ray/OR department per stretcher/bed together with the file
and PIN
card. Put on safety straps/side rails-up. 476
5.7.7 Endorse to X-ray/OR department staff.
5.8 Post procedure phase:
5.8.1 Receive patient from X-ray/RR staff with complete endorsement.
Republic of
Yemen 48Modern
48
Hospital
477
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Sigmoidoscopy
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in assisting
during
sigmoidoscopy procedure.
1 DEFINITION:
1.1 Sigmoidoscopy - the visualization of the anal canal , rectum, sigmoid colon through a
sigmoidoscope.
2 PURPOSES:
2.1 To diagnose malignancy, polyps, inflammation or strictures.
2.2 To aid in the detection of hemorrhoids, polyps, fissures, fistulas and abscesses within
the rectum
and anal canal.
3 CONTRAINDICATIONS:
3.1 Uncooperative client.
3.2 Severe rectal bleeding.
3.3 Painful advanced stage of anorectal conditions, such as fissures, fistula, or
hemorrhoids.
4 EQUIPMENTS:
4.1 Flexible sigmoidoscope
4.2 KY Jelly
4.3 Gloves
4.4 Biopsy Forceps
4.5 IV insertion set
4.6 Oxygen cylinder with accessories
4.7 Plastic Apron
4.8 Face mask
5 POLICIES:
5.1 Obtain informed consent for the procedure ( Form M1141 )
5.2 Proper instruction and health teachings should be given to the patient to the
procedure.
PROCEDURES:
6
5.3
Infection
control
policies
and
practices
should
be
employed
at
all
times.
6.1 Verify physicians order.
5.4
No procedure
be done without proof of payment.
6.2
Identify
correct to
client.
6.3 Let patient to sign an informed Consent for Diagnostic Procedure (Form M1141)
witnessed by the
treating physician.
6.4 Preparatory and Post Procedure Phase to be done:
6.4.1 Preparatory Phase :
6.4.1.1 Keep supplies and equipment ready at bedside.
6.4.1.2 Explain to client the purpose of bowel preparation.
6.4.1.3 Keep client on Nothing Per Orem (NPO) starting at 12:00 midnight before
the
procedure.
6.4.1.4 Administer fleet enema at 12:00 midnight and at 6:00 a.m. prior to
procedure.
6.4.1.5 Send the request form to Endoscopy
478Unit a day prior to the procedure.
6.4.1.6 Assess clients condition. Take vital signs.
6.4.1.7 Confirm time of appointment in Endoscopy Unit.
Republic of
Yemen 48Modern
48
Hospital
6.4.1.8 Transfer client with the file to Endoscopy Unit per stretcher with
safety strap.
6.4.1.9 Document the following:
6.4.1.9.1 Condition of client.
6.4.1.9.2 Mode of transfer.
6.4.1.9.3 Date and time of procedure.
6.4.1.9.4 Tolerance to bowel preparation.
6.4.1.9.5 Vital signs taken.
6.4.2 Post Procedure Phase :
6.4.2.1 Receive client and file endorsed completely by Endoscopy Nurse.
6.4.2.2 Assess clients condition when received after the procedure.
6.4.2.3 Transfer client to bed and place in comfortable position. Put side
rails up.
6.4.2.4 Check vital signs and record.
6.4.2.5 Observe client and notify the physician if any of these are observed:
6.4.2.5.1 Fever.
6.4.2.5.2 Bleeding.
6.4.2.5.3 Abnormal distention.
6.4.2.5.4 Any unusual complain of pain.
6.5 Record:
6.5.1 Clients preparation.
6.5.2 Specific procedure performed.
6.5.3 Tolerance to the procedure.
6.6 Resume diet per physicians order.
6.7 Charge the procedure and supplies used.
REFERENCES:
7
7.1 Rex DK Colonoscopy . Gastrointest Endosc Clin North AM 2000;10:
135-60
7.2 Sivak MV Jr, ed. Gastrointerologic endoscopy, 2nd ed. Philadelphia:
WB Saunders, 1995
7.3 Waye JD, Rex DK., Williams CB. Colonoscopy . Oxford: Blackwell
Publishing 2003
7.4. Nelson DB. Technical assessment of direct colonoscopy screening:
Procedural success, safety, and feasibility . Gastrointest
Endosc Clin
North Am 2002;12:77-84
7.5 Rex DK, Bond JH, Feld AD. Medical-legal risks of incident cancers
After clearing colonoscopy AM J Gastroenterol 1997;112:24-28
7.6 Rex DK. Rationale for colonoscopy screening and estimated
effectiveness
In clinical practice. Gastrointest Endosc Clin North AM 2002;12:65-75
7.7 Waye JD, Bashkoff E. Total colonoscopy: is it always possible.
Gastointest Endosc 1991; 37:152-4
7.8 Waye JD, Kahn O, Averbach ME. Complications of Colonoscopy
And flexible sigmoidoscopy. Gastrointest Endosc Clin North AM
1996; 343-77.
479
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Thoracentesis
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in assisting
during
thoracentesis procedure.
1 DEFINITION:
1.1 Thoracentesis - the aspiration of fluid or air from the pleural space.
2 PURPOSES:
2.1 To remove fluid or air from the pleural cavity for diagnostic or therapeutic purposes.
2.2 To obtain diagnostic aspiration on pleural fluid.
2.3 To obtain pleural biopsy.
2.4 To instill medication into the pleural space.
3 CONTRAINDICATION:
3.1 Contraindicated in patients with bleeding disorder.
4 EQUIPMENTS/SUPPLIES:
4.1 Syringes 50cc, 20cc, 5cc
4.2 Needles gauge 18, 23, 22
4.3 Cannula gauge 16, 18
4.4 Antiseptic solution
4.5 Local anesthetic
4.6 Sterile towel, drape, and gown
4.7 Sterile specimen container
4.8 IV tubing and 3-way stopcock
4.9 Large container for fluid
4.10Medication, if ordered
4.11Face mask, adhesive tape, transparent dressing, disposable gloves
4.12Equipment for taking vital signs
4.13Oxygen cylinder with O2 devices
4.14Pulse oximeter
5 POLICIES:
5.1 Procedure should be done under strict aseptic technique.
5.2 Patient should be well prepared physically, psychologically, physiologically, and
legally.
5.3 Follow standard infection control precautions.
5.4 Consent is obtained prior to procedure.
5.5 Obtain physicians order.
PROCEDURES:
6
6.1 Explain the procedure and obtain baseline assessment and history with close
attention to
respiratory status and vital signs.
6.2 Assemble equipment.
6.3 Ascertain the availability of X-ray films and laboratory result before the procedure.
6.4 Make the patient comfortable with adequate supports.
6.5 Position the patient:
6.5.1 Sitting on the edge of the bed, feet supported and head on a pillow over the
bedside table.
6.5.2 Straddling a chair with his/her arms and
head resting in the back of the chair.
480
Republic of
Yemen 48Modern
48
Hospital
6.5.3 If patient is unable to sit in a chair or side of bed, elevate head of the bed 3045o or place
on the affected side and elevate head of bed.
6.6 Support and reassure the patient during the procedure and encourage to refrain
from any
movement and coughing.
6.7 Wash hands and put on gloves.
6.8 Prepare the skin over the area where needle will be inserted.
6.9 Provide the physician with the available anesthetic, as needed.
6.10Provide all necessary equipment/supplies needed for aspiration, assist in the
procedure and
anticipate the doctors needs.
6.11If a considerable quantity of fluids is to be removed, the needle is held in place with
an adhesive
tape.
6.12After the needle is withdrawn, pressure is applied over the puncture site and a
small sterile
dressing is fixed in place.
6.13Place patient on bed rest in a comfortable position.
6.14Chest X-ray to be done as ordered.
6.15Administer oxygen prn.
6.16Aftercare of equipment.
6.17Remove gloves and wash hands.
6.18Send labeled specimen to the laboratory with charged request form.
6.19Monitor and record vital signs every 15 minutes for 1 hour. Check for asymmetry in
respiratory
movement, faintness, vertigo, tightness in chest, uncontrolled cough, blood tinge
frothy mucus,
and signs of hypoxemia. If noted, inform the doctor immediately.
6.20Document on the Nurses Notes:
6.20.1 Date and time
6.20.2 Name of physician
6.20.3 Amount and character of fluid obtained
6.20.4 Tolerance to procedure
6.21Charge the procedure and supplies used in the Inpatient Charging Form.
481
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
Hospital
48
PROCEDURES:
6.1 Preparatory Phase:
6
6.1.1 Verify the doctors order.
6.1.2 Obtain consent from the patient/ patients relative as witnessed by the doctor
who will
perform the procedure.
6.1.3 Make an assessment of the patient including allergies and medications taken by
that
patient.
6.1.4 Give health teachings regarding the procedure, instructs the patient not to take
any foods
or drinks at least 8 hours before the procedure (usually fasting over night).
Evaluate if
she/he fully understands the instruction given.
6.1.5 Give appointment.
6.2 On the Day of the Procedure:
6.2.1 Check the proof of payment.
6.2.2 Countercheck if the consent is signed.
6.2.3 Ask the patient if she/he is fasting.
6.2.4 Ensure that the dentures are removed.
6.2.5 Evaluate the patient if she/ he fully understands the procedure to be done.
6.2.6 Assist the patient and keep him comfortable in the procedure room. Provide
privacy.
6.2.7 Do hand washing . Wear disposable gloves.
6.2.8 Check instruments, accessories & equipments if functioning properly to prevent
the
delay of the procedure.
6.2.9 Establish intravenous ( IV) access.
6.2.10 Instruct the patient to swallow topical anesthetic or spray the throat to
decrease gag
reflex, as ordered.
6.2.11 Put the mouth guard with strap.
6.2.12 Assist the doctor during the procedure. Anticipate his needs.
6.2.13 Prepare biopsy forceps for possible biopsy taking
6.2.14 For helicobacter in CLO-test
6.2.15 Histopathology in Formalin
6.2.16 Monitor the patient and write in the documentation sheet.
6.2.17 Administer antibiotic prophylaxis ( if indicated )
6.3 Post Procedure:
6.3.1 Remove the mouth guard and clean the patient.
6.3.2 Monitor patients vital signs
6.3.3 Suction the secretions and provide airway
6.3.4 Continue to monitor and documents patients vital signs, including the return of
gag
reflex.
6.3.5 Observe for any abdominal distension, neck pain, signs of suggestive
perforation, gastro
intestinal bleeding, dysphagia, vomiting and notify the doctor at once.
6.3.6 Maintain NPO status until gag reflex returns.
6.3.7 Check for gag reflex by applying pressure on tongue depressor placed on the
back of the
tongue.
6.3.8 Make the necessary documentation including proper biopsy labeling.
6.3.9 After care of instrument and equipments.
483
6.3.10 Discharge the patient when fully recovered. Give the following instructions.
6.3.10.1 Date and time of next visit to revise result.
6.3.10.2Special instructions from the doctor , if any.
Republic of
Yemen 48Modern
48
Hospital
REFERENCES:
7
7.1 Blades EW, Chak A, eds. Upper Gastrointestional Endoscopy. In:
Gastrointestinal
Endoscopies Clinics of North America, Vol, 4(3) ( series ed. Sivak MV).
Philadelphia: WB Saunders, 1994
Sivak MV. Gastroenterologic Endoscopy. Philadelphia: WB Saunders,
1987
484
Republic of
Yemen 48Modern
MACHINES
Hospital
48
485
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
6.1.10 Press the buckles to give slack in the straps, then pull tight.
6.1.11 Make sure the lifter is unrestricted, raise patient, and weigh or proceed
transporting.
6.2 Bathing:
6.2.1 Place mesh-bathing sheet under the patient.
6.2.2 Place the lifter parallel to patients bedside with the bathinette folded inward
towards the
power box.
6.2.3 Move lifter next to the patient and unfold the top frame over and around
patient.
6.2.4 Raise lift and lower over patient by pressing the UP and DOWN button on the
hand
control.
6.2.5 Make sure that the frame clears the patient when lowering.
6.2.6 Attach hooks from buckles to grommets in bathing sheet with hooks pointing
down.
Press buckles for slack and pull tight.
6.2.7 Make sure lift is unrestricted, raise the patient.
6.2.8 Unfold bathinette under the patient and attach to perimeter of lifting frame.
Drain should
be at the foot end of the bed.
6.2.9 Connect the drain either to the waste container or to a floor drain such as
shower drain.
6.2.10 Attach diverter valve to the faucet and adjust the water temperature. Divert
water to
shower wand.
6.2.11 Wash hands, wear gloves.
6.2.12 Undress the patient and start bathing.
6.2.13 After bathing drain waste water from the system.
6.2.14 Disconnect the bathinette from the outer edge of the frame and slid it under
the patient
connecting it to the power box side of the frame.
6.2.15 Dry the patient and wipe under the bathing sheet to absorb excess moisture.
6.2.16 Lay a clean bath sheet onto the bed to keep bed linen from moisture when
lowering
patient onto bed. Lower lifter and place patient on the bed. Disconnect the
sheet and
remove lift.
6.2.17 Remove bathing sheet and bath sheet from the patient at the same time.
6.2.18 Provide clean gown for the patient and make him/her comfortable.
6.2.19 Aftercare of equipment:
6.2.19.1Bathinette
clean with non-abrasive cleaner or disinfectant. If machine7
SPECIAL
CONSIDERATIONS:
is7.1 When not in use, charge battery by plugging to the power cord into a wall
receptacle.washable,
Anderlift use normal hot cycle. Drip dry only. Do not put in dryer.
6.2.19.2Drain
hoses
disinfectant
is run through
hoses after each use.
will
not overcharge
andcan
be left charging
indefinitely.
7.2 Anderlift can be stored in collapsed position.
7.3 Lifter is not to be charged when in use by patient. Unit will not operate while
charging.
7.4 Moving lifter in collapsed position is not recommended.
7.5 Top buckles and hooks are to be used for bottom sheet; bottom buckles are to be
used for top
sheet.
487
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Breast Pump
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in operating a
breast
pump.
1 DEFINITION:
1.1 The Medela Breast Pump- is a piston pump based upon a simple and robust design
that aids in
expression of milk. There are two types of pumps:
1.1.1 Medela Breast Pump Lactina
1.1.2 Medela Breast Pump Heavy Duty
2 PURPOSES:
2.1 To re-establish maternal milk supply.
2.2 To stimulate lactation.
2.3 To relieve engorgement.
2.4 To reduce pressure on sore or cracked nipples.
3 INDICATIONS:
3.1 Mothers who have:
3.1.1 Breast engorgement/Breast Infection/Latch on problem and sored nipples.
3.1.2 Flat or inverted nipple.
3.1.3 Premature or hospitalized baby.
3.1.4 Low milk supply.
3.1.5 Part time/full time job.
4 EQUIPMENTS/SUPPLIES:
4.1 Breast pump with accessory kit
4.1.1 Piston with rubber seal
4.1.2 Cylinder with vacuum regulator
4.1.3 Cylinder holder
4.1.4 Valve breast shield
4.1.5 Milk bottle
4.1.6 Lid and disk
4.1.7 Tubing with connector
4.1.8 Insert for small breast
5 POLICIES:
5.1 Ensure that the machine is in proper working condition.
5.2 Bottle tubing must be sterilized before each use.
5.3 Periodic check up of the device by Biomedical Engineer must be done.
5.4 Pump must not be used in the presence of flammable anesthetics due to explosion
PROCEDURES:
6
hazards.
6.1 Follow the steps to assemble plastic accessory kit.
6.1.1 Pull the rubber seal over the base of the piston until it seats correctly.
6.1.2 Introduce the piston into the cylinder.
6.1.3 Screw the cylinder tightly in the cylinder holder.
6.1.4 Hold the assembly vertically and push it into the Lactina.
6.1.5 Twist the piston down to right. The guide piece on the cylinder holder must
engage in the
slit in the pump casing.
488
6.1.6
Republic of
Yemen 48Modern
48
Hospital
Attach the piston handle to the rubber clamp on the pump arm and ensure that
it can pivot
freely.
6.1.7 Snap the valve onto the breast shield to ensure that it locks into position
(select the proper
shield according to size of breast and nipple).
6.1.8 Screw the milk bottle on to the breast shield.
6.1.9 Insert the connector of the tubing into the breast shield.
6.1.10 Connect the other end of the tubing to the cylinder holder.
6.1.11 Set the vacuum regulator to minimum if required, suction strength can be set
at medium
or increased to maximum.
6.2 Plug in the breast pump to 110V.
6.3 Center the breast shield over the nipple. The breast shield should be pressed
against the breast to
form a seal.
6.4 Turn the breast pump on.
6.5 When the milk bottle is filled with desired quantity, switch off the breast pump and
disassemble
the accessory kit.
7 NURSING RESPONSIBILITIES:
7.1 The outside of the breast pump must be kept clean at all times, wipe it with a clean
cloth and
remove any milk residue with warm water/mild soap.
7.2 The disassembled plastic parts must be sterilized individually. The valve must
always be removed
from the breast shield.
8
7.3 Check the pump daily to make sure that there is no milk in the pump system.
7.4 When assembling sterilized parts, do not touch inside of parts.
SPECIAL CONSIDERATIONS:
8.1 Medela Heavy Duty Breast Pump is designed to operate optimally when the
regulator is at the
NORMAL. For treatment of very sored or cracked nipples, use the MINIMUM setting
only.
8.2 The collection cup/bottle should be held in an upright position to prevent milk being
sucked into
the overflow safety bottle/cylinder.
8.3 If the milk bottle has been overfilled and milk entered the connection tube, pumping
must be
stopped and the pump must be turned off. Disassemble the accessory kit.
8.4 Medela Heavy Duty Breast pump operates 48 cycles/run. Every cycle consist of 3
phases.
8.4.1 Vacuum Phase (suction phase)
8.4.2 Release Phase
8.4.3 Relaxation Phase
8.5 To stop pumping, pull breast shield between two suction phases gently from the
breast.
8.6 Before using the pump again, the tubing and overflow bottle must be washed.
489
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Defibrillator
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in operating a
defibrillator.
1 DEFINITION:
1.1 Defibrillator - an instrument by which normal rhythm is restored in ventricular or
atrial
fibrillation by the application of a high voltage electric current.
1.1.1 * Physio-Control Lifepak - consist of two modules:
1.1.1.1 ECG monitor module
1.1.1.2 Defibrillator module
1.1.2 * Code Master XL
1.1.3 * AED Lifepak 20 biphasic with pacing + pulse oximetry
2* Parts and Features refer to its respective operating manuals available in the
unit.
3 PURPOSES:
3.1 To terminate ventricular fibrillation or ventricular tachycardia without pulse.
3.2 To perform synchronized cardioversion. The defibillator delivers the countershock
within
milliseconds of the ECG R wave to prevent shock during absolute refractory period.
3.3 Pacing used to maintain cardiac rhythm when contractions initiated by natural
pacemaker are
inadequate.
4 EQUIPMENTS/SUPPLIES:
4.1 Defibrillator Machines
4.1.1 Physio Control Lifepak
4.1.2 Code Master-XL
4.1.3 AED Lifepak 20
4.2 Power cord
4.3 ECG cable
4.4 Electrodes paddle set (Adult/Pedia) + disposable set
4.5 ECG paper
4.6 Electrode gel
4.7 External pacer
5 POLICIES:
5.1 Defibrillation should be performed by Cardiologist/ACLS provider.
5.2 Only the prescribed energy level should be delivered to the client.
5.3 Machine must be kept charge at all time.
5.4 All staff in the unit should be familiar regarding the operation and precautions in
using the
machine.
5.5 All accessories of defibrillator should be available at all times.
5.6 Preventive maintenance is a must.
5.7 Any malfunction in the machine should be reported immediately to the Biomedical
Engineer.
5.8 User test and test load for energy charging should be done every shift according to
machine. :
5.9 Ensure client cable is attached to monitor
490at all times.
5.10ECG paper roll must be checked and monitor run for 3-5 seconds on testing paper
must be at
least half full.
Republic of
Yemen 48Modern
48
Hospital
491
PROCEDURES:
6.1 Defibrillating client with Code Master - XL
6.2 USER TEST unplugged the machine.
6.3 On the defibrillator, turn the energy select control to 100 joules energy level and
Republic of
charge. When
machine
alarms
press button simultaneously.
Yemen
48Modern
48
6.4 Remove the paddles from their holder by grasping the handles and lifting them
Hospital
straight up.
6.5 Holding both paddles in one hand, apply conductive gel to the electrode surface of
each paddle.
6.6 Press CHARGE on either apex paddle or on the instrument front panel.
6.7 Wait for the charge indicators CHARGE light.
6.8 Call out CLEAR to alert personnel to stand away from the client and bed.
6.9 Place the sternum paddle near the upper sternum in the client right mid-clavicular
line, just below
the clavicle.
6.10Place the apex paddle, on the chest just below and to the left of the clients left
nipple in the
anterior axillary line.
6.11Final clear out and apply 10 to 12 kg of pressure to each paddles and deliver the
shock.
6.12Briefly adjust paddle pressure and placement to optimize client contact.
6.13Verify that no one is in contact with client, the monitoring cable, the bed rails or
another potential
current pathway.
6.14Call out CLEAR three times to alert personnel to stand away from the patient.
6.15Press and briefly hold both shock buttons, simultaneously to deliver energy to the
client.
6.15.1 Resetting the selected energy level.
6.15.1.1To increase or decrease the selected energy level after pressing the
charge button,
perform the following steps:
6.15.1.1.1 Move the Energy Select control to the new energy level and
discharge.
6.15.1.1.2 Wait for the Charge Done indicators and shock again.
6.16Non Invasive Pacing Optional Defibrillation with Code Master - XL +Using the Pacer
6.16.1 Apply pads as instructed on the package.
6.16.2 Attach monitoring electrodes as instructed in using leads to monitor.
6.16.3 Attach the client cable to the Code Master XL+s ECG Input connector.
6.16.4 Attach the client cable leads to the monitoring electrodes.
6.16.5 Attach the pads adaptor cable to the defibrillator output connector. Pull the
latch
connector toward the front of the defibrillator to lock the connector in place.
6.16.6 Attach the pads to the pads adaptor cable and turn the twists lock.
6.16.7 Turn the Energy Select control to the monitor on position.
6.16.8 Press Pacer On to turn the Pacer On. The Pacer is always in demand/fix mode
when it is
turned on.
6.16.9 Select the best lead for monitoring while pacing and adjust the rate.
6.16.10Select the Pacing mode when in demand mode, the Pacer will only deliver
Pacer Pulses
when the patients heart rate is lower than the selected pacer rate. When in a
synchronized mode, the pacer will deliver Pacer Pulses at the selected Pacer
Rate. When
in fix mode only machine will take over.
6.16.11Press to start pacing, the monitor will now display the message PACING as
well as the
selected mode, rate and output.
6.16.12Verify that the Pacer Pulses are well positioned in the diastole.
6.16.13Increase output until the beat is captured, selecting an alternate lead could
help you to
determine capture.
6.16.14To set the lowest possible output level to capture, decrease the current by
decrements of 5
492
milliampule by pressing output.
6.17Defibrillation during Pacing
6.17.1 Set the desired energy level with Energy Select Control.
6.17.2 Press charge, the defibrillator will automatically turn off the Pacer and start
charging.
Republic of
Yemen 48Modern
48
Hospital
6.17.4 Call out CLEAR three times to alert personnel to stand away from the client.
6.17.5 Press button of the machine and briefly hold both shocks buttons located on
the cable
connector. The shock will be delivered through the multifunction pads.
6.17.6 After shock is delivered, the pacer remains off. Resume pacing if it is required.
6.18AED Lifepak 20 see attached manual.
6.19Post Operation Responsibilities
6.19.1 Turn the power off or standby.
6.19.2 Clear the paddles, controls and cables.
6.19.3 After each use user test should be done.
6.19.4 Return the machine and plug the power cord into an AC Power outlet. Ensure
that the
battery charge and AC power lights are ON.
6.19.5 Check that sufficient ECG paper, electrode gel, defibrillator pads are available
for the
next use.
6.19.6 Check the machine energy shift and call the Bio-med if needed.
6.19.7 Maintain the cleanliness and readiness of the machine and unit for next use.
SPECIAL CONSIDERATIONS:
7
7.1 There are different types of machine available within the hospital, physical features
vary but the
principles in defibrillating the patient remains the same.
7.2 For synchronized cardioversion, machine should be programmed in synchronized
mode and the
prescribed energy will be released only with each R - wave of the cardiac cycle.
7.3 Do not allow the gel to accumulate on hands or on the paddle handler to avoid risk
of electrical
shock.
7.4 Do not spread gel between the paddle electrodes on the chest. The patient can be
burned if the gel
forms a path between the electrodes.
7.5 SpO2 monitoring is optional in Code Master XL machine. Turn the defibrillator on if
necessary by
turning the Energy Select control to MONITOR ON. Press the SpO 2 ON/OFF button to
display
the SpO2 reading in the upper right corner of the display. The pulse amplitude
indicator shows the
quality of the SpO2 signal. The pulse rate is delivered from the pulse oximeter.
493
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Electrocardiography Machine
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in operating
an
electrocardiography machine.
1 DEFINITION:
1.1 Electrocardiography Machine A device intended for recording the hearts electrical
activity
under the conditions of the ambulant practice and clinical routine.
1.1.1 Types
1.1.1.1 Bioset 3500, 3700
1.1.1.2 Cardiostat 3, 31
1.1.1.3 Esaote Biomedika
2 PURPOSE:
2.1 To record the electrical activity of the heart.
3 EQUIPMENTS/SUPPLIES:
3.1 ECG machine with:
3.1.1 Leads
3.1.2 Recording paper
3.1.3 Conductive gel
3.1.4 Tissue
4 POLICIES:
4.1 Ensure that the machine is in good working condition.
4.2 Follow safety measures while using the machine.
4.3 Regular periodic preventive maintenance monitoring.
PROCEDURES:
5
5.1 Insertion of recording paper.
5.1.1 Press the cover opening button to release the cover.
5.1.2 Bring cover into upright position and put it aside.
5.1.3 Insert the paper block into the chamber, place it properly and pull some paper
out.
5.1.3.1 Insert the paper block in such a manner that the imprint side gets visible
if the paper
is pulled to the left. The black paper marks are above (behind).
5.1.4 Reinsert the cover.
5.1.5 Bring the recording paper into a symmetric position toward the cover.
5.1.6 Close the cover by slightly pressing its left verge.
5.2 Prepare the skin areas by applying conductive gel.
5.3 Place the electrodes to the prepared areas according machine manual instruction
5.4 Right arm (red)
5.4.1 Left arm (yellow)
5.4.2 Left leg (green)
5.4.3 Right leg (black)
5.4.4 4th intercostal space, right sternal border (w+r)
5.4.5 4th intercostal space, left sternal border (w+y)
5.4.6 Between left 4th and 5th intercostal space (w+g)
5.4.7 5th intercostal space, left midclavicular 495
line (w+br)
Republic of
Yemen 48Modern
48
Hospital
496
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Infusion Pump
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in operating
an infusion
pump.
1 DEFINITION:
1.1 Infusion Pump is a dual micro processor controlled electronic system with an
advanced lineal
peristaltic pump mechanism/precision pump chamber administration set to yield
volumetric
performance at an unparalleled level of safety and cost-effectiveness.
1.2 Types
1.2.1 Diatek Secura IV
1.2.2 Infusomat Secura
1.2.3 Infusomat fm
1.2.4 Volumed u VP 5005
2 PURPOSES:
2.1 For accurate and constant delivery of parenteral medications and IV fluids.
2.2 For long-term infusion of large volumes with high accuracy.
2.3 To ensure that the fluid is free from air by means of an air chamber.
3 EQUIPMENTS/SUPPLIES:
3.1 Infusion pump
3.2 Infusomat set
3.3 Extension set
3.4 Cannula lock/3 way stopcock
3.5 IV fluids
3.6 IV pole
4 POLICIES:
4.1 Ensure that the machine is in good working condition.
4.2 Ensure that the machine is plugged to the respective voltage 110 volts or 220 volts
continuously.
4.3 The machine is equipped with a free-flow protection and flow sensor must be free of
PROCEDURES:
5
dirt or fluid
5.1 Check
theprevent
equipment
for proper
functioning
and the completeness of its accessories
spills to
malfunction
of the
unit.
before
using, preventive maintenance should be done by the Biomedical Engineer.
4.4 Routine
5.2 Connect the power cord of the machine to the electrical socket.
5.3 Prime the set, fill drop chamber 1/3 to full. Do not overfill.
5.4 Place flow sensor over collar of drip chamber.
5.5 Open pump door by pulling down and out on ring at base of door latch.
5.6 Install pump chamber.
5.6.1 Insert bottom connector into lower pump chamber mounting notch and position
PVC
tubing in air detector tubing slot.
5.6.2 Insert top connector into upper pump chamber mounting notch. Verify pump
chamber is
positioned vertically and direction of flow to patient is downward.
5.6.3 Close and latch door.
497
5.6.4 Verify pump chamber is firmly seated in flow stop clamp. If necessary, push
into
position.
Republic of
Yemen 48Modern
48
Hospital
5.6.5 Fully open control pump. Verify that no falling drops are observed in drop
chamber.
5.7 Press green power switch. Wait for completing of self-test.
5.8 Enter desired flow rate on key pad (1-400ml/hour).
5.9 If Volume Limit feature is desired, press the volume limit ON/OFF/CLEAR button
and enter
the desired volume limit (1-999/ml).
5.10Press START/STOP button to begin infusion. Yellow indicator will illuminate to
indicate pump
is running. Volume infused indicator will change to 0 and increase in 1ml
increments as fluids
is delivered.
5.11To change the rate, stop fluid delivery by pressing the START/STOP button. Enter
the desired
rate and push the START/STOP button to restart the infusion at the new rate.
5.12When IV fluid is consumed the alarm sounds. Turn off the machine by pressing the
power
RESPONSIBILITIES:
6
ON/OFF.
Disconnect
the
end
tubing
from
the
patient
and
the
whole
tubing
system
6.1 Keep the machine always clean and dry.
from
thethe machine is not in use, the machine should be plugged into line power at
6.2
When
chamber.
all times to
keep the internal battery fully charged.
6.3 Inform Biomedical Engineer for any malfunction of the machine.
6.4 Inspect unit to make sure all display areas are free from spillage, the diaphragms
covering the
pump mechanism, and air line sensors are undamaged, and that the pressure plate
7
on the back of
the pump door is undamaged.
SPECIAL CONSIDERATIONS:
7.1 To operate pump on battery power, simply remove power plug from wall socket or
disconnect the
power cord from instrument rear panel.
7.2 The flow rate cannot be changed when the machine is delivering fluid to the patient.
7.3 If not restarted within 2 minutes, the audible alarm will sound. It can be silenced for
additional
two minutes interval by pushing the alarm mute button.
7.4 Flow sensor connector should attached properly to the machine.
7.5 Nurses should be aware of the alarm codes displayed in the unit.
7.6 During cleaning and disinfection, the unit should be disconnected from the line
power.
7.6.1 Flow sensor should be cleaned with alcohol swab or rinse under warm water,
dry
thoroughly.
7.6.2 It should be cleaned with damp cloth or sponge wet in warm water with a mild
detergent
or alcohol if desired.
7.6.3 After cleaning the unit, it should be disinfected by using a spray surface
disinfectant. Dry
the case and front panel surfaces after completion.
498
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: IVAC Temperature Plus
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in operating
an IVAC
Temperature Plus.
1 DEFINITION:
1.1 IVAC Temperature Plus - a digital thermometer capable of taking fast, accurate
temperatures,
with the use of a heat-sensing device known as thermistor to sense temperature.
2 PURPOSE:
2.1 To monitor body temperature in a fast and accurate manner.
3 EQUIPMENTS/SUPPLIES:
3.1 This device is composed of the following:
3.1.1 Probe with ejection button
3.1.1.1 blue oral/axilla
3.1.1.2 red - rectal
3.1.2 Carrying strap
3.1.3 Probe cover box
3.1.4 IVAC machine home base
PROCEDURES:
45.1
POLICIES:
Calibration Self-check:
4.1
Ensure
proper
condition
using
it. beep. The instrument will be in
5.1.1
Select
and working
remove one
probe;before
note an
audible
4.2 Any malfunction in the device should immediately report to bio-medical engineer.
Predictive
Mode.
5
5.1.2 Verify that the display briefly shows 188.8oF and all messages. The self-check
takes
place during this time.
5.1.3 Verify that the test display is replaced by three dashes (- - -). The three dashes
do not
appear if only one probe is installed in the instrument. Instead the temperature
of the
probe is displayed after the self-test (80.0oF - 26.7oC will be displayed if the
probe is at
below this temperature).
5.1.4 In monitor mode the message MONITOR MODE will display and the PULSE
TIMER
button should be released.
5.1.5 Touch the probe tip to the back of your hand or other warm surface.
5.1.6 If an advancing temperature is displayed, the thermometer successfully passed
the
calibration check.
5.1.7 If the message FIX ME 4 appears, the thermometer is out of calibration and
requires
service.
5.2 Operational use:
5.2.1 Start-up
5.2.1.1 Install a box of 20 probe covers in the storage compartment at the rear of
the
instrument.
499
5.2.1.2 With your thumb and forefinger, grasp the base of a probe and withdraw it
from the
storage well. This action automatically turns on the instrument.
5.2.1.3 Verify that all display segments, except the pulse timer clock
momentarily light and
that the instrument beeps once (instrument will beep twice in the monitor
mode).
Republic
of
When this sequence
is complete, the instrument will display three dashes (- -) Yemen 48Modern
48
indicating the instrument is ready for use.
Hospital
5.2.1.4 Insert the probe completely and firmly into a probe cover to ensure a
secure fit. The
device is ready to use now.
5.2.2 Oral Temperature Measurement use the blue, oral probe.
5.2.2.1 Have the patient open his/her mouth. Holding the probe, slightly insert
probe tip to
the sublingual pocket where the richest blood supply is located.
5.2.2.2 Hold the probe during the entire temperature measurement process and
keep the
probe tip in contact with tissue at all times. Do not allow patient to
reposition the
probe.
5.2.2.3 While the patients temperature is being determined, the tissue contact
pinwheel will
appear in the top right corner of the display and the three dashes (- - -) will
be
replaced by an advancing temperature.
5.2.2.4 An audible tone indicates that the measurement is complete, and the
patients
temperature (in degrees and tenths of a degree) will appear on the display
will clear
as the probe is returned to the storage well.
5.2.2.5 Observe the displayed temperature and remove the probe from the
patients mouth.
Hold the probe as you would a syringe and press the probe ejection button
at the
base of the probe to eject the used probe cover into a waste container.
5.2.2.6 Return the probe to the probe storage well. This will automatically turn
off and reset
the thermometer for the next temperature.
5.2.3 Rectal Temperature Measurement:
5.2.3.1 Touch the tissue about a half-inch (1.3) above the sphincter muscle and
carefully
insert the probe. (The use of lubricant is optional).
5.2.3.2 To ensure continuous tissue contact and maximize patient comfort, hold
the probe in
position until the audible tone sounds indicating the patients temperature
has been
reached.
5.2.3.3 Note the temperature, withdraw the probe, press the probe ejection
button to eject
the used probe cover, and return the probe to the storage well.
5.2.4 Axillary Temperature Measurement:
5.2.4.1 Place probe in patients axilla, making sure the tip of the probe is in
contact with the
position to the axillary artery with the patients arm held close to their side.
The three
dashes (- - -) will be replaced with the probe tip temperature as the probe
warms up.
5.2.4.2 Leave probe in place for the same length of time as required for taking an
axillary
temperature (the instrument will not beep to indicate final temperature
reading).
5.2.4.3 Observe patients temperature, remove probe, eject probe cover, and
return probe to
storage well.
5.2.5 Monitor Mode Operation: In monitor mode, the Temp. Plus II thermometer as it
500
rises or
falls.
5.2.5.1 Push and hold the pulse timer button.
5.2.5.2 Select and remove one probe and attach a probe cover.
5.2.5.3 When the display test has completed, indicated by three dashes (- - -) in
Republic of
Yemen 48Modern
48
Hospital
501
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Title: Multiparameter
(NELLCOR PURITAN BENNETT-4000)
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in operating a
Nellcor
Puritan Bennett-4000 multiparameter machine.
1 DEFINITION:
1.1 Multiparameter - a lightweight compact portable and accurate device designed to
monitor
essential vital signs, oxygen saturation and ECG. It is operated by power supply or
battery charge
and display parameters in eight languages.
2 PURPOSES:
2.1 To monitor the following:
2.1.1 ECG
2.1.2 Heart Rate
2.1.3 Non-invasive blood pressure (systolic, diastolic and mean arterial pressure)
2.1.4 Functional arterial oxygen saturation
2.1.5 Respiration rate
2.1.6 Temperature for adult and pediatric patients
3 CONTRAINDICATIONS:
3.1 During Magnetic Resonance Imaging (MRI).
3.2 Presence of flammable anesthetics (explosion hazard).
3.3 Do not use to monitor neonates.
3.4 Patients who are linked to heart lung machines.
4 EQUIPMENTS/SUPPLIES:
4.1 Multiparameter ECG cable
4.2 NBP hose and cuff
4.3 SpO2 cable and sensor
4.4 Temperature probe
5 POLICIES:
5.1 Multiparameter and its accessories should be checked regularly to ensure proper
working
conditions.
5.2 Only the appropriate multiparameter cables and accessories should be used to avoid
false
monitoring.
5.3 NPB - 4000 should not be used in the presence of flammable anesthetics to avoid
PROCEDURES:
6
explosion
6.1 Plug the monitor connection to electrical power.
hazard.
6.2 Connect client cables to front panel connectors (BP cuff, sensor, electrodes, probes)
5.4 Always to be connected to AC power.
then attach to
client.
6.3 Press the on/standby switch to turn on the monitor. The monitor will go through a
self-test before
displaying the monitoring screen. The screen will display waveform, areas and
frames.
6.3.1 If no leads or accessories have been connected
to client, the screen will appear
502
blank of
data.
and
If the monitor detects valid signals, then a typical presentation with waveforms
Republic of
Yemen 48Modern
6.7.3.3.5
48
Hospital
504
Republic of
Yemen 48Modern
Hospital
48
display.
6.8
SpO2 Monitoring :
At6.8.1
60 minutes
the sensor
stat measurements,
the
Connectafter
SpO2completion
cable then of
place
to a finger properly,
and that skin
displayed
NPB
integrity is
measurement
and the clock icon are removed.
acceptable.
6.8.2 Inspect the sensor site as directed to ensure skin integrity and correct position
and
adhesion of the sensor.
6.9 Respiration Monitoring:
6.9.1 This can be detected by using two of the three leads of the ECG electrodes and
cable.
6.9.2 Real time respiratory information is presented as a waveform on a graphic
frame,
respiration is presented in a numeric frame and in tubular trend date.
6.10Temperature Monitoring :
6.10.1 Measurement of client is accomplished by processing the signal from a probe
containing
resistance element whose impedance is temperature dependent.
6.10.2 Probes are furnished with a standard 10 feet lead, extension leads are
available.
6.10.3 The signal from the probe is conditioned by the monitor input gravity,
processed and the
measured values are shown in the numeric frame.
6.11Trend Data Storage :
6.11.1 Trend data in graphical or tubular format maybe presented on the screen.
6.11.2 Trend information in graphical format for a selected monitored parameter is
shown by
6.11.3 Clotting each of the 20 second averages as vertically positioned points on the
graph.
Displaying trend data :
6.11.3.1Rotate the knob to highlight the graphic frame in which the desired trend
is to
appear.
6.11.3.2Press knob. The level 1 menu for this frame appears frames 2 and 3.
6.11.3.3Remove the knob to highlight the trend description item in level 1 menu.
6.11.3.4Press knob. Control is returned to the level 1 menu.
6.11.3.5Rotate knob until return message is highlighted.
6.11.3.6Press knob. The display now contains a graphical trend (if selected) in the
previously highlighted graphic frame location.
6.12Printing:
6.12.1 Two types of real-time printed records maybe obtained by pressing the
appropriate button
on the printer in the right panel.
6.12.1.1Snapshot: A 20 second print recording real time graphical and numeric
information
beginning with the values 10 seconds before the print initiation and ending
10
seconds
after that event. Press the snapshot switch automatically all
AFTER CARE
RESPONSIBILITIES:
7
information
inNPB - 4000, charge all the time when not in use.
7.1 Keep the
themonitor
multiparameter
7.2 Keep the
clean anddisplay
tidy. window will be printed. Time is printed along the
bottom
7.2.1 Dampen a cloth with commercial, nonabrasive cleaner and wipe the top bottom
and front of the paper.
6.12.1.2Continuous:
A print of real time graphical and numeric information
surfaces lightly.
beginning
10 cables, sensors and cuffs, follow cleaning instructions in the directions for
7.2.2 For
seconds before initiating the action and continuing until stopped.
use
6.12.1.3Printing
in any
mode can be stopped
505 by pressing either of the two printer
shipped with those
components.
buttons
(snapshot switch, continuous switch).
6.13Press the on/standby switch to terminate monitoring.
Republic of
Yemen 48Modern
48
Hospital
7.3 Do not place the monitor in any position that might cause it to fall to patient, do not
lift the
monitor by the power supply cord or patients connections. Disconnections could
result in the
monitor dropping on patient.
7.4 Carefully route patient cabling to reduce possibility of patient entanglement or
strangulation.
SPECIAL CONSIDERATIONS:
8
8.5 If the accuracy of any measurement does not seem reasonable, first check the vital
signs by
alternate means and then check the NPB - 4000 monitor NPB - 4000 for proper
functioning.
8.6 The NPB - 4000 maybe used on a patient during defibrillation, but the readings
maybe inaccurate
for a short time.
8.7 Electromagnetic interference may cause disruption of performance. (e.g. cellular
phone, mobile
two-way radios, electrical appliances).
8.8 For pacemaker patients, the NPB - 4000 may continue to count pacemaker rate
during
occurrences of cardiac arrest or some arrhythmias.
506
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
7.3 Avoid applying additional tape to the probe to minimize the risk of impaired
perfusion and tissue
injury.
7.4 Clean the sensor by wiping 70% alcohol.
7.5 Sensors should be placed on the extremities positioned at heart level.
7.6 Do not use a damage sensor with exposed optical components.
508
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Septic Fluid Aspirator Medap P7040
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in operating a
Septic
Fluid Aspirator Medap P7040.
1 DEFINITION:
1.1 The Septic Fluid Aspirator P7040 - a high-performance, low-noise aspirator device for
continuous operation and is suitable for low flow rates and high vacuum.
2 PURPOSE:
2.1 To aspirate body fluids (septic fluids, blood and serous fluids) and particles contained
therein
from natural and artificial orifices.
3 CONTRAINDICATION:
3.1 The septic fluid aspirator is neither suitable for use in surgery nor as a drainage
aspirator. The
particles contained in the gas phase might lead to an early clogging of the humidity
filter.
4 EQUIPMENTS/SUPPLIES:
4.1 Medap Septic Fluid Aspirator
4.1.1 Silicone tube
4.1.2 Basic aspirator
4.1.3 Regulating screw
4.1.4 Rocker switch
4.1.5 Vacuometer
4.1.6 Suction nipple (optional)
4.1.7 Septic fluid jar cap
4.1.8 Float holder
4.1.9 Float
4.1.10 Gasket
4.1.11 Septic fluid jar
4.1.12 Suction unit
4.1.13 Bacterial filter cap
4.1.14 Filter paper (bacterial paper)
5 POLICIES:
5.1 Only qualified personnel are permitted to use this device in accordance with the
operating
instructions.
5.2 Ensure proper working condition of machine prior to operation.
5.3 The following part of the machine must be sent to CSSD daily for sterilization:
5.3.1 Septic fluid jar cap
5.3.2 Float holder
5.3.3 Float
5.3.4 Gasket
5.3.5 Septic fluid jar
5.4 Infection Control Policy must be followed when using the device.
5.5 Bacterial filter paper must be changed daily when in used.
509
Republic of
PROCEDURES:
Yemen
48Modern
48
6.1 Check
if the supply
voltage corresponds to the information on the type of label.
Hospital
510
Republic of
Yemen 48Modern
48
Hospital
511
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Syringe Pumps
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in operating a
syringe
pump.
1 DEFINITION:
1.1 Syringe Pumps - a continuous infusion device designed for precisely controlled
infusion of
liquids at a constant and exact delivery rate for long duration by means of a disposable
syringe.
1.1.1 Soveta
1.1.2 Secura
1.1.3 Fresenius
2 PURPOSE:
2.1 To deliver regulated small amount of infusion e.g. Heparin infusion. Dormicum,
Tracrium, Insulin
etc.
3 EQUIPMENTS/SUPPLIES:
3.1 Perfusor with cable
3.2 Perfusor syringe
3.3 Perfusor set
4 POLICIES:
4.1 Never start operating the machine when it is defective.
4.2 Check working condition before starting.
4.3 The infusion system should be filled in such a way as to avoid formation of bubbles.
PROCEDURES:
4.4Connect
In ordermains
to avoid
battery
discharge,
theand
pump
should
not be disconnected from the
5.1
cable
to pump
connector
mains
socket.
source
power
5.2 Switch the pump on with ON and OFF key. The green lamp mains will light. The 5
for period longer than 90 days to prevent permanent damage.
following
4.5
Correct will
voltage
should always be used.
messages
be displayed.
4.6
Repairs
should
be
performed
byisauthorized
persons.
5.2.1 NO MAINS!! Warning
that only
pump
not connected
to the mains, connect it to the
mains
Republic
press
of
YES.
Yemen 48Modern
48
Republic of
NURSING RESPONSIBILITIES:
48Modern
48
6.1 The Yemen
programmed
rate and volume values are accurate only, when the appropriate
syringe is
used,
Hospital
514
Republic of
Yemen 48Modern
48
Hospital
6.2 For cleaning and disinfection, the device must be switched off and disconnected
from the mains.
The unit is wiped with a disinfectant - soaked cloth or alcohol - based disinfectant can
be used
also. After disinfection, at least one minute should elapse before the pump is
switched on again.
6.3 Keep the rate 0 after the use.
6.4 Keep the machine clean and dry always.
6.5 The syringe should be labeled with the preparation of the infusion, date and time it
was started and
the signature of the nurse who prepared the infusion.
SPECIAL CONSIDERATIONS:
7
7.1 Perfusor secura has a precise setting of delivery rate combined with the selected
syringes either 25
or 50ml. It has pre-alarm intermittently for 3 minutes prior to the end of infusion.
7.2 Alarms will occur of there is low supply of battery or no mains and due to stoppage
of plunger
movement related to occlusion or end of infusion.
7.3 To operate the perfusor secura.
7.3.1 Place the syringe holder in the outboard position. Activate the black push
button and the
back motion lockout will be released.
7.3.2 Slide the syringe holder to the outboard position.
7.3.3 Deaerate the lines by turning the adjustment knob in a clockwise direction, the
lines will
be deaerated and at the same time the play in the drive system will be
eliminated. After
operation starts, neither the push button nor the rotary knob may be activated.
7.3.4 Program the rate.
7.3.5 To turn on the equipment, press the switch (green lamp lights). When the
equipment is
turned on, there will be a red fault lamp for a short time and the acoustical
alarm will
sound.
515
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Title: Ultrasonic Nebulizer
Applies to: General Ward and Specialty Units
CONTENTS: This General Ward policy and procedure deals with the guidelines in operating
an ultrasonic
nebulizer.
1 DEFINITION:
1.1 Ultrasonic Nebulizer - a device used in short therapeutic sessions to deliver moisture
or
medication by producing 100% humidity in a fine aerosol mist of fluid droplets that
ideally and
slowly settle deep into the lungs.
2 PURPOSE:
2.1 To mobilize the thick secretions and facilitate a productive cough.
3 EQUIPMENTS/SUPPLIES:
3.1 Corrugated tube
3.2 Mouth piece
3.3 Nebulizer mask (Adult and Pedia)
3.4 Solution cup
3.5 Brush
3.6 Bacterial filter
3.7 Dust filter
3.8 Silicon rubber ring
3.9 Sterile distilled water
4 POLICIES:
4.1 Ensure that the device is in good working condition.
4.2 Follow infection control measures.
4.3 Preventive maintenance of the unit should be done regularly by the Bio-Medical
PROCEDURES:
Engineer.
5
5.1
Preparation
of the device:
4.4
Obtain physicians
order. Identify the correct client.
5.1.1 Fix silicone rubber ring on the cylindrical tube on the bottom of nebulizing
room, and the
solution cup on silicone rubber ring.
5.1.2 Pour water into waterpool up to water level.
5.1.3 Set bacterial filter into place.
5.1.4 Fix checked valve, do not fix it upside down.
5.1.5 Fix corrugated tube on nebulizer outlet, and fix mouthpiece and/or nebulizer
mask on the
other end of corrugated tube.
5.1.6 Completely liquefied solution only should be poured properly into solution cup.
(capacity
of the cup : - 30ml)
5.2 Handling of the device:
5.2.1 Set time of nebulizing time
5.2.1.1 When the timer is set within 15 minutes, turn it over to a given time
clockwise once,
and then turn it counter clockwise again and fix the nebulizing time. For
continuous
516
use, turn time counter clockwise and fix at CONTIN. (when time indicates O,
the
unit will not nebulize).
Republic of
Yemen 48Modern
48
Hospital
Switch power on. Power lamp lights. Make sure water depletion lamp does not
light. If
517
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Republic of
Yemen 48Modern
48
Hospital
NURSING RESPONSIBILITIES:
5
5.1 Do after care of equipment.
5.2 Pull the power plug prior to each cleaning.
5.3 Clean parts carefully and thoroughly with disinfecting solution with water. Dry all
parts very well.
Make sure that no fluids penetrate the aspirator.
SPECIAL CONSIDERATION:
6.1 Do not switch on the aspirator when the vacuum present since the device
might over heat.
519
Republic of
Yemen 48Modern
48
Hospital
48 MODERN HOSPITAL
Manual: General Nursing Departmental Manual
Issued Effective:Replaces:
Title: OPTIUM XCEED GLUCOMETERDue for Review:Page 1 of 4
CONTENTS: This General Ward policy and procedure describes the glucotest laboratory and
nursing
responsibilities using the Optium Xceed Glucometer.
1 DEFINITION:
1.1 Optium Xceed (Abbott) is a device intended for POCT in the management of patients
with
diabetes.
2 PURPOSES:
2.1 To monitor blood glucose level in diabetic patients.
2.2 To measure -ketones (-hydroxybutyrate) the most important ketone bodies
circulating in the
blood.
2.3 To obtain quick results of glucose and -ketones in blood.
2.4 To specify the suitable and effective treatment.
The machine must not be used to make diagnosis or treat patients whose glucose may
be critical.
3 EQUIPMENTS/SUPPLIES:
3.1 Glucometer device (Optium Xceed Abbott)
3.2 Glucose strips and/or ketone strips
3.3 QC Material
3.4 Penlet sampler
3.5 Sterile lancet
4 PROCEDURES:
3.6 Small sharp disposable container
4.1 Specimen - Fresh blood drop is obtained using a lancing devise. The sampling site is
3.7 Disposable gloves
usually the
3.8 Alcohol swabs
finger tip. Other alternative sites may be used are the forearm upper arm or the base of
3.9 Small band-aid
the thumb.
3.10 Sterile gauze (2x2)
4.2 Calibration
4.2.1 The meter is calibrated:
4.2.1.1 When using it for the first time
4.2.1.2 Each time a new lot number of blood glucose or ketone test strips is opened.
4.2.2 Remove the glucose or -Ketone calibrator package from the new box of test
strips.
4.2.3 Open the calibrator package. Find the three raised bumps on the calibrator
package. Peel the
clear cover away from the three raised bumps.
4.2.4 Hold the calibrator with the LOT number (Glucose) or calibration CODE (-Ketone)
facing up.
4.2.5 Insert the calibrator into the strip port. Push it in until it stops. The Display Check
shows on the
display window as follows: first the time, month and day. Next the LOT number
(Glucose) or
calibration CODE (-Ketone) shows on the display window.
4.2.6 Check that the LOT number or calibration CODE on all these items matches:
4.2.6.1 Display window
520
4.2.6.2 Test strip calibrator
4.2.6.3 Test strip instructions for use
4.2.6.4 Test strip foil packet
Republic of
Yemen 48Modern
Hospital
48
4.2.7 Remove the calibrator from the meter and store it in the meters carrying case.
4.3 Blood Glucose Testing Procedure
4.3.1 Remove the glucose test strip from its packet and insert the three black lines at its
end into the strip
port.
4.3.2 Push it until it stops, the meter turns on automatically. The following items shows on
the display
screen one after another.
4.3.2.1 Time, month and day
4.3.2.2 LOT number for the box of glucose strips in use.
4.3.2.3 Apply blood message
4.3.3 Obtain a drop of blood from the finger tip of the patient using the lancing device.
4.3.4 Touch the blood drop to the white area at the end of the test strip. Continue touching
till the meter
begins the test and a countdown starts.
4.3.5 At the end of the countdown, the blood glucose result appears on the display window
and is stored
in the meters memory. Also write down the result in the patients result logbook.
4.4
Blood
-Ketone
Testing
Procedure
4.3.6
Removing
the
test strip
shuts off the meter.
4.4.1
It
is
indicated
for
monitoring
patients with diabetes specially if:
4.3.7 Discard the test strip properly.
4.4.1.1 Blood glucose is higher than 300 mg/dL
4.4.1.2 Unusual blood glucose levels are obtained.
4.4.2 Remove the glucose test strip from its packet.
4.4.3 Insert the three black lines at its end into the strip port and push it until it stops,
the meter turns
on automatically. The following items show on the display screen one after another.
4.4.3.1 Time, month and day
4.4.3.2 CODE number for the box of -ketone strips in use.
4.4.3.3 Apply blood message
4.4.4 Use the lancing device to obtain a blood drop from the finger tip of the patient
using the lancing
device. (Important: Use only fingertip blood samples for blood -Ketone monitoring.)
4.4.5 Touch the blood drop to the purple area on the top of the test strip. The blood is
drawn into the
test strip.
4.4.6 Continue to touch the blood drop to the purple area on the top of the test strip
until the meter
begins. The display window shows the countdown starts.
4.4.7 At the end of the countdown, the blood -Ketone result appears on the display
window with the
4.5 Quality Control ( QC )
word KETONE. The result is stored in the meters memory as blood -Ketone result.
4.5.1 QC is performed when patient testing is anticipated frequently on a daily basis
You should
for units
also write down the result in the patients result logbook.
providing that daily testing. It is done by the clinical staff at the POCT site and is
4.4.8 Removing the test strip shuts off the meter. Discard the test strip properly.
recorded in the
QC logbook. (This includes information about test result, control level, control lot, test
strip
information, operator ID, test time and date and comments). QC results are reviewed
regularly by
the laboratory.
4.5.2 QC Procedure
Three level control solutions can be used for glucose or -ketone testing.
An opened control solution is valid for use up to 90 days.
4.5.2.1 Remove the glucose or -ketone test strip from its packet.
4.5.2.2 nsert the three black lines at its end into the strip port.
4.5.2.3 Push it until it stops, the meter turns521
on automatically. The following items
show on the
display screen one after another.
4.5.2.3.1 Time, month and day
Republic of
Yemen 48Modern
Hospital
48
4.5.2.3.2 LOT number for the box of glucose strips and CODE number for the box of
-ketone
strips in use.
4.5.2.3.3 Apply blood message
4.5.2.4 Mark the test as a control test.
4.5.2.5 Turn the control solution bottle upside down three to four times to mix the
solutionthen
apply a drop of control solution to the test strip.
4.5.2.6 Continue to touch the control solution to the test strip until the meter begins
the test.
4.5.2.7 At the end of the countdown, the control result shows on the display window.
The result is
stored in the meters memory as a control result. In the QC logbook, record the
result as a control
result.
4.5.2.8 Removing the test strip shuts off the meter. Discard the test strip properly.
4.5.2.9 Compare the control result to the Expected Results for Use with MediSense
Control
Solutions range printed on the controls.
4.5.2.10 If Controls results are within the range, the meter and test strips are
4.6 Maintenance
working
correctly.(IfProcedure for daily cleaning )
4.6.1
Store
the meter
its carrying
case.repeat testing with a new strip. If result is
the control results
fall in
outside
the range,
4.6.2
Daily
cleaning
of
the
meter
is
done
with a soft cloth and 10% Na hypochlorite or
still not within
70%
alcohol.
the range, contact the laboratory.
4.6.3 Do not try to clean the strip port.
4.6.4 Replacing the battery - When the meter displays the message denoting low
battery on its screen,
replacement should be done.
4.6.4.1 Gently push the battery cover in and up with your thumb. Lift the battery
cover out of the
meter.
4.6.4.2 Pull on the plastic tab sticking out of the meter to remove the old battery.
4.6.4.3 Insert a new CR2032 Lithium (coin cell) battery with the plus sign (+) facing
up.Special Considerations
4.7
4.6.4.4
Place
the notches
onstrip
the battery
into
appropriate molded areas, and
4.7.1
DO NOT
"press"
the test
against cover
the test
site.
then
pushit
in
and
4.7.2 DO NOT scrape the blood.
down
till ause
click
is flat
heard.
4.7.3
DO NOT
the
side of the test strip.
4.7.4 DO NOT use test strips that have passed the expiration date on the package since
they may
cause false results.
4.7.5 Test strips automatically absorb the sample into the strip.
4.7.6 Confirmation beep helps eliminate wasted test strip and short sampling.
4.7.7 The device gives results within 5 seconds (Glucose) and 10 seconds (Ketone) and
has a
memory capacity of 450 memory readings.
4.7.8 For clients on hemodialysis, test is done before and after dialysis through the
arterial port ofthe
extracorporeal circuit.
4.7.9 Referrence Ranges
4.7.9.1 Blood glucose : 70 120 mg/dL
4.7.9.2 Blood -ketones : Less than 0.6 mmol/L
4.7.10 Critical Ranges
4.7.10.1 Blood glucose : Less than 40 mg/dL
More than 500 mg/dL (Adult)
More than 300 mg/dL (Newborns)
522
4.7.10.2 Blood -ketones : > 1.5 mmol/L
Republic of
Yemen 48Modern
48
Hospital
523
Republic of
Yemen 48Modern
OTHER
DEPARTMENTS
Hospital
524
48
Republic of
Policy No.
RS002 Yemen
48
48Modern
Hospital
48 MODERN HOSPITAL
Page 1 of 8
CONTENTS: This OM describes the policies, procedures & responsibilities of Respiratory Care
Unit personnel with regards to arterial blood gas sampling in SGH.
1 DEFINITION of TERMS:
1.1 Arterial punctures involve drawing blood from a peripheral artery (radial, brachial, femoral,
dorsalis pedis) through a single percutaneous needle puncture. Results obtained from
sampling arterial blood gas are the cornerstone in the diagnosis and management of
oxygenation and acid-base disturbances.
2 PURPOSES:
2.1 To provide guidelines to assure that all blood gas punctures and samples are performed
properly with patient safety as the foremost consideration.
2.2 To ensure that arterial blood samples are properly handled from the time that they are
obtained until the time that they arrive at the location where the analysis are performed.
2.3 To establish guidelines for notifying the physicians of blood gas values outside the normal
limits/range (panic values).
2.4 To provide guidelines for a safe and effective technique for assessing collateral circulation
in the hand prior to arterial puncture (Allens Test).
3 INDICATIONS:
3.1 The need to evaluate the adequacy of ventilation (PaCO2), acid-base status (pH), and
oxygenation status (PaO2).
3.2 The need to determine the patients response to therapeutic intervention. (e.g. O2
Therapy).
3.3 The need to monitor severity and progression of a documented disease process.
4 CONTRAINDICATIONS
4.1 Negative results on Allens test are indicative of inadequate blood supply to the hand and
suggest the need to select another extremity or the site for puncture.
4.2 Arterial puncture should not be performed through a lesion or through or distal to a
surgical shunt.
5 HAZARDS and POSSIBLE COMPLICATIONS:
525
Republic of
Yemen 48Modern
48
Hospital
5.1 Arteriospasm
5.2
5.3
5.4
5.5
5.6
526
Republic of
Yemen 48Modern
48
Hospital
approximately 45 to 90 angle.
6.5.1.1.3 No test for collateral circulation can be performed.
6.5.1.1.4 Care must be taken not to obtain venous blood, puncture the nerve or
puncture the bicipital aponeurosis.
6.5.1.2 Third (3rd) choice: Dorsalis Pedis Artery
Rationale.Key points
6.5.1.1.1 If unable to obtain sample from brachial arteries (due to bandages,
casts, burns, etc.) then puncture the dorsalis pedis artery.
6.5.1.1.2 Dorsalis pedis artery is very peripheral. Care must be taken not to
insert the needle too deep.
6.5.1.1.3 Bevel of needle should be up and artery penetration is at
approximately 45 to 90 angle.
6.5.1.1.4 No test for collateral circulation can be performed.
6.5.1.1.5 The foot is perfused with blood from both the dorsalis pedis as well as
the posterior tibial arteries with good circulation through the plantar
arches in the foot.
6.5.1.2 Fourth (4th) choice: Femoral Artery (Emergency/Code situations only)
6.5.1.2.1 A physicians written or verbal order specifically indicating femoral
artery puncture is required.
6.5.1.2.2 Only RTs experienced with femoral puncture is allowed to perform
femoral puncture.
6.5.1.2.3 Procedure is reserved only for emergency/code situations or extreme
hypotension.
6.5.1.2.4 A longer needle (1-1 ) may be required, but needle must not be
larger than 23G
6.5.1.2.5 Angle of entry is 90.
6.5.1.2.6 Assessment of hemostasis is mandatory, as bleeding into the fascial
planes may persist unnoticed.
6.5.1.3Infants and children under 12 years:
First (1st) choice: Radial Artery
Second (2nd) choice: Dorsalis Pedis Artery
Third (3rd) choice: Brachial Artery
527
6.5.1.3.1
6.5.1.3.2
6.5.1.3.3
Republic of
Yemen 48Modern
48
Hospital
6.5.1.3.4
7 RESPONSIBILITIES:
7.1 Attending physician shall initiate written or verbal orders (documented in patients file)
regarding all arterial blood gas sampling. The physicians order shall include the following:
Oxygen Flow
Oxygen device
Ventilator setting
FIO2
7.1.1
7.1.2
7.1.3
7.1.4
528
Republic of
Yemen 48Modern
48
Hospital
7.4.4 Proper reporting of ABG (panic values) results
7.4.1 All RTs shall perform procedure in accordance with the procedure established in
this policy and procedure manual.
8 EQUIPMENTS:
8.1
8.2
8.3
8.4
8.5
8.6
8.7
8.8
8.9
529
Republic of
Yemen 48Modern
48
Hospital
9.1.9.2Fill up the laboratory request form with all the necessary information.
9.1.9.3Check/ verify for a complete physicians order in the patients file.
530
Republic of
Yemen 48Modern
48
Hospital
affect result of analysis.
9.1.26 Insert the needle into needle stopper making sure that the needle does not
protrude through the rubber.
9.1.27 Remove needle and apply luer tip cap on syringe. Agitate syringe to mix sample.
9.1.28 Fully immerse entire syringe with the capped end downwards in slush ice water or
keep between ice packs if no ice slush is available.
9.1.29 Check puncture site. If no evidence of bleeding is present apply adhesive
bandage.
9.1.30 Place sample in biohazard bag and send sample to laboratory.
9.1.31 Remove gloves & wash hands.
9.1.32 Dispose all waste following infection control policies.
9.1.33 Proper documentation of the procedure should be done in the Respiratory
Therapy Treatment Sheet and in the Ventilator Check List if the patient is
mechanically ventilated and should include the following.
9.1.33.1Date & time ABG sample was drawn.
9.1.33.2Puncture site
9.1.33.3Result of Allens test
9.1.33.4Oxygen device, flow, FIO2 or ventilator settings
9.1.33.5Hemostasis status
9.1.33.6Name & ID # of therapist
531
Republic of
Yemen 48Modern
48
Hospital
532