PRELIM: INTENSIVE NURSING PRACTICUM

MODULE 1: CLIENT EDUCATION AND STAFF NURSING 3.0

COMMUNICATION

What is communication?
It is a process of exchanging
➢ Information
➢ Ideas
➢ Thoughts
➢ Feelings
➢ Emotions
Through
➢ Speech
➢ Signals
➢ Writing
➢ Behavior
Communicating with patients would be very challenging to healthcare professionals
especially on how to break bad news, and work with families and caregivers. The nurse must
learn how to talk effectively including treatment.
Medical students must be trained to improve skills on assessing, and building relationships
with patients.

Communication skills are considered as core competency .

Learning — and using — effective communication techniques may help you build more
satisfying relationships with patients and become even more skilled at managing their care.

Effective communication has practical benefits. It can:

➢ Help prevent medical errors
➢ Lead to improved health outcomes
➢ Strengthen the patient-provider relationship
➢ Make the most of limited interaction time

Types of communication

1.Verbal
➢ By word mouth or a piece of writing
➢ Kiss

2.Non- verbal
➢ wordless messages
➢ Signals
➢ gesture, body language, posture, tone of
➢ voice or facial expressions
➢ Behavior

Levels of communication
1. Intrapersonal Communication is communication that occurs in your own mind.
It is the basis of your feelings, biases, prejudices, and beliefs.
➢ Examples are when you make any kind of decision – what to eat or wear. When you
think about something – what you want to do on the weekend or when you think
about another person.
2. Interpersonal communication is the communication
between two people but can involve more in informal conversations.
➢ Examples are when you are talking to your friends. A teacher and student discussing
an assignment. A patient and a doctor discussing a treatment. A manager and a
potential employee during an interview

Communication
1. Use proper form of address
➢ Establish respect by using formal language

2. Make patients comfortable

➢ Provide Client with comfortable seats,
➢ Be aware that older patients may need to be
escorted to and from exam rooms, offices ,
restrooms, and the waiting area.
➢ Check on them often if they have a long wait in
the exam room.

Communication with older patients

3. Establish rapport
➢ Introduce yourself and your role
➢ Speak slowly and show interest about their
concerns.

4. Don’t rush
➢ Give time to process their answers
➢ Suggest a list of concerns to

5. Avoid interruption
➢ Give time to process their feedback,
➢ Listen attentively

6. Active listening
➢ Give time to process their answers
➢ Suggest a list of concerns prior to
visit/consultation

7. Demonstrate Empathy
➢ Exercise patience and compassion especially if the client has chronic confusion

8. Avoid Medical Jargon

9. Be careful about your language
➢ Some words have different meaning to older people
10. Ask Instead of order
➢ The core needs of many seniors is to feel relevant and respected. You can help
validate these needs by frequently asking instead of ordering when
➢ communicating with the older adult.
For example:
○ Instead of: “You’re having soup for lunch today.”
○ Say: “Would you like to have some soup for lunch?” or “We’re having soup for
lunch today, okay?”
11. Ask Instead of Assume
➢ Similarly, ask questions instead of making assumptions when it comes to your
actions in relation to the older adult.
For example,
○ Instead of turning the lights off in the senior’s room without asking, say, “I’m
going to turn off the lights for you, okay?” If the senior protests, let her have
her way if it’s harmless. Otherwise, explain why it’s important for you to do
what you need to do (in most cases for the sake of senior’s health and
well-being)
12. Use “I” instead of “You” Language
➢ We know from the study of effective communication that people (including many
older adults) generally don’t respond well when they feel like they’re constantly being
ordered what to do. Such “bossy” language is often manifested in the use of “you”
statements, followed by a directive.
For example:
➢ “You must exercise today!”
➢ When people feel like they’re being bossed around on a regular basis, they’re more
likely going to respond with what psychologists call the “Three F’s — Fight, Flight,
and Freeze," leading to behavioral problems such as argument, avoidance, or
stonewalling.
➢ Instead, use statements that begin with “I,” “It,” “We,” “Let’s,” and “This,” to convey
messages. For example: “I will help you exercise today

15. Offer Choices Whenever Possible

➢ Many older adults desire to maintain a sense of independence. This may be
especially important when seniors feel their physical and cognitive limitations, but still
desire ways to maintain some level of local control in their lives.
➢ Whenever possible and appropriate, offer choices to an older adult when interacting
with him or her. This can be something as simple as asking whether they'd like to
➢ have choice A or choice B for lunch. Having the ability to exercise choice can
provide the older adult a greater sense of confidence, esteem, and security, as the
senior feels the power to be proactive in life.

Barriers to communication
1. Physical Barrier
a. On different sites
b. Outdated equipments
c. Noise
2. Perceptual Barrier
 a. Worry
b. Fear
c. Guilt
3. Emotional Barrier
4. Cultural Barrier
5. Language Barrier
6. Gender Barrier

NURSE'S TOUCH-PROFESSIONAL COMMUNICATION

● Client’s Education
- Client needs
- Best environment materials
- Client of different age groups
- Motivation for learning
- Child vs older adults
● Different teaching approaches
● Best way to learn
- Textbook
- Listening
- Observe, hands-on
● Domains off learning
- Cognitive
- Affective
- Psychomotor
● Comprehensive of Information
- Individual client teaching
- Group teaching
★ ICU - 1:2
★ WARD - 1:6
Note: Depends on the patient’s acuity
★ Space requirement: 3-4 inches
★ Light: Not too dark

1. Assessment of the client

- Where to begin
➢ Assessment or data collection
➢ Determine individual needs
➢ Its is a process of exchanging information, ideas, thoughts, feelings,
emotions through speech, signals, writings and behavior

Consider
○ Age
○ Ability to speak
○ Culture
○ Health Statue - for health education and assessing ability to
understand
 ○ Sexual Orientation
○ Ethical principles
■ Autonomy
■ Beneficence
■ Justice
■ Non maleficence
Diversity
○ Culture
○ Income
○ Sexual orientation

2. Best Learning Environment

- Best environment
➢ Individual needs vs. group needs
➢ Content needs
- Privacy and confidentiality
- Physical environment - lighting, ventilation

3. Promoting a Positive Learning Environment

➢ Conducive to learning
○ Space requirements - 3-4 inches away from the patient
○ Noise may disrupt -
○ Limit interruptions
■ Barriers of Communication
● Cultural Barrier -an issue arising from a
misunderstanding of meaning
● Emotional Barrier-mental limitation that prevents you
from openly communicating your thoughts and feelings.
● Language Barrier
● Gender Barrier
● Physical Barrier
➢ Light
○ Appropriate for content
➢ Temperature
○ Focus on the client comfort
4. Culture
➢ Encounter differences
➢ Avoid ethnocentrism - once group is superior to others
➢ Accept, respect other cultures
○ Appropriate interventions
5. Cultural variables that affect learning
➢ Six specific variables
○ Communication - language barrier, the institution should have an
interpreter, be particular with tone and words to be used.
○ Personal space - sign of respect and dignity
○ Social organizations - fairness, equality, and social justice
○ Time - fidelity
○ Environmental control
 ○ Biological variations
6. Reading level for written material
➢ Printed educational materials (PEMs)
➢ RMCI Policy: Nurses are not allowed to write home instruction it should
be the resident
○ Ensure learning, comprehension
○ Assess client reading level
○ Recommended PEM reading level
■ 5th grade level, lay terms
7. Teaching clients of different ages
➢ Stage-specific competencies
➢ Developmental stage
○ Physical, cognitive, and psycho-social maturation
➢ Developmental trends
○ Based on client’s age
8. Pedagogy
➢ Helping children learn
➢ Stages of childhood
○ Infant and toddler - Repeat verbalization, play with them, give them
reward as long as it is not contraindicated
○ Preschooler
○ School-age
○ Adolescent
a. Infant and toddler
➢ Birth to 3 years old
➢ Sensorimotor cognitive stage
○ Learn through senses
➢ Psychosocial stage
○ Trust vs mistrust
○ Autonomy vs shame, doubt
○ Naturally curious but dependent
➢ Focus teaching toward caregiver
○ Include child when possible
■ Play with equipment
➢ Strategies
○ Repetition, sensory stimulation, allow play
b. Preschooler
➢ 3 to 6 years old
➢ Pre-operational cognitive stage
○ Magical thinking
○ Limited sense of time
➢ Psychosocial stage
○ Initiative vs guilt
○ May view illness as punishment
○ Short attention spans
○ Concrete thinkers
➢ Build trust, teach in bursts
➢ Strategies
 ○ Drawing, stories, play
○ Positive reinforcement
c. School-age child
➢ 6 to 12 years old
➢ Concrete operations cognitive stage
○ Draw conclusions
○ Increased conversational skills
➢ Psychosocial stage
○ Industry vs inferiority
○ See sleeves as individuals
○ More realistic, understand cause and effect
➢ Promote sense of independence
➢ Strategies
○ Step-by-step instructors, structured teaching, use past experiences
d. Adolescence
➢ 12 to 18 years old
➢ Formal operational cognitive stage
○ Think outside the box
○ Understand complex information
➢ Psychosocial stage
○ Identity vs role confusion
○ Abstract thinking, logic reasoning
➢ Strategies
○ Treat as adults
○ Respect privacy, individuality
○ Interact with client alone
○ Audiovisuals, computer resources

9. Andragogy
➢ Teaching adults
○ Independent
○ Resistant to change
➢ Responsibilities
○ Relevance of information
○ Solving current problems
➢ Strategies
○ Drawing on past experiences
○ Encouraging self-directed learning
○ Focusing on immediate problem

10. Geragogy
➢ Teaching older adults
➢ Physical challenges
○ Diminished eyesight, hearing, mobility
○ Identity challenges, tailor teaching plan
➢ Cognitive challenges
○ Slower processing time, decreased memory, altered time perception
➢ Strategies
 ○ Reminiscence, involvement, repetition of information
○ Material appropriate for specific physical challenges

11. Learning Styles

➢ How individuals process information
○ Visual
○ Auditory
○ Tactile
➢ Identify learning style
○ Observation
○ Interviews
○ Administer tools

a. Visual
➢ Visual preference
○ Reading content
○ Observing demonstration
➢ Strategies
○ Handouts to read
○ Videos to watch
○ Demonstration of technique

b. Auditory
➢ Auditory preference
○ Verbalize information
○ Client restates information
➢ Specific strategies
○ Talk about information
○ Encourage group discussion
○ Use audiotapes
c. Tactile
➢ Tactile preference
○ Highlighting information
○ Taking notes
➢ Specific strategies
○ Keep client’s hands busy
○ Handling equipment
○ Taking notes
d. Kinesthetic
➢ Kinesthetic preference
○ Talking, doing
○ Work hands-on
➢ Specific strategies
○ Return demonstration
○ Simulation
○ Role-playing

Learning domains:
 ➢ Three domains of learning
○ Cognitive
○ Affective
○ Psycho-motor
➢ Methods appeal to each

Cognitive domain:
➢ Thinking domain
○ Intellectual abilities, thinking skills
➢ Levels of cognitive behavior
○ Knowledge - information given to you; emphasizes remembering, recall of
ideas
○ Comprehension- understanding
○ Application- apply the appropriate knowledge
○ Analysis- involves ability to distinguish facts, making hypothesis
○ Synthesis- involves with the production of unique information; testing the
hypothesis
○ Evaluation- judgment; values of ideas or information
➢ Specific methods
○ Written materials, one-on-one discussion, audiovisuals

Affective domain:
➢ Feeling domain
○ Feelings, values, emotions, attitudes
➢ Levels of affective behavior
○ Receiving - awareness of the needs
○ Responding - accepting the information that is given to you
○ Valuing
○ Organization
○ Characterization
➢ Specific methods
○ Role-playing, group discussion

Psychomotor domain:
➢ Skills domain
○ Physical skills, abilities
○ Patient’s physical skills about a procedure (e.g. Insulin injection)
➢ Levels of psychomotor behavior
○ Perception
○ Set
○ Guided responses
○ Mechanism
○ Complex overt response
○ Adaptation
○ Origination
➢ Specific methods
○ Skill demonstration, encouragement of skills practice, return skills
demonstration
Individual and group education
➢ Individual client education
○ Individual learning needs
○ Personalized learning plan
➢ Group education
○ Advantages
■ Interactions, sharing
○ Disadvantages
■ Time, effort
➢ Allows focus on domains
➢ Assessment of the learner
➢ Main advantage = personalization
➢ Encourage involvement, discussion
➢ Interaction
➢ Disadvantages
○ Too much information
○ Puts clients on the spot, isolate
➢ Demonstrate psychomotor skills
○ Identify skill, purpose, steps, expectations
○ Use equipment client will use
○ Repeat as needed
➢ Focus on what to do
○ Decreases confusion
○ Promotes understanding

Gaming
➢ Activity has preset rules, is competitive
○ Increase retention
➢ Individuals or groups
➢ Identify objectives, rules
➢ Provide praise, reward

Lecture
➢ Teaching a group
○ Prepare material fit for all members
➢ Advantages
○ Deliver large amount of information
➢ Drawbacks
○ Limited interaction; difficult to address affective, psychomotor domains
➢ Effective lecture delivery
○ Introduction, main content, summary
➢ Engaging your audience
○ Humor, audiovisuals
➢ Setting
○ Good lighting, focus on lecturer

Group Discussion
 ➢ Encourage sharing of information, thoughts, feelings
○ Allows teaching in cognitive, affective, psychomotor domains
➢ Group size
○ Keep small; 6 to 8 members
➢ Beginning the discussion
○ Overview of objectives
➢ Role of facilitator
○ Flexible flow of discussion
○ Discussion stays on topic
○ Give each member equal chance to contribute

Simulation
- Fictional experience reflecting real-life situation
➢ Promotes retention
- Allows teaching in cognitive, affective, psychomotor domains
- Follow with debriefing
❖ Disadvantages
➢ Development takes time, planning
➢ Never same as real life

Evaluation Strategies
➢ Nursing process
○ Begins with assessment
○ End with evaluation
➢ Goal of teaching
○ Learning has occurred
○ Objectives met
➢ Continuous process
➢ Specific strategies

Questioning
➢ Evaluating learning
○ Individual or group
➢ Ask for information
○ Doesn’t threaten client
➢ Attentively listen, clarify

Return demonstration
➢ Psychomotor skill following demonstration
➢ Promotes client success
○ Has necessary equipment
○ Cues available
➢ Opportunity for observation
○ Determine client understanding, need for additional teaching
➢ “Teach back” method
○ Adds cognitive domain

Determining a Client’s Readiness to Learn

 ➢ Client expresses interest in learning
➢ PEEK
○ Physical
○ Emotional
○ Experiential
○ Knowledge

Physical Readiness
- Five Factors
➢ Measures of ability
➢ Complexity of task
➢ Environmental effects
➢ Health status
➢ Gender

Emotional Readiness
➢ Factors
○ Anxiety level
○ Support system
○ Motivation

Additional Factors of Emotional Readiness

➢ Risk-taking behavior
○ Address needs
○ Develop strategies to minimize risk
➢ Frame of mind
○ Primary concerns
○ Willingness to learn
➢ Developmental stage

Experiential Readiness
- Five components
➢ Level of aspiration
➢ Past coping mechanisms
➢ Cultural background
➢ Loss of Control
➢ Orientation
- Parochial
- Cosmopolitan

Knowledge Readiness
➢ Three components
○ Present knowledge base
○ Cognitive ability
○ Learning style
■ Visual
■ Auditory
 ■ Tactile
■ Kinesthetic

Barriers to Learning
➢ Obstacles
○ Factors with negative effect

1. Physical deficits
➢ Sensory deficits
○ Trouble seeing, hearing
➢ Physical deficits
○ Communication disorders
○ Chronic illness
➢ Include client’s family, caregiver

Lack of Time
➢ Start planning
○ Identify learning needs
➢ Effective use of time
○ Add discussion while caring for client
○ Incorporate family when they visit
○ Watch videos during mealtime
➢ Schedule sessions

Learning Disabilities
➢ Doesn’t indicate lack of intelligence
➢ Client who has dyslexia - is a common learning difficulty that can cause problems
with reading, writing and spelling.
○ Focus on other senses
➢ Client who has ADD (attention-deficit disorder)
○ Quiet room, minimal distractions
○ Praise, rewards
➢ In doubt? Ask client

Literacy
➢ Ability to read, understand, interpret information written at 8th grade level or
higher
➢ Low literacy clues
○ Anxiety, avoidance
➢ Strategies
○ Simplified written materials
○ One step at a time
○ Variety of methods that appeal to senses
○ “Teach back” method, repetition
➢ Nurse-client relationship
○ Trusting, nonjudgmental
STAFFING
Delegation of tasks to reduce nurses burnout.
1. Centralized staffing - staffing decisions are made by the HR department or nursing
service staffing center.
2. Decentralized staffing - unit manager (head nurse or nurse supervisor) makes the
staff scheduling → includes preparing monthly unit schedules and holiday/vacation
schedules, covering staff absences, and reducing staff during low patient census or
acuity.
3. Scheduling - process of determining a set number and type of staff for a future time
period by assigning individual personnel to work specific hours, days, or shifts, and in
a specific unit/area over a specified period of time.
4. Staffing pattern - list of total number of direct - care staff by skill level scheduled or
each shift
5. Staffing effectiveness - evaluation of the effects of nurse staffing on quality, patient,
financial, and organizational outcomes.

Steps in Staffing:
1. Determine the number of personnel needed
a. To fulfill the philosophy and goals
b. To meet fiscal planning responsibilities
c. To carry out the selected patient care delivery system
2. Recruit, interview, select, and assign personnel based on established job description
and performance standards
3. Use organizational resources for induction and orientation
4. Ensure each employee is adequately socialized to the organization values and unit
norms
5. Use creative and flexible scheduling based on patient care needs to increase
productivity and retention

Staffing
➢ Nursing-to-patient ratio
○ Reflects the actual patient care assignment
○ Can be state-mandated
○ May be changed based on the conditions of patients, census, and unit bed
capacity (wards, special areas) - required by health authority (e.g. 1:1 ratio in
ICU)
➢ Nursing direct-care hours
○ Number of nursing staff hours assigned to provide direct care to a patient or
groups of patients for a specific period
○ Calculated per patient day or nursing hours per patient day (NHPPD)

Skill mix - range of types and levels of ability and preparation in the workforce
Skill level - function of education and competency for the job
Nursing workload - patient care (direct) and non-patient care (indirect) activities performed
by the nurse within a given period of time
Patient Classification System (PCS):
● Patient acuity system
● Tool used in managing and planning the allocation of nursing staff according to
nursing care needs
● Assist nurse leaders/managers in determining workload requirements and staffing
needs
● Patients are categorized or grouped according to the amount and complexity of
nursing care requirements, including nursing time (24 hours) and skills

Patient Classification System

Category I: Self-care 1-2 hours of nursing care/day

Category II: Minimal care 3-4 hours of nursing care/day

Category III: Intermediate care 5-6 hours of nursing care/day

Category IV: Modified intensive care 7-8 hours of nursing care/day

Category V: Intensive care - all hours is 10-14 hours of nursing care/day

given to the patient
Morning Shifts: lab tests, patient transfers, surgeries, doctor’s rounds, etc.
Afternoon Shifts: procedures that could not be accommodate in the morning; admission
and discharge orders
Night Shifts: less demand from the patient, sometimes morning care is done at night shift;
follow up care
NOVICE TO EXPERT
● The Benner model is designed to emphasize the skill acquisition of health care
professionals (Benner, 2001). Used to increase retention and skill progression with
nurses, done with annual appraisal.
○ Novice, a new practitioner’s practice is driven by rules and tends to provide
task focused care. Heavily dependent on theory.
○ Advanced beginners, providers have developed safe practice but lack a
strong knowledge base to found their practice and management skills. They
had enough experience to identify common solutions for problems.
Provisionary staff nurses/ 2-3 or 6 mos in the field
○ Competent providers, NPs will find they can prioritize and begin to use past
experiences to form their care.Has been on the job for 2 to 3 years. Lacks
the multi-talent of proficient providers but can still make abstract and critical
decisions.
○ Proficient providers have a good sense of what their patient situation is and
can prioritize needs and routinely predict accurate outcomes. Been there for
ages in a certain area, 5-10 years.
○ Expert providers, NPs are confident, have an extensive knowledge base
and will be able to quickly grasp complex patient situations. More than 10
years

SOCIALIZATION INTO PROFESSIONAL NURSING

- Great impact to values
Organizational Culture
● Innate based on the unit a nurse belongs to
● Example: different ways of endorsement

Ethnocentrism
- is a belief that one's way of life and view of the world are inherently superior to others
and more desirable.
- Not effective for nursing-patient care

Transition
● Passage
● Change
● Excitement, fear, stress, anxiety, relief
● 4 Phases: honeymoon, shock, recovery (1-3 months) , resolution

Honeymoon Phase
● Excitement
● Sense of accomplishment

Socialization into professional nursing

● Acquiring knowledge
● Skills
● Behaviors
Professional identity
● Values, Customs
● Unique way of thinking

Transition from expert student to professional nurse

● Expected phases
● Stages of development

Strategies for success

● Biculturalism
● Residency programs
● Self-stress management techniques

TOPIC 1: CLINICAL INSTRUCTOR

Qualities of a Clinical Instructor

● Communication skills
● Good rapport
● Know the methods of delivering care
● Advanced knowledge
● Ability to implement the knowledge in practice
● Good teaching skill
● Physically active and healthy
● Pleasing personality
● Neat dressed
● Empathetic and sympathetic
● Should have positive philosophy of life
● Punctuality
● Good team spirit
● Good listener and motivator
● Mentally alert

PRACTICING CLINICAL INSTRUCTOR

- detailed job description of a Clinical Instructor

DUTIES AND RESPONSIBILITIES:

A. Lecture
1. Inculcate nursing concepts and theories with Christian values to nursing students.
2. Presents the objectives of every lesson before the start of the class.
3. Systematically organizes the lesson and relates this to actual situations and
experiences.
4. Displays a good sense of humor and considers students' needs and feelings.
5. Ensures a harmonious relationships with students in the classroom conducive for
learning
6. Manages the class with discipline and respect
7. Conducts consultation hours for students having predicament on the subject matter
and course.
8. Speak the English language as the medium of instruction.
9. Gives time for classroom discussion and answers students' queries clearly and with
competence
10. Compute scholastic grades of students and entertain complaints about tests and
grades.
11. Formulates examination paper and quizzes to evaluate the competence of nursing
students.
12. Utilizes audio- visual aids in conducting classes such as use of powerpoint
presentations, pictures and actual hospital equipment.
13. Acknowledge books, internet and the library as sources for more knowledge
14. Attends and actively supports meetings, seminars and university events for
professional development.
15. Maintains professional relationship with the Dean, Administrators, colleagues,
personnel and other Faculty of other Colleges of the University.

B. Clinical Area (Related Learning Experience)

1. Assist students in providing holistic nursing care to various kinds of patients
2. Exhibit skills in guiding students in the implementation of Nursing Care
3. Supervises nursing students assigned in the ward in the assessment, nursing
diagnosis, planning, implementation and evaluation of patient care
4. Demonstrate quality patient care by actually working with the students at the bedside.
5. Trains and supervises students in the proper care of the patients like giving personal
hygiene (i.e. oral care, care of the hair, bathing, dressing,stripping, and bed making).
6. Assist students in accurate checking and recording of vital signs; temperature, pulse,
respiration and blood pressure.
7. Aids students in the administration of medications, treatments and nursing
procedures to prevent errors.
8. Helps nursing students in ensuring correct and complete documentation of
medications, treatments and nursing procedures done.
9. Facilitates accurate carrying out of Doctor's order by the students.
10. Assist students in the admission and discharge of patients with due regard to
relevant procedures such as relation to property and valuables and carries out
assessment of needs of admissions and formulates care plans.
11. Aids students in maintaining proper alignment of patients' body and utilizing proper
body mechanics.
12. Supervise students in performing passive range of motion or other therapeutic
exercises as ordered.
13. Assists students in giving health teachings or education to patients and significant
others.
14. Supervises students in wound- dressing, urinary catheterizations, administration of
oxygen therapy, giving of enema, applying compresses( ice bag and hot water bag)
and many others.
15. Correct students' errors tactfully and prudently.
16. Receives endorsement from the outgoing shift and ensures a comprehensive
endorsement of the unit to the incoming shift.
 17. Exhibit skills in guiding students to ensure safety needs of various kinds of patients
including the elderly and the use of equipment properly (side rails, restraints,
footstool, etc.)
18. Teaches students in measuring and recording of patient’s intake and output during
the entire shift.
19. Maintains implementation of standard policies of the university affiliated institutions.
20. Maintains good interpersonal relationship with the patients, patient’s relatives,
supervisors, colleagues, hospital staff and all members of the health team.
21. Supervises students during preoperative, intraoperative and postoperative nursing
procedures.

5 Nursing Instructor Qualities Every Student Nurse Secretly Hopes For

"For every successful student, there is an excellent mentor behind".

So here are five (5) qualities every nursing student secretly hopes for their clinical
instructors.
1. Ability to recognize people's emotions.
2. Shows dedication and motivation.
3. Demonstrate competitiveness in clinical skills.
4. Respects students as individuals.
5. Show humor

An Effective Clinical Instructor:

□The most important characteristics of an effective clinical instructor are having:
● Intrinsic motivation
● Teaching skills
● Adequate clinical competence
● Professional ethics
● Sufficient clinical experience
● Appropriate communication skills
● Professional acceptability
● Appropriate appearance and being a faculty member

PCI (PRACTICING CLINICAL INSTRUCTOR) -WARD

A. Requirements - 50%
● Objectives - 10%
● Lesson Plan - 30%

(Ward Class and Bedside)

● Anecdotal Behavioral Record - 10% - if they follow prescribed uniform, observes
break
● Daily Plan of Activities - 10% - ex. 6am-6:30 prepare medication
● Content of Pre and Post Test - 10%
● Written Evaluation - 10%
● Student’s Requirements - 20%

STUDENT’S REQUIREMENTS - 20%

 Objectives - 10 pts.
Drug study - 20 pts.
Problem List - 20 pts.
NCP (Nursing Care Plan) - 40 pts.
Written Evaluation - 10 pts.

B. Performance- 50% (Using the PCI Clinical Efficiency)

NOTE:
● PCI will check the student's requirements and solve for students grades using our
Clinical Efficiency Tool.
● If two students' staff have been assigned to a particular area, they will be under the
supervision of the CI.
● The rest of the group will be supervised by the PCI, who will be supervised and
graded by the CI.

Requirements of PCI (Classroom): 50%

Objectives - 10%
Lesson Plan/ Course Outline - 45%
DPA - 10%
Preparation: Content of Pre and Post Test -25%
Evaluation - 10%
Performance Evaluation - 50% (Refer for Evaluation Tool)

How to make Objectives: Bloom's Taxonomy

I. Remembering
-Exhibit memory of previously learned material by recalling facts, terms, basic
concepts and answers.
● Choose
● Define
● Find
● How
● Label
● List
● Match
● Name
● Omit
● Recall
● Select
● Show
● Spell
● Tell
● What
● When
● Where
● Which, who, why
II. Understanding
-Demonstrate understanding of facts and ideas by organizing, comparing, translating,
interpreting,giving descriptions and stating main ideas.
● Clarify
● Compare
● Contrast
● Demonstrate
● Explain
● Extend
● Illustrate
● Infer
● Interpret
● Outline
● Relate
● Rephrase
● Show
● Summarize
● Translate

III. Applying
-Solve problems to new situations by applying acquired knowledge, facts,
techniques, and rules in a different way.
● Apply
● Build
● Choose
● Construct
● Develop
● Experiment with
● Identify
● Interview
● Make use of
● Model
● Organize
● Plan
● Select
● Solve
● Utilize

IV. Analyzing
-Examine and break information into parts by identifying motives or causes. Make
inferences and find evidence to support generalizations.
● Analyze
● Assume
● Categorize
● Classify
● Compare
● Conclusion
 ● Contrast
● Discover dissect
● Distinguish
● Examine
● Inspect
● List
● Survey

V. Evaluating
-Present and defend opinions by making judgements about information, validity of
ideas or quality of work based on a set of criteria.
● Agree
● Appraise
● Assess
● Award
● Choose
● Determine
● Explain
● Evaluate
● Influence
● Interpret
● Measure
● Prioritize

VI. Creating
-Compile information together in a different way by combining elements in a new
pattern or proposing alternative solutions.
● Adapt
● Build
● Change
● Choose
● Combine
● Compile
● Compose
● Construct
● Create
● Develop
● Discuss
● Formulate
● Improve
●
Writing Learning Objectives for Nursing:​
● A learning objective is a statement which explains a specific goal that you want to
achieve in your future learning. ​
● The learning objective should be something that you can measure by doing specific
activities within a definite time frame. ​
How do you write nursing goals and objectives?​
● ​SMART is an acronym for the guidelines nurses should use when setting their goals:​
 ● Be specific. Setting broad nursing goals allows them to be open for interpretation. …​
● Keep it measurable. For goals to be effective, there must be some way to measure
your progress. …​
● Keep it attainable. …​
● Be realistic. …​
● Keep it timely.​
● SMART :What does it mean? ​
➔ Questions to help you think about this: ​
➢ Specific: A learning objective should relate to a specific skill or performance you
want to achieve. Use an action verb to help you measure your performance. ​
○ What exactly am I going to achieve?​
○ What strategies have I identified? ​
○ Is the objective clear and understandable?​
○ Have I used an ‘action’ verb? ​
➢ Measureable: A learning objective should make clear how your performance or skill
can be measured. ​
○ How will I know that I have achieved my learning goal?​
○ How can the changes be measured? ​
➢ Achievable: A learning objective must be possible to achieve in terms of your role as
a nursing student and the amount of time on placement.​
○ Can I achieve this objective within my role as a student nurse? ​
○ Can I achieve this objective within the stated time frame?​
○ Have I considered any limitations or constraints? ​
➢ Realistic: A learning objective must be realistic in terms of your existing skills and
abilities and the resources you have available to you as a student. ​
○ Is this objective possible to achieve for me?​
○ Can I achieve this objective by using the resources that I have identified?​
○ Do I have access to the resources that I need to achieve this objective? ​

➢ Timeframe: A learning objective must include a realistic timeframe to measure your

progress within the time allocated for your placement. · Is there a stated deadline for
achieving this objective? ​
○ Is the timeframe realistic in terms of your abilities and the length of
placement?​

There are Two Types of Objectives:​

1. Specific Objective: is a precise statement of a proposed change in the learner ,
which is directed to what the student will achieve.​
2. General Objective: would be more like an aim, and would be a broad statement of
intent.​

How do you write an objective?​

​5 Steps to Writing Clear and Measurable Learning Objectives​

● Identify the Level of Knowledge Necessary to Achieve Your Objective.​
● Before you begin writing objectives, stop and think about what type of change you
want your training to make. …​
● Select an Action Verb.​
 ● Create Your Very Own Objective.​
● Check Your Objective.​

What are the 3 learning objectives?​

​The Learning objective or objectives that you use can be based on three areas of learning:​
1. knowledge, ​
2. skills and ​
3. attitudes. … ​
➔ They help you and your students evaluate progress and encourage them to take
responsibility for their learning.​

How to Make an Objective:​

1. Identify the Level of Knowledge​
● Necessary to Achieve Your​
● Objective​
● Use the acronym K – S - A​

Knowledge​- This domain focuses on increasing what ​participants know.​

- Learning safety rules, troubleshooting,​ and quoting prices from memory are all​
examples of this level of learning.​
Skills​- This domain focuses on​changing or improving the​tasks a learner can perform.​
Attitude​- Changes how a learner chooses to act.​
- Compliance training is a good​example of when you will have to​teach to this domain.
- It’s usually the hardest to craft objectives for this, since it’s dealing with feelings,
emotions, and attitudes.​

Examples of Objectives:​

Knowledge:​

Familiarize and Familiarize and orient myself with the clinical set-up of the area
orient assigned.​

Identify​ Identify the different health problems of my client.​

Apply​ Apply my learnings and critical thinking in dealing with my clients’ health
problems.​

Coordinate and Coordinate and communicate with the other health team members in
communicate​ providing patient care.​

Provide Provide individualized primary care to attend to patients’ needs.​

Recognize​ Recognize the needs of my client and apply proper nursing intervention.​

Skills

Display Display master and efficiency when performing nursing procedures.​

Perform Perform an accurate recording of clients’ data and information.​

Administer​ Administer medications accurately/correctly after checking the Doctor’s

Order Sheet.​

Demonstrate Demonstrate verbal and non-verbal communication skills towards co-staff,

hospital personnel and clients.​

Conduct Conduct appropriate health teachings regarding patients’ disease condition

Render Render effective and accurate nursing care to clients.

Document and Document and record data concerning patients’ care.

record​

Attitude

Report Report to area of duty on time.​

Show ​Show courtesy and respect to clients and relatives.

Establish Establish rapport and good interpersonal relationships with clients and their
family.

Display Display flexibility when performing tasks related to patient care.

Manifest Manifest sensitivity towards the needs of my client, physically, emotionally and
spiritually.

Foster Foster responsiveness when dealing with clients.​

Example:

SPECIFIC OBJECTIVES - KSA standard (by order or random)

Lesson Plan
● A lesson plan is a teacher’s daily guide for what students need to learn, how it will be
taught, and how learning will be measured.​
● This ensures every bit of class time is spent teaching new concepts and having
meaningful discussions — not figuring it out on the fly!​

The most effective lesson plan have six key parts:​

1. Lesson Objectives​
2. Related Requirements​
3. Lesson Materials​
4. Lesson Procedure​
5. Assessment Meth​
6. Lesson Reflection​

1. Lesson Objectives
● These objectives let you easily tell if your lesson has effectively taught your
students new concepts and skills.​
 ● It can feel overwhelming to pin down specific takeaways for a lesson, but you
can break the process into steps to do it in a breeze!​
● First, it’s best to view your lesson objectives as goals for your class and
students.​
● One of the most popular goal-setting strategies is the “SMART” criteria, which
ensures goals are focused.​

In the context of lesson planning, you can use the SMART criteria to determine your
lesson objectives:​
● Is the objective specific?​
● Is the objective measurable?​
● Is the objective attainable by all students?​
● Is the objective relevant to your class and students?​
● Is the objective time-based to align with your syllabus?​

2. Related Requirements​
● Related requirements are national, state, or school standards that dictate
what you need to teach in a class.​
● Every lesson you teach should help you hit those requirements. Listing them
in your lesson plans helps you satisfy those requirements while focusing on
the end goal of your class!​
● Laying out each lesson plan according to your requirements can be tedious
work, but it will ultimately help you stay organized and aligned with what
you’re supposed to teach!​
3. Lesson Materials​
● The third section on your lesson plan is the list of materials that you need to
teach the lesson and measure student outcomes.​
● This section prepares you to deliver your lessons every day.​
● Without this list, you may accidentally forget to print an important document or
sign out the shared laptop cart!​
Common types of lesson materials include:​
● Student handouts​
● Textbooks​
● Visual aids​
● Grading rubrics​
● Activity packets​
● Computers / Tablets​
➔ The list of materials for each lesson depends on what you plan to teach, how you’ll
teach it, and how you’ll measure lesson objectives.​
➔ Because of this, many teachers compile their list of lesson materials in tandem with
their lesson procedure!​
4. Lesson Procedure​
● Your lesson procedure is in-depth explanation of how the lesson will progress
in the classroom.​
● The lesson procedure is essentially step-by-step instructions that walk you
through everything from the time students enter the classroom until the bell
rings at the end of the period.​
 ● When writing your lesson procedure, you need to choose the type of activities
that will help students meet the lesson objectives.​
5. Assessment Meth​od
● The assessment method measures whether your students learned a lesson’s
information and met your lesson objectives.​
6. Lesson Reflection​
● By this point, your lesson has clear objectives, a plan for teaching, and a way
to assess student learning.​
● But if you don’t critically consider whether you succeeded, you’re doing a
disservice to your future students!​

Lesson Reflection Questionnaire

● When completing your lesson reflection, ask yourself questions like:​
● Did a part of the lesson take longer than expected?​
● Was there a portion that students asked for a lot of help with?​
● Did students breeze through the information with no problem?​
● Were students engaged and interested in the lesson?​
● Were the objectives met by most (or all) of the students?​

Making a Daily Plan of Activities​

➢ Example of a Daily Plan of Activity (DPA)

AREA: Medical/Surgical Ward Date: October 01, 2021​

Shift: 6-2​
● ​5:45Am Report to area of duty (Station 4)​
Pre-conference/Orientation​
● 6:00Am Receive Endorsement​
● 6:30Am Go with the Nurses’ Rounds​
● 7:00Am Reading of assigned Patient Chart​
● 7:15Am Prepare medications​
● 7:30Am Do morning and bedside care to patient​
● 7:45Am Vital Signs Taking ​
● 8:00Am Graphing and recording ​
Giving of medications​
● 8:30Am Perform nursing procedures (e.g. nebulization, follow up IV,
bed making)​
● 9:30Am Go with the Doctor’s Rounds/Carry out Doctor’s Orders​
● 10:30Am Break​
● 10:45Am Do sample charting and have it checked by the CI​
● ​11:00Am Transcribe on the chart the partially checked charting​
● 11:15Am Prepare medications​
● 11:30Am Vital Signs Taking, graphing and recording​
● 12:00Pm Giving of medication / assist in the giving of patients’ diet​
● 12:15Pm Lunch Break​
● 12:45Pm Check chart for data’s to be completed/signed​
● 1:00Pm Finish sample charting/have it checked​
● 1:30Pm Measure intake and output, record​
● 1:45Pm Close charting have it countersigned by the CI​
● 2:00Pm Give complete Endorsement
 ➢ Example of A Lesson Plan

​ ate: October 01, 2021​

D
Area: St. Ezekiel Moreno Health Center​
​Topic: Expanded Program of Immunization​
Objectives: By the end of exposure, utilization of activities and health​
teachings, the students will be able to:​
1. Re-familiarize and master the Expanded Program of Immunization.​
2. Specifically know the EPI target diseases, vaccines, doses, routes and sites
of immunization.​
3. Understand and promote the importance of immunization.​

Activity: ​
1. Conduct a health teaching about EPI(Expanded Program of Immunization) for
which the students can master the program for related purposes.​
2. Test the students’ comprehension and retention abilities by conducting a
20-items quiz.

Materials/Resources:​
1. Visual Aids​
2. Printed handouts​
3. Prepared test questionnaire​

CIVILITY MENTOR-FOUNDATION OF PROFESSIONALISM AND CIVILITY

-Foundations of professionalism and civility is a virtual learning experience

where you focus on patient safety, self-reflection, empathy, and how norms
setting supports client care. Play as a nurse to build confidence and
communication skills when dealing with uncivil or conflicted situations.
- Nurses experience incivility, lateral violence, and bullying at an alarming rate.
- The perpetrator can be a provider or a nursing colleague
Consequences of disruptive behavior include:
● Poor communication, which can negatively affect client safety and productivity,
● resulting in absenteeism, decreased job satisfaction, and staff turnover.
● Some nurses may choose to leave the profession due to these counterproductive
behaviors.
● If disruptive behavior is allowed to continue, it is likely to escalate. Over time, it can
be viewed as acceptable in that unit or department culture​

Types of Disruptive Behavior

1. Incivility - is defined as an action that is rude, intimidating, and insulting. It includes
teasing, joking, dirty looks, and uninvited touching.
2. Lateral violence is also known as horizontal abuse or horizontal hostility.
- It occurs between individuals who are at the same level within organization.
- For example, a more experienced staff nurse can be abusive to a newly
licensed nurse
 - Common behaviors include verbal abuse, undermining activities, sabop a
form of bullying ad are prohibited even if the nurse is off duty and it is posted
off-site from the facility.
★ Increase staff awareness about disruptive behavior.
★ Avoid making excuses for disruptive behavior.
★ Support zero tolerance for disruptive behavior
★ Establish mechanisms or open communication between staff nurses and nurse
managers
★ Adopt policies that limit the risk of retaliation when disruptive behavior is reported.

Civility- treating others with respect

Malpractice Claims: Communication is ⅓ (2015 study)
Norms Examples:
● Patient safety
● Look for ways to support colleagues’ work
● Give colleagues the benefit of the doubt
Norms can help:
● Reduce negativity
● Address problems
● Give better care
Techniques
● Neutral observations
● “I” statements
Speaking up
● Improves client outcomes
● Reduces conflict
● Improves work experience

FDAR (Focus Charting)

ASSESSING
- Collection, validation, and communication of patient data.
Purpose:
- Make a judgment about the patient’s health status, ability to manage his or her own
healthcare, and need for nursing.
- Plan individualized holistic care that draws on patient strenghts and is responsive to
changes in the patient’s condition.

Activities:
1. Establish the database:
a. Nursing history
b. Physical Assessment
c. Review of patient record and nursing literature and consultation with patient’s
support people and healthcare professionals
2. Continuously update the database
3. Validate data
 4. Communicate data

DIAGNOSING
- Analysis of patient data to identify patient strenghts and health problems in the
independent nursing intervention can prevent or resolve.

Purpose
- to determine actual or potential problems

Actions
1. Interpret and analyze patient data
2. Identify patients strenghts and health problems
3. Formulate and validate nursing diagnosis

OUTCOME IDENTIFICATION AND PLANNING

- Specification of (1) patient outcomes to prevent, reduce, or resolve the problems
identified in the nursing diagnoses, and related nursing interventions.
Purpose
- Develop an individualized plan of nursing care.
Activities
1. Establish priorities
2. Write outcomes, and develop and evaluate strategy
3. Select nursing interventions
4. Communicate plan of nursing care

IMPLEMENTING
- Carrying out the plan of care
Purpose
- Assist patients to achieve desired outcomes - promote wellness, prevent disease and
illness, restore health, facilitate coping with altered functioning
Activities
1. Carrying out plan of care
2. Continue data collection, and modify the plan of care as needed
3. Document care

EVALUATING
- Measuring the extent to which the patient has achieved the outcomes speciffied in
the plan of care; identifying actors that positively or negatively influenced outcome
achievement; revising the plan of care if necessary.
Purpose
- Continue, modify, or terminate nursing care
Activities
1. Measure how well the patient has achieved desired outcomes.
2. Identify factors that contribute to the patient’s success or failure.
3. Modify the plan of care (if indicated)

What if FDAR Charting and why is it used?

 - A charting method used by nurses to help focus on a specific patient problem,
concern, or event.
- Saves time and decrease duplicate charting.
- Advisable for nurses who have a lot of patients and is easier read by othe
professionals.
- It gives other professionals a snapshot of what went on during your shift in a concise
manner.

General Principles
1. All principles about nursing documentation apply to Focus Charting
2. Focus Charting is a method of organizing pertinent patient information in a
systematic narrative approach which includes data, action and response
3. Focus charting provides a structure of a patient centered care. It utilizes nursing
health assessment to acquire knowledge on current patient’s status, formulate a
focus, provide appropriate actions or interventions and monitor desired progress and
outcomes

*picture*

4. Focus Charting enhances communication among the members of the health team
through interdisciplinary documentation that is creating a focused, unified, non
duplicative record of patient care.
5. The Focus Charting uses column format that separates the topic words or phrases
from the body of the notes
6. The four key elements are as follows: Focus, Data, Action and Response
7. The focus charting utilizes a three column form labeled as follows: Date and Time,
Focus and Data, Action and Response.

8. All charting should contain the 3 components of FDAR. In case that the response
does not meet the expected outcome, the nurse should document the evaluation
according to the present status of the patient. When another focus arises during the
shift, adequate spaces should be left for the response of the previous charting before
beginning another FDAR. All responses should be filled earlier as the focus is
resolved or at the end of the shift.
9. Multiple foci may arise during the entire shift; hence the nurse may have multiple
problems.
10. Entries should be written in chronological order.
11. “Nota Bene” (N.B) may be written after the response to document significant data
related to patient care but irrelevant to the focused problem. All data for the N.B.
should be written after the response of the last Focus Charting during the shift. (not
relevant to the problem,

Focus
● This is the subject/purpose for the note
● Nursing diagnosis
● Event (Admission, transfer, discharge teaching, etc.)
● Patient event or concern (Code Blue, vomiting, coughing)
 ● Identifies the content or purpose of the narrative entry separated from the body of the
notes in order to promote easy data retrieval and communication
● It is a keyword used to describe concerns and eliminates negative connotations of
the word problem
● The focus becomes the index to identify all patient notes that relate to a specific
assessment or patient problem

Uses of Focus
● To evaluate progress from the plan of care
● To document a new finding
● To identify presence of acute changes in patient’s condition
● To document a significant event in patient care

Focus
● Abnormal lab results
● Admission
● Airway impairment
● Allergic reaction
● Anxiety
● Aspiration
● Cardiovascular
● Central line therapy
● Chest tubes
● Code (white, blue, etc.)
● Cognitive impairment
● Confusion
● Comfort
● Constipation
● Coping
● CNS status
● Dehydration
● Incontinence
● Infection
● Isolation
● Mental status
● Nausea vomiting
● Neurovascular
● Musculoskeletal
● Pain control
● Physician visit
● Physical status
● DNR
● Dialysis
● Discharge
● Edema
● Fall
● Fatigue
● Family concerts
 ● Fluid balance
● Fever
● GI GU status
● Health teaching
● Hemorrhage
● Suicidal
● Hypotension
● Hypertension
● Hypothermia
● Hyperthermia
● Respiratory status
● Restraints
● Skin Integrity
● Spiritual Interventions
● Swallowing
● Substance abuse
● Teaching
● Telemetry
● Vital signs
● Wound Care

Data
➢ These include subjective and objective cues and description of events supporting the
existence of the focus.
➢ Contains only subjective and objective data
➢ Lays the supporting evidence for why you are writing the note
➢ “This is what the patient is saying and what I’m seeing.”

Action
This includes both present and future independent and collaborative nursing interventions
relative to the identified focus. The independent nursing activities are written first before the
dependent ones
- “Verbal area”
- What you did about the findings you found in the data part
- Nursing interventions (ccalling the doctor, repositioning, administering pain
medication, etc.)

Response
It describes the response of the patient to the interventions given and the expected
outcomes. It evaluates the progress of the patient.
- How the patient responded to your action.

Do’s and Dont’s

- Choose language which is:
➢ Objective
➢ Precise
➢ Specific
➢ Thorough
 - Avoid inconsistencies

POOR WRITING GOOD WRITING

Eats poorly Ate ½ the meal and drank 80 ml fluid

Patient confused Patient unable to recognize family

Uncooperative Refuses to assist with AM care

Patient complaining of pain Complaining of constant, sharp RUQ

abdominal pain

Good day Patient states has been pain free with out
medication and still able to complete ADLs

Diuresing well Furosemide (Lasix) 10 mg IV at 2:30 PM

resulted in 1000 ml of clear, yellow urine

Walking ad lib Walks around the unit, up to the elevator

and back to room without ant discomfort

Procedure
1. When starting focus charting, the nurse on duty makes sure that the biographical
data of the patient, the date and time are filled up.
2. The nurse identifies focus problem of the patient and writes it on the designated
column of the form
3. The nurse starts the charting by stating the status of the patient as received by the
nurse during the rounds including all attachments.
4. Begin the DAR with data gathered, followed by actions and eventually the response
5. NB can be added for additional significant data which are not included in the
management of the focus problem,
6. The nurse in duty signs the charting above the printed name.

Date & Time FOCUS DAR

11/19/19 Received awake on bed with IVF # 2 PNSS 1L x 100 cc/hr at

6-2 shift Hyperthermia left metacarpal vein with gauge 20 IV cannula, remaining

solution is 450 cc and without other attachments.

7:00 AM Data: Temp. 38.5 degrees Celsius

Flushed skin & warm to touch

Action: Assessed temperature per axilla

Tepid sponge bath done

Instructed SO to let patient wear

 Loose clothing

Instructed SO to let patient

Drink a lot of water

7:15 AM Provided opportunity for patient to rest

Paracetamol (Biogesic) 500 mg/tab 1 tab given per orem.

Date and Time FOCUS DAR

11/19/19 Action: Temp. rechecked 37.8 degree Celsius

8:30 AM Response: Patient body temperature reduce to

1:30 PM 37.5 degree Celsius

N.B.

10:30 AM Visited by Dr. Reyes with orders.

11:00 AM CBC taken and follow up result

1:50 PM Endorsed

Student Name, SN/ CI Name/ Staff Nurse

For Discharge
1. The nurse on duty verifies orders for discharge
2. The nurse places the phrase “For Discharge” in the focus column.
3. The DAR column is filled up as follows:
○ Admitted last (date of admission), (age), (sex), (address) who came in due to
(chief complaint).
○ The data comprise the present assessment findings and improvement in the
laboratory and diagnostic results available.
○ The action consists of the discharge
○ The response includes the verbalization of the patients or the significant
others’ readiness for discharge and acceptable return demonstration of
procedures concerning health care..

🖊
○ N.B. may be added if with significant data to document and note.
Pens
Black 6-2
Blue 2-10
Red 10-6

Date & Time FOCUS DAR

 11/19/19 Received awake on bed with IVF #2 PNSS 1L x 100 cc/hr

6-2 shift At left metacarpal vein with gauge 20 IV cannula,

Remaining solution is 450 cc and without other

attachments

For discharge Admitted last November 16, 2019, 26 y.o., female, from

Brgy. 2, Bacolod City who came in due to fever.

Data: with discharge orders

fever not noted

Action:Instructed the following:

Maintain and observe proper hygiene

Avoid overcrowded areas

Consume well balanced diet

For follow up check up on 11/25/19 at

Doctor’s clinic

10:00 AM For repeat CBC

Response: Patient verbalized understanding of

going home instructions.

N.B.

May go home billed

Discharged ambulatory with an improved condition

Documentation Dos:
● Do write your OWN observations and sign over the printed name. Sign and initial
every entry.
● Do describe patient’s behavior
● Do use direct patient quotes when appropriate
● Do be factual and complete. Record exactly what happens to the patient and care
given.
● Do draw a single line through an error and mark this entry as “ERROR” and sign your
name.
● Do use next available line to chart
● Do document patient's current status and response to medical care and treatments
● Do write legibly. Do use standard chart forms
 ● Do use only approved abbreviations
● Don’t make or sign an entry for someone else.
● Don’t change an entry because someone told you to
● Don’t label a patient or show bias
● Don’t try to cover up mistake or accident by inaccuracy or omission
● Don’t “white out” or erase an error
● Don’t throw away notes with an error on them
● Don’t squeeze in a missed entry or “leave space” for someone else who forgot to
chart
● Don’t write over the margin
● Don’t use meaningless words and phrases, such as “good day” oe “no complaints”
● Don’t use pencil

Situation
During the 6-2 shift rounds, the patient received asleep on bed with IVF # 4 PNSS 1L x 60
cc/hr infusing well. Cough is still noted with whitish sputum. Patient is afebrile and eupneic
with BP of 110/70mmHg, cardiac rate of 80. At 9 am, the attending physician made rounds
with the following orders:
● May go home
● Discontinue IVF
● Continue medications: cefuroxime 500 mg Q8H and Paracetamol 500 mg PRN Q$H
for fever
● Resume pre-hospitalization diet
● No restrictions on activity
● For follow up check up at the doctor’s cline after 1 week

Date/Time: FOCUS DAR

2/7/2022 Received asleep on bed with IVF # 4 PNSS 1L x 60 cc/hr infusing well

6-2 shift

For discharge Data: afrebrile

A 53 year old male was admitted due to fever with a body temp. Of 39 C yesterday (11-7-19,
2-10 shift). During the 6-2 shift, productive cough was noted. Patient’s IVF is #2 PNSS 1L x
100 cc/hr at left metacarpal vein with guage 20 IV cannula, remaining solution is 450 cc and
without other attachments. 8 am vital signs are as follows: T 37.3 C, CR 67 bpm, RR 20 cpm
and BP 120/70 mmHg. At 10 am, the patient complained fever of 38.4 C
Labs:
- WBC of 12 x 10^9/L
- Sputum AFB (-)
- For follow up: sputum gram staining and culture sensitivity
Medications:
- Paracetamol 500 mg PRN Q4H for fever
- NAC 600 mg effervescent tab in 50 cc water ODHS
- Cefuroxime with ipratropium + salbutamol Q6H

RMCI GUIDELINES
Policy- All healthcare personnel who are involved in the measuring of intake and output as
part of the client care to patients shall endeavour to do it with utmost accuracy in accordance
with the standards of the medical profession.
Level
● RN
● Nurse Attendant

Intake and output (I &O)

- This is the measurement of the fluids that enter the body (intake) and the fluids that
leave the body (output).
- The two measurements should be equal. (what goes in… must come out)

Intake and Output

● Defined as the measurement and recording of all fluid intake and output during a 24
hour period provides important data about the client's fluid and electrolyte balance.
● Unit of measurement of intake and output is mL (milliliter).
● To measure fluid intake, nurses convert household measures such as glass, cup, or
soup bowl to metric units.
● Gauge fluid balance and give valuable information about the patient's condition.

Remember! Intake
● Oral fluids
● Ice chips
● Foods that are tend to become liquid at room temperature
● Tube feedings
● Parenteral fluids
● Intravenous medications
● Catheter or tube irrigation
● Gelatin
● Broths
● Ice cream

Remember! Output
● Urine
● Vomitus and liquids feces
● Tube drainage
● Wound drainage and draining fistulas
Do
● Identify whether you patient has undergone surgery or if he has a medical condition
or take medication that can affect fluid intake or loss
● Measure and record all intake and output. If you delegate this task, make sure you
know the totals and fluid sources
● At least every 8 hours, record the type and amount of all fluids he’s received and
describe the route as oral, parenteral, rectal, or by enteric tube.
● Record ice chips as fluid at approximately half their volume
● Record the type and amount of all fluids the patient has lost and the route. Describe
them as urine, liquid stool, vomitus, tube drainage and any fluid aspirated from a
body cavity.
 ● If irrigating a nasogastric or another tube or the bladder, measure the amount instilled
and subtract it from total output.
● For an accurate measurement, keep toilet paper out of your patient’s urine.
● Measure drainage in a calibrated container. Observe it at eye level and take the
reading at the bottom of the meniscus.
● Evaluate patterns and values outside the normal range, keeping in mind the typical
24 - hour intake and output.
- 6-8 void/day (normal)
● When looking at 8- hour urine output, ask how many times the patient voided, to
identify problems.
● Regard intake and output holistically because age, diagnosis, medical problem, and
type of surgical procedure can affect the amounts. Evaluate trends over 24 to 48
hours.

Don’ts
● Don’t delegate the task of recording intake and output until you’re sure the person
who’s going to do it understands its importance
● Don’t assess output by amount only. Consider color, color changes, and odor too.
● Don’t use the same graduated container for more than one patient.

Importance of Monitoring Intake and Output

1. It is an important clinical care process that provides the means to determine the
progress of the disease and the beneficial as well as the detrimental effects of
treatment.
2. Help caregivers ensure that the patient has a proper intake of fluid and other
nutrients.
3. Helps determine whether there is adequate output of urine as well as normal
defecation

Body Mass Index (BMI)

● Healthy weight is indicated by a BMI of 18.5 to 24.9
● Overweight is defined as an increased body weight in relation to height. It is indicated
by a BMI of 25 to 29.9
● Obesity is an excess amount of body fat. It is indicated by a BMI greater than or
equal to 30.
BMI= weight (kg) / height (m2)

Significance of Measuring Intake and Output

● Inform
○ Strict MIO (short and concise)
○ Use SBAR approach (Situation, Background, Assessment, Recommendation)
● Required - calibrated glass, urinal, bedpan
● Explain (Risks)
● Emphasize
LOFI - Limit output fluid intake for 1Liter/day

Formula
% weight change = (usual weight - present weight) x 100
Pediatric
OUTPUT divide WEIGHT divide 8 hours (constant)
● cc/kg/hr
Example:
1. 200cc/ 29kg/8hr = 0.8 urine cc/hour
★ NORMAL URINE CC/HOUR IS 0.5 - cut off reference, if below 0.5 there is
fluid volume deficit / dehydration or problem
★ If there's stool - minus 10
★ kg divide to 2.2 =cc
D5IMB purple - less than 2 yrs old
D5NM orange label - more than 2 yrs old

2. 360cc/10kg/8hr = 4.5 cc/hr → continue administering treatment

- Weigh the actual weight of the diaper with no urine then deduct to final output

AnthroPometric Tools
Weight
WODAC - weigh once daily before meals
● Weigh at the same time of the day wearing similar clothing to ensure accurate weight
readings
● Daily fluctuations generally are indicative of water weight changes.
● Percentage weight change calculation (weight change over a specified time
➢ Greater than 2% in 1 week indicates a significant weight loss.
➢ Greater than 7.5% in 3 months indicates a significant weight loss
➢ “Ideal” body weight based on height (plus or minus 10% depending on frame size.
○ Males: 48 kg (106 lb) for the first 152 cm (5 ft) of height and 2.7 kg (6 lb) for
each additional 2.5 cm (1 in)
○ Females: 45 kg (100 lb) for the first 152 cm (5 ft) of height, and 2.3 kg (5lb)
for each additional 2.5cm (1in)

MIO Facts
Clinical Values
➢ Fluid intake and output (I&O)
○ Adult: 2000 - 3000 ml (2-3 L) per day
○ Total average output: 1750-3000 ml/day
➢ The metric system is used for fluid measurement
➢ The measurement should be recorded in ml. (Milliliters).
○ The average adult intake is 2500-3000mL. Per day.
○ The average output is 2500-3000mL. Per day.
Example:
1. CTT monitoring: 700 Remaining Solution(RS)
800 Drained
300 irrigation
(Given 1000 cc)
How much will be the urine output?
Formula: 1000-700 =300
800-300 =500
Answer:500
★ Cystoclysis - If output is negative (if continuous within 2 hrs refer to physician),
check if there is obstruction, do not flush
Sources of fluids
● Oral fluids; (NGT, jejunostomy tube)
● Food
● Intravenous fluids
Sources of fluid excretion:
● Lungs; (CTT)
○ Owl - original water level - minus lang sa OWL and present OWL = output
● Skin; (jackson pratt)
● Kidneys; (Foley catheter, cystoclysis , nephrostomy tube)
○ Cystoclysis - Infuse cold saline; deduct irrigation volume instilled from the
total output collected from the patient
● Intestines, (Colostomy, Ileostomy tube, T-tube, hemovac)

Measurement of Volume
1 tablespoon (tbsp) = 15 milliliters (ml)
3 teaspoons (tsp) = 15 milliliters (ml)
1 cup (C ) = 240 milliliters (ml)
8 ounces (oz) = 240 milliliters (ml)
1 teaspoon (tsp) = 5 milliliters (ml)
1 cup (C ) = 8 ounces 9oz)
16 ounces (oz) = 1 pounds (lb)
1 ounce (oz) = 30 milliliters (ml)

Common metric conversions used for I&O

1cc = 1ml 1 ounce =30 ml 1L= 1000 ml
● To convert from ounces to ml. Multiply by 30
(Ex. 6 oz. x 30ml. = 180ml)
● To convert from cc/ml to ounces , divide by 30
(Ex. 240cc/30cc = 8 oz.)
★ Sizes of containers vary
★ Know your facility’s container measurement system.

Intake & Output: Metric Conversions

Using the basic volume conversion, convert the following equations to the metric system.

Basic conversions:
1ml = 1cc
1 ounce (oz) = 30 ml
1 cup = 8 oz
1 pint = 2 cups

Hints
To convert from ml. or cc. To ounces, divide by 30
To convert from ounces to ml. or cc., multiply by 30
MIO Cut Off Time
● 6 am - 2 pm - 5:01am-1pm
● 2pm-10pm - 1:01pm-9pm
● 10pm-6am - 9:01pm-5am

Purpose of the Intake-Output Chart

- The amount of fluid required by a person and the urine output varies age, weight
activity and physical surrounding
- Special precautions required for certain clients

MIO SHEET
Exercise:
- Nurse Martin is on a 6-2 shift and received a post TURP client with cystoclysis fluid
(NSS) is at 800 ml and the urine bag has 200 ml of urine. At 1pm, cystoclysis fluid is
at 300cc with urine output of 1000 ml.
- How much is the client’s actual urine output in a shift?
Donning and Doffing of Personal protective Equipment

What is PPE
- A specialized clothing or equipment worn by an employee (nurses, doctors, and other
healthcare personnels) for PROTECTION and SAFETY against INFECTIOUS or
HAZARDOUS agents that could cause serious workplace injuries and illnesses
- These injuries and illnesses may result from contact with chemical,
radiological, physical, electrical, mechanical, or other workplace
hazards
- Personal protective equipment may include items such as gloves, safety
glasses and shoes, earplugs or muffs, hard hats, respiratory, or coveralls,
vests and full body suits.

Why PPE’s are important?

1. It keeps you from being liable for your own injuries
2. Serious conditions may result from a failure to protect yourself
3. It ensures safety and productivity at work.

Purpose of Donning and Doffing

- Meticulous donning and doffing of PPE is a vital step in reducing contamination of
healthcare workers caring for patients with transmissible infectious diseases

Personal Protective Equipment Items

MASK (N95)​
- An N95 respirator is a respiratory protective device designed to achieve a
very close facial fit and very efficient filtration of airborne particles. ​
- Note that the edges of the respirator are designed to form a seal around the
nose and mouth. ​
- Surgical N95 Respirators are commonly used in healthcare settings and are
a subset of N95 Filtering Facepiece Respirators (FFRs), often referred to as N95s​

​ LOVES​
G
- Gloves help keep your hands clean and lessen your chance of getting
infected.​
- Wear gloves every time you touch blood, bodily fluids, bodily tissues, mucous
membranes, or broken skin. You should wear gloves for this sort of contact,
even if a patient seems healthy and has no signs of infection.​

FACE SHIELD​
- aims to protect the wearer's entire face (or part of it) from hazards ,chemical
splashes (or potentially infectious materials​

EYESHIELD​
- Safety glasses, as a minimum, are required where there is a potential
of eyes being struck by projectile objects. ( vomitus, blood and bodily
fluid splashes)​
Eye and face protection must be worn when potential exists for
contamination of mucous membranes.​
 Since the goal is to provide protection of the eyes, nose and mouth, protection may consist
of one of two choices: 1) eye protection (that includes side shields) and a face mask, or 2) a
chin length face shield only.​

​ OWN​
G
- Gowns are classified by their ability to withstand penetration by blood or
body fluids.​
- An isolation gown is a non-sterile gown used to keep clothing from getting
contaminated. These are fluid resistant enough to keep body fluids away
from clothing for a short period of time. ​
- Used for care of patients on contact precautions and for splash-generating
procedures. May be disposable or non-disposable.​
Level 1 - bunny suit
Level 2 - yellow/blue gown (isolation gown)
Level 3 - with PPE
Level 4 - complete set (hazmat)

​ AZMAT SUIT​
H
- designed to cover the whole body and other clothing to protect against dirt or
other outside contaminants. Coveralls are one piece and loose fitting for ease
of movement, with sleeves, full leggings and often a hood to cover the head.​

​ URGICAL HEAD CAP

S SURGICAL SHOE COVER​
​
​

DONNING PPE
● ​DONNING – means “ PUTTING ON ”​
● This is the process of putting on required personal protective equipment necessary to
perform one's tasks. ​
● This involves putting on the required apparel before patient contact and must be
performed in the following order; hand hygiene, gown, mask, eye or face protection,
and gloves. ​
PPE DONNING AS PER CDC​

DOFFING PPE​
● DOFFING – means “ TAKING OFF “​
● This is the process wherein extra precaution must be observed.​
● When doffing, hand hygiene must be performed after taking off each item; starting
with gloves, eye or face protection, gown and mask. ​
● If the proper procedure is not followed, blood, body substances, and other potentially
infectious material could be transferred to both healthcare workers and patients.​

PPE DOFFING AS PER CDC​

Donning of Personal Protective
Evaluation Tool
1. Engage a trained observer
2. Ensure that you are well hydrated
3. Tie hair back
4. Remove all jewelry (no stones rings, watches, bracelets, etc.
5. Ensure that the facial hair has been shaved completely before donning the N95
respirator
6. Check the available personal protective equipment for:
a. Correctness
b. Completeness
 c. Size
d. Quality
7. Perform hand hygiene
8. Don shoe cover/ Booties
9. Perform Hand Hygiene
a. Palm to palm
b. Right palm over left dorsum; Left palm over right dorsum
c. Fingers interlaced
d. Fingers interlocked
e. Rotational rubbing if the thumb
f. Rotational rubbing of the palm with clasped fingers.
10. Don your first layer of gloves
11. Don coverall
12. Don impermeable re-usable gown
13. Put on N95 Respirator
a. Check that piece is one that you have previously fit tested and passed with
certification
b. Hold the respirator with your dominant hand cupped under it
c. Allow the straps to hang freely underneath it.
d. Place the respirator against your face, completely covering your nose and
mouth.
e. Pull the top strap over and place it on the crown of your head
f. Pull the bottom strap over your head and place it on the nape of the neck,
below your ears
g. Use the two fingers of each hand to press the nose piece and shape it to the
contour of your nose.
h. Do a seal check. Place both hands in a cupped position while moving it
around the respirator and blowing out. Ensure that no air escapes the edges
of the respirator.
14. Don surgical cap
15. Don the hood of your coverall
16. Don eye/face protection (Googles/Face shield)
17. Don second layer of gloves. Ensure that NO SKIN IS EXPOSED between the gloves
and gown cuffs.
18. In the presence of a trained observer, simulate activities that you are about to
perform to ensure that personal protective equipment will not malfunction during
patient exposure.
19. Get confirmation/ approval of the trained observer before proceeding to the patient
care area.

Doffing
1. Engage a trained observer
2. Ensure that you are at least 6 feet from the patient
3. Ensure that you have enough space to avoid contamination of PPE
4. Check for signs of gross contamination
5. Manually remove all contaminants before continuing the doffing process.
6. Perform Hand hygiene using alcohol based hand rub
a. Palm to palm
 b. Right palm over left dorsum; Left palm over right dorsum
c. Fingers interlaced
d. Fingers interlocked
e. Rotational rubbing of the thumb
f. Rotational rubbing of the palm with clasped fingers
7. Doff the disposable/reusable outer gown
a. Break the waist tie by pulling firmly from the front without overreaching at the
back
b. Break the neck tie by pulling firmly from the front. Avoid reaching for the back
c. Cross the arms and firmly grasp the front of the gown below the shoulders.
Slightly bend your upper body forward while pulling the gown away from you
d. Keep your hands in the sleeves while slowly rolling the gown away from the
your body
e. Pull the hands out while removing the outer gloves with the sleeves, one are
at a time taking caution not to contaminate the inner garment with soiled PPE.
f. Dispose dirty PPE in their appropriate bins
8. Perform hand hygiene
9. Exit the room
10. Remove eye/face protection
a. Grasp the back strap of your eye protection
b. Lean slightly forward while passing the strap over your head (back to front
direction) and removing the eye protection away from you. Take caution not to
contaminate face with soiled part of the eye/face protection
11. Perform hand hygiene
12. Remove surgical cap
13. Perform hand hygiene
14. Remove booties
15. Perform hand hygiene
16. Doff Coverall
a. Unzip the cover all. Ask assistance from the trained observer if needed
b. Grasp the outside of the coverall at the shoulders. Trained observer/assistant
may do this while standing at your back
c. Slowly pull the coverall in a downward motion until it falls off your shoulders
completely
d. Slowly roll the coverall outward while doffing
e. Remove your arms by slowly pulling it down until its at your waste, being
careful not to touch your scrubs or skin
f. To completely doff the coverall (you may sit on a clean chair, if needed) grab
the coverall and pull it away from your body, one leg at a time
g. Dispose the coverall in the appropriate bin
17. Perform hand hygiene
18. Doff the first layer of gloves
19. Perform Hand Hygiene.
20. Doff the respirator mask
a. While leaning slightly forward, place your hands at the back of your head and
grab the bottom strap
b. Carefully pull it over your head and release it front
c. Avoid touching the front part of your FPR (facepiece respiratory)
 d. While still leaning slightly forward, place your hands at the back of your head
and grab the top strap
e. Carefully pull the top strap over your head and release in front, still avoiding
touching the front of the FPR
f. Discard the soiled FPR in the appropriate bin or place in a brown bag for
reuse in accordance to the institutional protocol
21. Don a new maks
22. Perform Hand Hygiene

Medication Distribution Record

Level
● MD
● RN

Policy
- All health care personnel who are involved in the giving of medication to patients
shall endeavor to do it with utmost accuracy in accordance with the standards of the
medical profession

1.NURSE ON DUTY CHECKS PHYSICIAN'S WRITTEN ORDERS

1.1 IDENTIFIES PATIENT'S CHART CORRECTLY
1.2 CONFIRMS PATIENT'S IDENTITY

Loading dose - extra dose to increase the effect of the drug

2. NURSE ON DUTY REQUESTS MEDICINES FROM PHARMACY

SCANNING OF REQUEST
➢ Click the scanner icon
➢ Insert Physician’s order sheet (FACE DOWN) unto the
scanner
➢ Click new scan
➢ Click scan button
➢ Type name of the patient & room number
➢ Types remarks
➢ Click upload image
NOTE: If patient's account is closed, the nurse in charge gives the transcription note to
the watcher and instructs to purchase the medicines from our pharmacy. Nurses are not
allowed to administer medicines purchased from other pharmacy. For stat orders, nurse on
duty calls and gets medicines from pharmacy immediately if stocks are not available in the
nursing station.
- 9 am time required - administer 11 am (2 hours) for standing dose give within 2 hours

● Stat orders - 30-45 mins ordered (1 hour before OR, from Pharmacy)
● Single dose orders - Medication administered at once at specified time (chemo
drugs)
 ● Standing medications - prescribed by the physician with frequency

Nurse on duty makes medication card that includes the following:

➢ Room number/bed
➢ Patient's full name
➢ Name of medication (generic name in lowercase and brand name
➢ enclosed in parenthesis), dosage, route, frequency, and timing of
➢ administration
➢ Nurse's signature over printed name (trodat stamp)
➢ Date the medication card is made (date it was advised by physician)

If doctor put OD 7am - put 7 am in the card the put AP’s timing below the time

If in delivery room, follow timing

If Card is Lost/Damage

● Remake the card and write "R" on the lower left corner of the medication card.
● Affix signature over printed name and the date it was ordered on the lower right
corner of the medication card.

NNO - no new orders (not valid)

Green medication card - intramuscular injection
Blue medication card - subcutaneous injection
Orange - IVTT
White - oral medication
Yellow - topical / eye drops / suppository / inhaler / lotion / creams / gel

Midazolam - anxiolytic drugs, should be given after patient is transferred in the stretcher of
OR
NURSE ON DUTY DOCUMENTS MEDICATION GIVEN:
● * All medications administered shall be documented on the chart right after it was
given with medication card as guide (to prevent medication error)
● All medications administered should be signed by the nurse who administers it on the
medication and treatment record
● Nurse on duty carries out doctor's order ( provide time for baseline and avoid
medication error)
● Corresponding generic names written in lower case shall be indicated in all
medications ordered by the physicians - in riverside it is called mar (medication and
treatment record) located on 8th page on charge
➢ If the names are full, have another medication sheet then put your name on new
sheet
- First column is time, if the patient refused or NPO, encircle or sign if not NPO.
if there is NPO do not sign. If the patient refused the medication on the
second column, put D without signature.
- SIGN ONLY WHEN PATIENT RECEIVED MEDICATION
- First column is time, the second column is the signature.
- Encircle the time and not the
● IF IN DOUBT ALWAYS CLARIFY WITH THE ATTENDING PHYSICIAN THE NAME
OF MEDICINES AND ITS DOSAGE

● STANDING MEDICATIONS, NURSE ON DUTY WAITS FOR 30 MINUTES TO 1

HOUR FOR THE DISPATCHER TO DELIVER MEDICINES (Pneumatic tube in 10
mins the medication is on the station)
○ Standing medication contains frequency while stat medication does not have
frequency but “now”
,
● PREPARE DESIRED DOSE DO NOT PUT MEDICATION CARDS TOGETHER
WITH OPENED TABLETS AND CAPSULES INSIDE THE PLASTIC PACKET
- Contamination
● NOTE: “PREPARE YOUR OWN MEDICATIONS AND GIVE ONLY THE
MEDICATIONS THAT YOU PREPARED”
● If STAT, a nurse on duty prepares medicine as soon as she gets the medicine from
the pharmacy. Nurse who receives the medicine should affix her signature above
printed name and the date the time it was received

NURSE ON DUTY ADMINISTERS MEDICINE OBSERVING THE TEN (10) RIGHTS IN

GIVING
MEDICATIONS
1. RIGHT PATIENT/CLIENT
2. RIGHT MEDICINE/DRUG
3. RIGHT DOSAGE
4. RIGHT ROUTE OF ADMINISTRATION
5. RIGHT DOCUMENTATION
6. RIGHT TIMING
7. RIGHT EDUCATION
8. RIGHT ASSESSMENT
9. RIGHT EVALUATION
10. RIGHT TO REFUSE

Close pharmacy system - medication are within Riverside hospital

● ALWAYS USE MEDICATION TRAY IN GIVING MEDICATION DO NOT CARRY

MEDICATION PACKETS IN YOUR POCKETS/HANDS

● ENTER ROOM COURTEOUSLY AND WITH A SMILE INFORM PATIENT THAT HE

IS ABOUT TO TAKE HIS MEDICATION

● PLACE PATIENT IN UPRIGHT POSITION (UNLESS CONTRAINDICATED)

EDUCATE PATIENT ON THE ACTION OF EACH MEDICATION

● PROVIDE DRINKING WATER ASSIST PATIENT WHEN NEEDED DO NOT HOLD

MEDICINES WITH YOUR BARE HANDS

● NEVER LEAVE MEDICATIONS NOT TAKEN BY PATIENT AT BEDSIDE IN CASE

PATIENT IS ASLEEP OR IN THE RESTROOM, INSTRUCT WATCHERS TO
INFORM THE NURSE ONCE PATIENT IS READY TO TAKE THE MEDICATION.

● IV ANTIBIOTICS SHOULD BE GIVEN BY IV DRIP BY USING

VOLUMETRIC/SOLUSET INTRAVENOUS INFUSION SETS AN REGULATED AS
ORDERED. THE CONNECTING NEEDLE SHOULD BE CHANGED FOR EVERY
ADMINISTRATION OF ANTIBIOTIC IF USED AS A SIDE DRIP OR PIGGY
BACK(UNLESS SPECIFIED BY THE PHYSICIAN)

● NOTE: USE SEPARATE VOLUMETRIC/SOLUSET PER ANTIBIOTIC

● ANTIBIOTICS ORDERED TO BE GIVEN IV PUSH MAYBE GIVEN BY PINCHING

OR KINKING IV TUBING AND PUSHING THE ANTIBIOTICS UP TO THE DRIP
CHAMBER TO ALLOW SLOW ADMINISTRATION OR TO BE REGULATED AS
ORDERED
- If there is needle prick, report an incident report so that you will be given with hepa
drug to prevent hepatitis from patient

● OBSERVE REACTIONS/SIDE EFFECTS OF DRUGS. EPINEPHRINE IS

AVAILABLE IN THE E-KIT AT THE NURSE'S STATION FOR ANAPHYLACTIC
SHOCK

● NOTE: FOR SIGNS OF ANAPHYLACTIC SHOCK: CALL FOR CODE 99

IMMEDIATELY

● Signs of Anaphylactic shock: Call for Code 99 / blue immediately. RAPID AND
SEVERE DROP IN BLOOD PRESSURE, WHEEZING, CHEST TIGHTNESS,
DIFFICULTY OF BREATHING, RAPID PULSE, SWEATING, DIZZINESS, FAINTING
AND UNCONSCIOUSNESS, THROAT SWELLING WITH A FEELING OF THROAT
 TIGHTNESS, A LUMP IN THE THROAT, HOARSENESS OR OBSTRUCTED
AIRFLOW

● TESTING OF DRUGS:
● NURSE SHOULD DO INTRADERMAL TESTING FOR ANTIBIOTICS AS
ORDERED. DOCUMENTATION SHOULD CONSIST OF THE DRUG, DOSE,
METHOD, SITE, AND TIME OF ADMINISTRATION AND SIGNATURE OF THE
NURSE ABOVE PRINTED NAME

Test does - ¼ of medication for initial dosage

● AFTER 30 MINUTES, NURSE ON DUTY NOTIFIES INTERN ON DUTY/RESIDENT

ON DUTY TO READ THE TESTING AND GIVE THE INITIAL DOSE IN CASE
WHERE IOD /ROD IS UNAVAILABLE TO READ THE SKIN TEST AND GIVING OF
DOSE IS DUE, THIS MAYBE DONE BY A SENIOR NURSE. SENIOR NURSE
INFORMS THE IOD/ROD OF THE RESULT. IOD/ROD SHALL SIGN THE
MEDICATION SHEET WITHIN 24 HRS.

AFTER A NEGATIVE READING, INITIAL DOSE OF INTRAVENOUS MEDICATION IS

GIVEN BY IOD/ROD. IOD/ ROD SHOULD AFFIX HIS SIGNATURE AFTER WRITNG (-)
SKIN TEST AT THE BACK OF THE MEDICATION AND TREATMENT RECORD RIGHT
AFTER THE ENTRY OF THE SKIN TEST BY THE NURSE AND RECORD THE INITIAL
DOSE WITH PROPER DOCUMENTATION ALSO ON THE NURSE'S RECORD
- IV test - done by physician and not nurse

INTRAVENOUS TESTING SHOULD BE PERFORMED, INTERPRETED AND

ADMINISTERED BY THE RESIDENT/INTERN ON DUTY. PROPER DOCUMENTATION
SHOULD BE DONE ON THE CHART AND THE RESIDENT/INTERN CONCERNED MUST
AFFIX HIS/HER SIGNATURE

* Pls. Be guided with the commonly used

injectables and their stabilities. Identification of sound-alike and look-alike drugs (SALAD)
- each stations must have a list of injectable drugs with their corresponding stabilities and
drugs that sound-alike and look-alike drugs

SALAD
NURSE ON DUTY PREPARES MEDICATION:
● COMPARE THE LABEL OF RECEIVED MEDICINES TO THE MEDICATION
CARD/DR'S ORDERS
High Alert Medication (HAM)
● CHECK EXPIRATION DATE
● ALL DOSAGE CALCULATIONS ARE TO BE DONE BY 2 RN, INDEPENDENT OF
EACH OTHER; SHOULD THE RESULT BE UNIDENTICAL, THE CALCULATION
SHOULD BE REDONE AND A THIRD NURSE SHOULD BE ASKED TO
INDEPENDENTLY CHECK THE CALCULATIONS. IF THERE IS STILL NO
AGREEMENT, THE PHYSICIAN IS TO BE CONSULTED
● If a patient is on NPO and an antibiotic needs to be given, do not give. Check
physician's order if treatment medications should be administered.
● If more than 1 doctor (co manage), ask the main physician first in administering
drugs.
● Document telemed, and it should be signed by the doctor
● If stat, a nurse on duty prepares medicine as soon as she gets the medicine from the
pharmacy. Nurse who receives the medicine should affix her signature above printed
name and the date and time it was received
Note: Prepare your own medications and give the only medications that you prepared
● Observe Reactions/Side Effects of Drugs. Epinephrine is available in the E-kit at the
nurse’s station for anaphylactic shock
For signs of Anaphylactic Shock: Call for Code Blue immediately (#188)
➢ Rapid and severe drop in blood pressure
➢ Generalized Skin Rash
➢ Diarrhea
➢ Swelling
➢ wheezing , chest tightness, restlessness/anxiety
➢ Rapid pulse, sweating, dizziness, fainting and unconsciousness
➢ Throat swelling with a feeling of throat tightness, a lump in the throat, hoarseness of
obstructed airflow
★ Attention, Attention, Code blue paging Dr.

NSD 07-03-0014 March 19, 2007

- All

Medicines to be recovered from the Pharmacy:

All Doses of medication should be reconciled every shift
➢ Ciprobay
➢ Clexane
➢ Clovis
➢ Fortum
➢ Invanz
➢ Jarazol
➢ Kefox
➢ Meronem
➢ Natravox
➢ Omepron
➢ Rizek
➢ Rocephin
➢ Tazidem
➢ Tazocin
➢ Tienam
➢ Xtenda
➢ Zeptrigen
➢ Zinacef

Procedure in Giving Parenteral Medication:

- All parenteral medications should be dissolved at the nurses station
- Dissolved medication will be withdrawn at bedside
- Explain to patient action, dosage,
frequency and route of
administration

● Nurse Duty must affix her

specimen signature after writing
her full name on the space
 provided for in the medication and treatment record

● If medicine is unavailable or
contraindicated, nurse should encircle the
specific timing it was omitted on the
medication and treatment record

● Date and time of starting dose and last dose should

be written at the back of the medication card

● Indicate the time medication was

given

3/21/2022 Review

Fractional Doses - TID, x4 doses, x6 doses, needs to be given in many doses throughout
the day
for electrolyte imbalance, mannitol (cerebral edema), etc.
Drugs with Precautions

You will administer Digoxin but the px HR is 50 bpm

After reassessing, write the time and encircle and write nurse’s remarks that the AP was
called.

If the patient is asleep during the time of administration, ask the folks if there are any
unusualities. And then note “asleep” in the sheet. Make sure to endorse next shift. If IVTT,
the drug can still be given, timing reinforcement must be done for the folks and px
If patient vomitted, encricle time, write “Have vomitous”, inform AP, and then give 2 hours
later or as instructed

If refused, encircle time and write refused

If patient was at hemodialysis, utz, etc. write “at hemodialysis”

If patient cannot pay for meds and will not be served by Pharmacy, write “prescribed”
Drug hold

Changed Brand
Pre Op

Medications Requiring Special Precautions must be charted accordingly

- Digoxin -check for cardiac rate, hold for CR below 60 BPM
- Methylergometrine Maleate - hold for BP 130/90 mmHg and above
- Anti Hypertensives - hold for BP 80/60 mmHg and below

How much should I give

Desired dose x volume

__________________
Stock on hand

Gtts/min = total vol x drop factor

-------------------------------
Times in minutes
● Stat - give immediately
● Standing - medications with instructions
● Single Written orders - given once on a specific time (ex. preop)
● Medication with fractional doses - color red

TPR SHEET DOCUMENTATION

To record the temperature, pulse rate, respiratory rate and blood pressure taken from the
patient in the TPR sheet.

Equipment:
TPR sheet
Blue/ black ink pen
Red ink pen

SAMPLE TPR SHEET

PROCEDURE

1. On admission, fill up the date of admission and the

number of days as “ on admission” to signify the day
of admission, located on the left upper portion of the
TPR graphing sheet. Each succeeding days of the
patient’s stay in the hospital should be dated
accordingly.

● Do not write the date in advance to avoid error in

graphing under the wrong date. The succeeding days
would be marked with the corresponding numbers in
Arabic numerals ( 1, 2, 3, 4 etc.) until such a patient
will be discharged.
 ● While the Post –op days and OB days should be
numbered in Roman numerals (I, II, III, IV etc.).

2. Using a blue/black ink pen, record the temperature

reading by encircling the baseline temperature (37 ⁰C)
then continuously make a line until you reach the exact
temperature reading taken from the patient.
2.2. The succeeding horizontal line located above and below
the baseline is counted as by ones.
2.3. Record the temperature reading in the column of the
nearest time the temperature was taken.

Example: Temperature taken around 1:30pm, can be

recorded initially under 12pm of the same date..

3. Using a red pen, record the pulse rate by encircling

the baseline pulse rate reading (80 bpm ) then
continuously make a line until you reach the exact
pulse rate reading taken from the patient.
3.1. The horizontal line located above and below the baseline
is read as by 2’s.
3.2. The horizontal line located above and below the baseline
is read as by 2’s.

4. Using a blue/black pen, record the respiratory rate in

the Respiration portion and the weight in the weight
portion located below the form.
 5. Using a blue/black pen, record the blood pressure
reading within the shift where the time of the BP
reading was taken.

6. Using a blue /black pen, record the number of times

the patient urinate within the shift.
6.1 If the patient has a Foley catheter or a diaper, write “FC”
for catheter, “D” for diaper then write the amount of urine
collected or weighed within the shift.

7. Using a blue/black pen, record the number of times

the patient had BM within the shift.
7.1 If the patient has a colostomy, write the word “C “ instead
of the number of times the patient had BM during the shift and
indicate the amount if loose (in cc/ml).

NOTE :
The next vital signs 4 hours after the initial vital signs were
taken, shall be recorded under the time and shift specified in
the TPR graphing sheet.

8. A drop or rise in temperature occurred 1 or 2 hours

after the initial reading is documented as a broken line
(in red ink). Indicate the time of drop or rise occurred using blue or black ink.

9. Connect the last temperature reading continuously to

the next temperature reading.

NOTE : If the patient is asleep or refused to have vital

signs taken, put asleep or refused under the time or shift
of refusal/asleep in a vertical manner. For temperature
and pulse rate, connect the last temperature/pulse rate
reading to the next temperature/pulse rate reading.

- If the patient is discharged/ expired, put the name

DISCHARGED or EXPIRED in a vertical manner
then the time the patient was discharged/expired
under last temperature and pulse rate reading.

Documentation:

1. Patient’s Chart

2. Census Logbook

Medication Sheet

Purpose: To provide a tool for the recording of all medications and treatments done to every
patient

MEDICATION AND TREATMENT RECORD

(Therapeutic sheet)
– is a record of all medications and treatments
legally prescribed by the physicians and checked/
implemented by the nurse within her hour of duty.
Policy Description:
1. All healthcare personnel who are involved in giving medications to patients shall
endeavor to do it with utmost accuracy in accordance with the standards of the
medical profession.
2. When possible, no abbreviations shall be used. But if needed, all healthcare
personnel involved in the administration and documentation of medication shall use
the standard and internationally accepted medical abbreviations (HS - hours of sleep,
OU - both eyes, OS - left eye, OD - right eye).

POLICY:
RULES IN THE USE OF THE MEDICATION AND TREATMENT RECORD:

1.1 On admission, in transcribing medication to the Medication and Treatment Record,

always refer to the written order from the physician’s order sheet and not from the copied
orders such as the kardex.

All medications and treatments administered to the

patient must be documented accurately and on time.

Checking Medications sequence: physician’s order,

kardex, MAR, nurses record, medication card

NAME AND INITIALS

1.2 Person responsible for giving of medication and
treatment should affix their specimen signature on the
space provided in MEDICATION NURSE and INITIALS
portion of the medication sheet for the purpose of
identification
➢ 6-2 pm: use blue ballpen

DRUG ALLERGIES
1.3 If the patient has allergies, write the name of the medicines in the Drug Allergies portion
of the medication sheet. It should be written in RED INK PEN

1.4 The name of the medication / treatment,

dosage, route of administration, frequency
it is to be given and the date the medicine was
ordered must be clearly indicated in the
column provided.
➔ ANST - after antigen test
➔ If positive for skin test for left arm,
perform skin test on the right arm, if still
positive, put positive mark between
parent
1.5 Write the name of the drugs ordered in the medication sheet with their generic name in
small letters/lower case and the brand name should start in Capital letter(enclosed in
parenthesis). .

The generic name should be written first followed by the brand name

● Write the word “ID” for initial dosage

given and the time it was given and
your initial/sign.
● Write the timing of the drugs in the left
box provided under the TIME.
● If you skip a dose because of certain
reasons e.g patient is at Hemodialysis,
put the time and write “at HD” and put
a circle around the time the medication
was not given.
➔ If discontinued, put “arrow” then
put “HOLD” and date today
● Then record the time the next dose was
given. If you change the timing
because of a skipped dose, draw a
vertical line along the old timing and
write the new timing beside the old one.
● New changes and re-ordered medication should be considered as new entries and
must be treated as such. No alterations in the previously written orders should be
made.
● For the medications ordered every other day, mark the column X when the dose is
omitted.
● For medications with a required number of dosage, indicate the total number of
doses to be given in a fraction in red ink pen.
➔ 6 doses x 6 (red)
● When recording medications administered, always refer to the medication card on
hand to avoid error.
● When the spaces provided are already filled up and there are remaining spaces
below, do not use the remaining spaces. Get a new Medication and Treatment
Record. All medications will have to be transcribed accurately as when using a new
sheet.
● When refilling, transcribe all the orders and other information from the old sheet to
the new one. Take note that only the current medication is to e transcribed. The
original date of the order, or the date of change in the orders would have to be written
on the space provided.
● For patients that are
scheduled for operation, draw
a horizontal arrow using red ink
and write the word PRE-OP
above the line.
 ● Then after the operations
write the word POST – OP in
the middle of the medication
sheet and write the new
medications ordered post-
operatively.

If the doctor ordered resume all

previous medications to resume,
it should be treated as new
entries.

In doing the skin testing: (back portion of

medication sheet)
cefuroxime (Zegen) 750mg IV 0.1cc injected at right
inner forearm as skin test.

(-) Dr. David Signed NOD (nurse on duty)

➢ If doctored ordered no skin testing, verify the

patient for allergic history
➢ Get sign from dr. 30 minutes after getting skin
test result

In doing the IV testing:

ampicillin+sulbactam (Ampimax) 1.5gm IV 0.1ml + 0.9 ml sterile water,
1 ml given as IV Test by PGI Babar.

(-) PGI Babar/ Dr. Bautista Dr. Bautista/PGI Babar/NOD

➔ Don't perform skin tests for macrolide antibiotics, only IV TEST.

➔ Check skin test result after 30 mins (assess for
DOB, chest pain, allergy), if NONE, inform
physician for counter sign, then nurse can give
antibiotics

● In recording the stat medications given, write

the date and time the medications were given.
● In documenting PRN medications given, write
the reason for giving such medications.

NOTE:
If the doctor ordered:
cefixime (Tergecef) 200mg 1 capsule 2x a day, give
first dose now.
Record this in the medication sheet as initial dose (as
standing medication).
If the doctor ordered:
cefixime (Tergecef) 200mg 1 capsule now then 2x a
day.
Record this as stat medication.

In documenting IVF started, write the site the IV was

inserted and the gauge of needle that was used.

● In starting a side drip/piggyback, write the

medication and write the word side drip.
● Then the succeeding IVF’s should be labelled as
Main line and Side drip.
● If with multiple side drip you could label it as side
drip A, side drip B etc.
If the patient has several IVF’s, and an IVF rate is
decreased, Write the IVF #, the name of the IVF, the
remaining solution and the present IVF rate.

NOTE:
● In changing an IVF, if the remaining solution is
more than 500 retain the present IVF number.
● If the remaining solution of the IV fluid is less than
500, you should write the next bottle number.
● If the patient has a central catheter, record the IVF
as port A, port B, and port C; Blue port, white port,
and brown port, or proximal, central and distal area.
● If the IV fluid was discontinued and changed to
heparin lock, record it as such. But if the IVF was
again restarted, put the word SET B then the
present IV bottle.
● In documenting BLOOD TRANSFUSION, write
the date and time the blood was started, blood
type and RH factor, blood preparation, amount of
blood, crossmatching results, serial number, and
expiration date. The number of units of blood
transfused may be included.

Fractional doses: 3/3 (red ballpen)

Med card if complete: put diagonal mark then date, then
rip the paper in front of nurse

ALL REFERRALS SHOULD HAVE A CONSENT.

● Co-management - do not refer to other physician if nurse did not acquire consent
from the patient
● Consult (surgical consult, cardio consult, gastro consult etc.)
● Cardio-pulmonary evaluation

NOTE:
If the doctor ordered:
➔ Cefixime (Tergecef) 200mg 1mg 1 capsule 2x a day, give first dose now.
➔ Record this in the medication sheet as initial dose (as standing medication)
➔
If the doctor ordered:
➔ Cefixime (Tergecef) 200mg 1 capsule now then 2x a day
➔ Record this as stat medication
Patient Care Classification Using Four Levels on Nursing Care Intensity
Category 1
● Feeds self, entirely self-sufficient, up and about to bathroom alone
● Patient for diagnostic procedure and simple treatment (D&C, Biopsy)
● Patient with surgical dressing procedure
● Patient with no unusual or adverse emotional reaction

Category 2
● Needs some help in caring for himself, needs in getting up to the bathroom
● Patients with IVFs, foley catheter, bladder irrigation, enemas (only one of these)
● Patient taking anti-hypertensive. Hypotensive, diabetic, cardiac and anticoagulant
medications
● Patient with mild symptoms, mild debility and mild emotional reaction
Category 3
● Cannot feed self but able to swallow, cannot turn without help
● 2 or more contraptions (side drip a, side drip b, medications)
● Pre and post-surgery with severe frequent incontinence
● Patient with IVTT medication, with tracheostomy, needs suctioning
● Patient with RBS monitoring and insulin medication
● Confused and disoriented patients

Category 4
● Completely dependent for nursing care (yellow port, blue port)

Acuity
● 5 Acuity 3 patients and 1 Acuity 1 patient
● (3x5) → 15 + (1x1) → 1 = 16
➢ 1 patient rbs monitoring qr, insulin coverage, ctt procedure at bedside, gcs q hour
Who will you prioritize first?
1. Stat ctt - airway priority (1st) ʕ •ᴥ•ʔ cutie
2. Blood transfusion - circulation ᕦʕ •ᴥ•ʔᕤ
3. Rbs monitoring ʅʕ•ᴥ•ʔʃ
4. GCS ʕ ㅇ ᴥ ㅇʔ

RECEIVING ENDORSEMENT
Acuity 3 and 4 Patients

Importance of the End-of-Shift Report

● A proper end of shift report is compilation of details recorded by a patient’s nurse.
● Written by nurses who are wrapping up their shifts and provided to those nurses
beginning the next shift.
● These details should include a patient’s current medical status, along with his or her
medical history, individual medication needs, allergies, a record of the patient’s pain
levels and a pain management plan, as well as any discharge instructions.

Tips For An Effective End-of-Shift Report

1. Use concise and specific language - interpret data
2. Record Everything
○ Every notable detail of a patient’s status, regardless of how minute, may
prove to be vital during the course of recovery.
○ It’s important to fill your end-of-shift report with every piece of relevant
information that relates to your patient’s condition.
○ Omitting an item that may seem unimportant could lead to disaster if it’s not
communicated to the incoming nurse.
3. Conduct bedside reporting as often as possible
4. Reserve time to answer questions
5. Review Orders
○ A patient’s condition can change drastically and may require immediate
attention. In some cases, especially when working with patients in the
 intensive care unit (ICU), specific care orders may be placed by a head nurse
or supervising physician, and it’s vital that each nurse fully understands them.
2. Prioritize Organization
3. The PACE Format
○ Patient: List all of the patient’s personal information including age, medical
history details, current condition and latest symptoms.
○ Actions: Include a step-by-step account of the facility’s treatment plan.
○ Changes: Detail the patient's ongoing needs and list all actions the incoming
nurse should take during his or her shift.
○ Evaluation: Provide notes on the patient’s reaction to treatment, along with
any other important observations you make during your shift.
● Head to Toe
○ A popular method for formatting end-of-shift reports, this technique provides a
convenient road map for incoming nurses.
○ Incorporate this method into your reports to cover all patient details from most
important to least, including condition, progress, specific needs and any
instructions for following orders.

Endorsement
- Provide pertinent idea

Purpose
● To serve as a guide for a thorough turnover of patients
● To ensure safe and quality continued care

Level
Nurse, Nursing Attendants, Midwives, Riverside College Students and Clinical

Policy
1. DPOTMH advocates continuity of care of its patients from one shift to the next shift
2. The safe patient turnover requires proper endorsement every shift.
2.1 Deficiencies on nursing documentation identified during endorsement shall be
complied immediately
3. Continuity of care requires a thorough turn-over of all patients in a given area
4. Medication cards due for the incoming shift, those with changes, and those made for
newly ordered medications shall be endorsed (frequency, dose, timing, doctor)
5. Any unusual incidents shall be endorsed
6. Strict confidentiality shall be observed during endorsement
7. Completeness of E-cart, apparatus, and equipment, and fire brigade team shall be
endorsed separately between the assigned personnel.
8. Endorsement starts 15 minutes before the start of a new shift. There are three (3)
shifts/day:
● Morning Shift - 6:00 - 2:00pm (5:30 endorse)
● Afternoon shift - 2:00 - 10:00 am (1:30)
● Night shift - 10:00 pm - 6:00 am (9 pm)
Procedure
1. The station starts the endorsement with a prayer followed by a recitation of the mission
and vision statements.
2. The endorsing nurse reads the Kardex and the receiving nurse takes note of pertinent
information required in delivering healthcare.
3. The endorsing nurse reviews together with the receiving nurse the entries made on the
patient‟s chart during the shift.
4. The outgoing shift endorses the following to the incoming shift:
4.1. Total Census per shift and acuity
4.1.1 Number of admission
4.1.2 Number of discharges - if there is 6 discharge, minus the 6 to the acuity
4.1.3 Transferred in patients
4.1.4 Transferred out patient
4.1.5 Number of Deaths (if any) - make sure to print out ECG report, check
v/s, prepare forms for authority to transfer the body, write the final diagnosis
4.1.6 Absconded / Out on pass (if any) - inform billing office, inform guard,
inform nurse supervisor, doctor, document, file 3 copies of incident report
- Make incident report (3 copies)
Out on pass - patient will go to ATM, bank, X-ray outside hospital
4.2. Using Kardex, endorse in sequence:
4.2.1. General data
4.2.1.1. Room number/Bed number
4.2.1.2. Name of patient
4.2.1.3. Age
4.2.1.4. Status
4.2.1.5. Attending physician/s and consultant/s (visited with or
wo=without orders)
- Under the services of the Main AP, then co mgt (ex. Dr..
Nueva, visited for consult)
- Indicate if visited or to be followed up (endorse to remind
doctor that they have a patient, also to update co manage
doctors)
4.2.1.6 Chief complaints (include past surgeries & working diagnosis)
- Came in due to dizziness, DOB, cough (unproductive)
- Increased BP (highest and lowest value of BP)
- Update on patients case
- Working diagnosis
4.2.1.7 Special procedure (post UTZ, 2D, echi, etc.) or surgeries done,
sex and weight of baby, date and time of delivery (Post C-section)
- Post - mention Ejection Fraction (EF)
4.2.1.8 Anesthesia
4.2.1.9 Post operative procedure
4.2.1.10 Blood transfusion (if any) - (Post BT 3 units packed RBC, feb
26,2022) include date
4.2.1.11 Post Code or Mayday (include number of times defibrillation
was delivered, ordered joules)
4.2.1.12 Post ICU, post intubation, post extubation and date the
patient had received anointing of the sick/extreme unction
4.2.2 Diet (write using pencils)
4.2.2.1 Specific diet ordered by the attending physician or any
changes made
- LOFI - limit oral fluid intake (8am start today- 8 am due
tomorrow)
4.2.2.2 Any food allergies
4.2.2.3 Food preferences and religious idiosyncrasies (if any)
4.2.2.4 Oral fluid intake restrictions include due time or or increase in
oral fluid intake
42.3 Priorities include :
4.2.3.1 Frequency of vital signs monitor
4.2.3.2 Neurovital signs monitoring (complete GCS)/ circulatory status
/abdominal girth/ abdominal status monitoring/ daily weight
4.2.3.3. Presence of tubings like foley catheter, NGT, AV shunt, ET,
packing & other attachment, etc. (to include the due date of dressing
and/pr change of water level, present thora level and latest thora
output)
- Attached to ET to MV with the following set up: Tidal volume
400, Back up rate 16, FIO2 40%, PEEP 5cm water, level 23,
ET size 7.5/8
- With CTT at left or right, bottle #1 original water level of 300 cc,
present thora level of, bottle # 2
- With O2 at 2L/min with remaining O2 of….

4.2.3.4 Intake and output, and hourly urine monitoring. (Include latest
urine output)

4.2.3.5 Oxygen: liters/minute and if continuous or PRN,content of the

tank.
4.2.3.6 Voiding due of post operative or post partum patients, post
removal of catheter, morphine precaution include; due date and time.
Voiding due:
● OB - 3 hours
● IN/Surgery - 6 hours
4.2.3.7 Attachment to monitoring or life sustaining equipment like
cardiac monitor, pulse oximeter (include last reading), mechanical
ventilator (include set up), etc.
4.2.3.8. CVP monitoring include (include last reading)
- Include the baseline and ano gn himo mo, “nubo kagina gin
fast drip namon….. Continue to monitor patient lang”
• Emphasize the following:
4.2.3.9 DNAR status
4.2.3.10 Schedule of PT/OT
4.2.3.11 Presence of weights/traction, molds, cast, drains, packings,
etc.
4.2.3.12 Activity and limitation
4.2.3.13 Allergies other than food
4.2.3.14 Morse Fall Scale/Humpty Dumpty Scale
 4.2.3.15.Diagnostic Test ordered
4.2.3.16 Laboratories to be done(if requested or not) and those results
that need to be followed up.
4.2.3.17 DIS (Department of Imaging Sciences) procedures like
X-rays, Ultrasound, CT Scan, Mammography, IVP, etc. (if requested or
not), if results need to be followed up
4.2.3.18 ECG
4.2.3.19 EEG
4.2.3.20 BIO-Z
4.2.4. Special Notations
4.2.4.1 Manner of admission (direct to room, ER, from OR, from
Hemodialysis, DR, etc.)
4.2.4.2 Contemplated surgeries (date and time), CP evaluation
consultant, Anesthesiologist, securing informed consent for OR or
special procedures like Tracheostomy, Thoracentesis, Paracentesis
(Include if with signed consent, with OR schedule, if okay for OR and
name of Billing personnel)
4.2.4.3 Morphine protocol-observe and refer the following:
Amy complications within 24 hours of morphine administration refer to
Anesthesiologist. If within 72 hours, refer to Surgeon
4.2.4.3.1 Respiratory rate below 12 breaths/min
4.2.4.3.2 Blood pressure below 90/60 mmHg
4.2.4.3.3 PONV (pruritus, oliguria, nausea and vomiting)
4.2.4.3.4 Urine output less than 30 cc/hr for 2 consecutive
hours or as ordered by the doctor
4.2.4.4 Referrals and consultations with remarks if seen, examined,
done or referred to Resident on Duty or Attending Physician
4.2.4.5 Orders like: prepare intubation set, folks appraised of patient’s
conditions
4.2.4.6 Schedule for diagnostic exams to be done in the Operating
Room, Delivery Room, Emergency Room requiring consent,
anesthesia and preparations needed
4.2.4.7 Removal of drains, tubings like NGT, etc.
- Foley catheter is not removed in Morphine Precautions
because urine output is being measured hourly, reduction in
urine may indicate morphine toxicity
- Flat on bed, semi fowler's position
4.2.4.8 Sutures or any packing
4.2.4.9 Schedule for Hemodialysis
- Intravenous fistula - time posted, indicated in chart and kardex,
“save right arm” means there is fistula
4.2.4.10 Reservations for blood transfusion
4.2.5 Medication
The following should be endorsed:
4.2.5.1 Any medication that are: discontinued, hold, shifted, reduced,
increased, newly ordered, and change of timing.
- Initial and end time
4.2.5.2 Diluted medicines at the ref
 4.2.5.3 Medicines with required number of doses (fractional doses)
4.2.5.4 Specific timing ordered by attending physicians
4.2.6 PRN medication
4.2.6.1 Any PRN medication given during the previous shift - include the time
of the last dose
- Endorse evaluation (for example, paracetamol - “from 38 patient’s
temperature dropped to 37)
4.2.7 Treatments
4.2.7.1 USN
4.2.7.2 Warm/Cold compress
4.2.7.3 Heat lamp treatment
4.2.7.4 Sponge bath
4.2.7.5 Topical medication
4.2.7.6 Eye, ear, nose installation/irrigation
4.2.7.7 Vaginal/rectal applications
4.3.7.8 Hot Sitz Bath
4.2.8 Stat and Single Future Orders (only single dose depending on doctor’s order)
4.2.8.1 any medication to be given at a later date/time but not to exceed 2
times
4.2.8.2 all medication and treatment ordered to be implemented immediately
only once
4.2.8.3 Orders necessary for pre-operative preparation and medication
4.2.8.4 Orders necessary for preparation of diagnostic procedures.
4.2.9 IV Fluids
4.2.9.1 Includes IVa and blood transfusions ordered in series, appropriately
numbered and checked as hooked up
4.2.9.2 Specify either pre-operative, post-operative, Piggy back, Set B or
blood unit.
4.2.9.3 Specify the need to refer for follow up or to be referred to resident on
duty or direct to attending physician
4.2.9.4 indicate if to be terminated after a specific number of IV or for Heparin
lock
- “With IVF at right neck, bottle number 1 side trip A….”
4.2.9.5 IVFs ordered in series and appropriately numbered, amount of
solution, rate, remaining solution, time due, and incorporation, if any. If
infused via infusion pump or syringe pump specify the due date of infusion
set.
4.2.10 Latest vital signs and Intake and output
4.2.11 Completeness of the Emergency Cart contents and things borrowed from the
E-cart that needs to be replaced or followed up.
4.2.12 Completeness of equipment/apparatus and functionality
4.2.12.1 BP apparatus
4.2.12.2 Stethoscope
4.2.12.3 Laryngoscope
4.2.12.4 Bag Valve Mask with connecting tube for oxygen enhancement
4.2.12.5 Suction apparatus
4.2.12.6 Drip meters/infusion pumps/plumset (should be changed every 3
days)
 4.2.12.7 Cardiac monitor
4.2.12.8 Tympanic thermometer
4.2.12.9 Portable oxygen
4.2.12.10 Keys
4.2.13 Fire Brigade Assignment

Work Instruction
Endorsing Nurse
1. Relays pertinent information related to the patient to the incoming nurse.
2. Ensures the completeness of Emergency Cart, Functionality of Apparatus, and
Equipment, and Fire Brigade Team.
Receiving Nurse
1. Receives endorsement from the outgoing shift.
2. Checks the completeness of Emergency Cart, Functionality of Apparatus, and
Equipment, and Fire Brigade Team.
Documentation
1. Kardex
2. Nurse Endorsement Notes
3. Endorsement Logbook
4. Patient’s chart
5. Medication Card

Intravenous Therapy ｡ﾟ･（>﹏<）･ﾟ｡

- Involves administering fluids via an IV catheter to administer medications,
supplement fluid intake, or give fluid replacement, electrolytes, or nutrients

IV Therapy: Peripheral Sites

● Dorsal and ventral veins - are commonly used

 ● Cephalic and Basilic - commonly prominent veins

IVT is a therapy that delivers fluids directly into a vein. The intravenous route of
administration can be used both for injections, using a syringe at higher pressures; as well
as for infusions, typically using gravity or infusion machines.

The intravenous route us the fastest way to deliver medications and fluid replacement
throughout the body, because the are introduced directly into the circulation

ISOTONIC HYPOTONIC HYPERTONIC

Equally dissolved - Less solutes and - Contains more

more of the solvent dissolved particles and is
- Causes the cell to found in the normal cells
swell due to shifting - Cells shrink
of water because it pulls water out of
the cell

0.9% Nacl 0.45% Nacl 3% NaCl

Lactated Ringer 0.33% Nacl 5% NaCl

Ringer’s solution 0.2% Nacl 3% NaCl

5% Dextrose in water 2.5% Dextrose water >5% D/W example, D10W

1) Considerations
2) Preprocedure
3) Equipment
A. Correct size of catheter
- 16 gauge for clients who have trauma, rapid fluid volume
- 18 to 20 gauge for clients who are having surgery, rapid blood administration
- 22 to 24 gauge for other clients (adults)
B. Tubing
C. Infusion pump
D. Clean gloves
E. Scissors or electric shaver for hair removal
Note: D50% Water given to hypoglycemic patient
NURSING ACTIONS
● Check the prescription (solution, rate)
● Assess for allergies to latex, tape, or iodine
● Follow the rights of medication administration (including compatibilities of all IV
solutions)
● Perform hand hygiene
● Examine the IV solution for clarity, leaks , and expiration date.
● Prime the tubing
● Don clean gloves before insertion
● Assess extremities and veins
● Clip hair at and around the insertion site with scissors or shave it with an electric
shaver
.45% NaCl - hydration status pedia; if done D5IMB
PNSS - dark green
D5W - red
D5LR - pink
D5NM - orange

CLIENT EDUCATION
● Identify the client and explain the procedure
● Place the client in a comfortable position

Indications
Fluid replacement
Medication

Complications
● Infiltration
● Air embolism
● Thrombosis
● Phlebitis
● Thrombophlebitis
● Cellulitis
● Hematoma
● Extravascular drug administration
 ● Extravasation
● Hypervolemia
● IV catheter- related bloodstream infections
● Hypersensitivity reactions
● Nerve, tendon or ligament damage
● Venous spasm

Equipment
● Non-sterile gloves
● IV cannula or IV catheter
● IV solution for continuous infusion
● Infusion plug with flush solution (NSS or heparin) for heparin lock
● Arm board or splint (optional)
● Infusion tubing
● Infusion pump machine available
● IV pole or stand
● IV insertion kit: tourniquet, surgical tape, alcohol swabs, 2x2 sterile gauze,
transparent dressing, adhesive labels

Procedure
1. Verify doctor’s orders for IV insertion. IVF infusion and administration of emergency
medications
2. Prepare necessary equipment for the procedure
3. Put on clean gloves prior to IV insertion
4. Assess the patient's vein; choose the appropriate site, location, size and condition.
Avoid an arm that has been compromised (e.g. AV fistula (may comprise the integrity
and clot that will result in infection), edematous, etc.)
5. Apply tourniquet 5-12 cm (2-6 in) above injection site depending on the condition of
the patient

Intra Procedure
Nursing Actions
● Select the vein by choosing
○ Distal veins first on the nondominant hand
○ A site that is not painful or bruised and will not interfere with activity
○ A vein that is resilient and has a soft, bouncy feeling

● Document in client's medical record

○ Date and time of insertion
○ Insertion site and appearance
○ Catheter size
○ Type of dressing
○ IV fluid and rate
○ Number, locations, and conditions of previously attempted catheterization
○ The client’s response
Inserting a peripheral IV catheter
Date and time IV

Sample Documentation:
09/30/2021, 1423, Inserted 22-gauge IV catheter into right wrist cephalic vein (one
attempt); applied sterile occlusive dressing. IV lactated Ringer’s infusing at 100mL/hr per
infusion pump without redness or edema at the site. Tolerated without complications.

L. Turner, RN

Be sure to document thoroughly and accurately throughout the clients course of IV

therapy
6. Check for radial pulse below tourniquet
7. Prepare a site with an alcohol swab according to hospital policy in circular motion.
Follow aseptic non-touch technique
8. Using an appropriate IV cannula, pierce skin with the correct technique
9. Insert catheter progressively until backflow is visualized
10. Position the IV catheter parallel to the skin. Hold the stylet stationary and slowly
advance the catheter until the hub is 1 mm to the puncture site

11. Slip sterile gauze under the hub. Release the tourniquet, remove the stylet while
applying gentle digital pressure over the catheter with one finger about 1-2 inches
from the tip of the inserted catheter.
12. Connect the infusion pump
13. Open the clamp and regulate the flow rate
14. Secure and apply the appropriate taping technique

Note
● In administering IV medications during emergency, the nurse must state out loud to
the healthcare team the IVTT medication and dose if given as well as other drip
medications if started
Example: If epinephrine every 3 minutes is ordered, the nurse states out loud the medication
and the number of doses given: “1st epinephrine given” and so on
● Take note of all medications given as to the time and dose. Do appropriate
documentation
Postprocedure
Nursing Actions: Maintain the patency of IV access
1. Do not stop a continuous infusion or allow blood to back up into the catheter for any
length of time. Clots can form at the tip of the needle or catheter and can lodge
against the vein’s wall, blocking the flow or fluid
2. Instruct clients not to manipulate flow rate device, change settings on IV pump, or lie
on the tubing
3. Make sure the IV insertion site’s dressing is not too tight
4. Flush intermittent IV catheters with the solution the facility specifies after every
medication administration or every 8-12 hr when not in use
5. Monitor the site and infusion rate at least every hour

Guidelines for safe IV insertion medication

Needlestick

Needle brand
Auto guard 22 - 20 gauge
Introcan 26 - yellow green
Vasofix g 22-20
Neoflon g 24 - violet

★ IV Catheter should last for only 72-96 hours

Why do you think indi mo anay e remove ang previous line na due to today if ma insert ka
man new line?
- In case if looking for a new vein fails, it might delay meds.

How long can IV catheters stay in place?

- 72-96 hrs

Why do you think patients have to save their right arm (no BP, IV insertion, blood extraction
etc) if the right arm has an arteriovenous fistula?
- Ma guba ang AVF if e insertan pa gd iban na IV

Nursing diagnosis of AVF:

- Disturbed body image, risk for infection, risk for bleeding

Guidelines for Safe IV Medication Administration

● Use an infusion pump to administer medications, such as potassium chloride, that
can cause serious adverse reactions. Never administer them by IV bolus. (check
patient hourly)
● Double check not only the dose of potassium the provider prescribed, but also the
correct dilution or amount of fluid.
● Add medications to a new IV fluid container, not an IV container that is already
hanging
 ● Never administer IV medication through tubing that is infusing blood, blood products,
or parenteral nutrition solutions.
● Verify the compatibility of medications with IV solutions before infusing a medication
through tubing that is infusing an IV solution

Needlestick prevention
● Be familiar with IV insertion equipment
● Do not use needles when needleless systems are available
● Use protective safety devices when available
● Dispose of needle immediately in designated puncture-resistant receptacles
● Do not break, bend, or recap needles

Advantages
● Rapid effects
● Precise amounts
● Less discomfort after initial insertion
● Constant therapeutic blood levels
● Less irritation to subcutaneous and muscle tissue

Disadvantages
● Circulatory fluid overload is possible if the infusion is large or too rapid
● Immediate absorption leaves little time to correct errors.
● IV fluid administration can irritate the lining of the vein
● Failure to maintain surgical sepsis can lead to local and systemic infection

Ways to Administer IV Medications

● Given the medication the pharmacist mixed in a large volume of fluid (500 to 100ml)
as a continuous IV infusion, such as potassium chloride and vitamins.
● Deliver the medication in premixed solution bags from the medication’s manufacturer
● Administer column-controlled infusions
● Give an IV bolus dose

Types of IV Access
1. Peripheral vein via a catheter
2. Jugular or subclavian vein via central venous access device through venipuncture
(such as a peripherally inserted central catheter, or PICC), or by surgical intervention
with implantation of access ports for long term use

Specific considerations
● Older adult clients, clients who are taking anticoagulants, and clients who have
fragile veins
○ Avoid tourniquets. Use a blood pressure cuff to help visualize, but not over
distend, the veins to help prevent hematoma formation
○ Do not slap the extremity to visualize veins
○ Instruct the client to hold his hand below the level of his heart to help distend
and thus visualize the veins
○ Avoid using the back of the client’s hand
○ Avoid rigorous friction while cleaning the site
 ● Edema in extremities
○ Apply digital pressure over the selected vein to displace edema
○ Apply pressure with an alcohol pad
○ Cannulate the vein quickly
● Obese clients
● Use anatomical landmarks to find veins

Preventing IV infections (⌐▀͡ ̯ʖ▀)︻̷┻═̿ ━一

● Use standard precautions
● Perform hand hygiene before and after handling IV systems
● Change IV sites according to facility policy (usually 72 hrs)
● Replace continuous and intermittent infusion tubing according to facility policy
(usually every 24 to 48 hrs)
● Remove catheter as soon as there is no clinical need for them
● Replace catheters when suspecting any break in surgical aseptic technique such as
during emergency insertions
● Use a sterile needle or catheter for each insertion to attempt
● Avoid writing on IV bags with pens or markers, because ink could seep through the
bag and contaminate the solution
● Replace the tubing immediately for potential or actual contamination
● Do not allow fluids to hang for more than 24 hr unless it is a closed system (pressure
bags for hemodynamic monitoring)
● Wipe all ports with alcohol or an antiseptic swab before connecting IV lunes or
inserting a syringe to prevent the introduction of microorganisms into the system
● Never disconnect tubing for convenience or to reposition the client
● Do not allow ports to remain exposed to air

Complications (●﹏●)
● Complications require notification of the provider and complete documentation. Use
new tubing and catheters for restarting IV infusions after detecting complications
● Infiltration (infiltration of a non-vesicant solution)
● Finding: Pallor, local swelling at the site, decrease skin temperature around the site,
damp dressing, slowed infusion

The difference between an infiltration and extravasation is the type of medicine or fluid that is
leaked.
● Infiltration – if the fluid is a non-vesicant (does not irritate tissue), it is called an
infiltration.
● Extravasation – if the fluid is a vesicant (a fluid that irritates tissue), it is called an
extravasation.

Treatment
● Stop infusion and remove the catheter
● Elevate the extremity
● Encourage active range of motion
● Apply a cold or warm compress depending on the type of solution that infiltrated the
tissue
 ● Check with the provider to determine whether the client still needs IV therapy. If so,
restart the infusion proximal to the site or in another extremity

Prevention ┏( ゜)ਊ゜)┛
● Carefully select the site and catheter
● Secure the catheter

1. Extravasation (infiltration of vesicant or tissue damaging medication)

Findings: Pain, burning, redness, swelling

Treatment
● Stop the infusion and notify the provider
● Follow the facility’s protocol, which may include infusing an antidote through the
catheter before removal
Prevention
● Closely monitor the IV site and dressing
● Always use an infusion pump

2. Hematoma
Findings: Ecchymosis at the site (>1cm)
Treatment
● Do not apply alcohol
● Apply pressure after IV catheter removal
● Use a warm compress and elevation after bleeding stops
Prevention
● Minimize tourniquet time
● Remove the tourniquet before starting the IV infusion
● Maintain pressure after IV catheter removal

3. Catheter embolus
Findings
● Missing catheter tip after discontinuation
● Severe pain at the site with migration, no symptoms if no migration
Treatment
● Place a tourniquet high on the extremity to limit venous flow
● Prepare for removal under x-ray or via surgery
● Save the catheter after removal to determine the cause
Prevention
● Do not reinsert the stylet needle into the catheter
4. Phlebitis/thrombophlebitis
Findings:
● Edema; throbbing, burning, or pain at the site; increased skin temperature; erythema;
a red line up the arm with a palpable band at the vein site; slowed infusion
Treatment
● Promptly discontinue the infusion and remove the catheter
● Elevate the extremity
● Apply a cold compress to minimize the flow of blood, then apply a warm compress to
increase circulation
 ● Check with the provider to determine whether the client still needs IV therapy. If so,
restart the infusion proximal to the site or in another extremity
● Obtain a specimen for culture at the site and prepare the catheter for culture if
drainage is present
Prevention
● Rotate sites at least 72hr or sooner according to facility policy
● Asses IV sites using a phlebitis scale
● Avoid the lower extremities
● Use hand hygiene
● Use surgical aseptic technique

5. Cellulitis
FInding:
● Pain, warmth, edema, induration, red streaking, fever, chills, malaise
Treatment
● Promptly discontinue the infusion and remove the catheter elevate the extremity
● Apply warm compresses three four times/day
● Obtain a specimen for culture at the site and prepare the catheter for culture if
drainage is present.
Administer
● Antibiotics
● Analgesics
● Antipyretics

Prevention
● Rotate sites at least 72hr or sooner according to facility policy
● Asses IV sites using a phlebitis scale
● Avoid the lower extremities
● Use hand hygiene
● Use surgical aseptic technique

6. Fluid overload
Findings:
● Distended neck veins, increased blood pressure, tachycardia, SOB, crackles in the
lungs, edema, additional findings varying with the IV solutions
Treatment
● Slow the IV rate or stop the infusion
● Raise the head of the bed
● Assess vital signs and oxygen saturation
● Adjust the rate after correcting fluid overload
● Anticipate administering diuretics
Prevention
● Use an infusion pump
● Monitor I&O

Inotropes and Vasopressors

 Inotropes
- Are drugs that improve the performance of heart muscle fibers, thereby improving
cardiac output. They have either an inotropic effect, altering heart contractility, or a
chronotropic effect, altering heart rate.

Vasopressors
- Are drugs that increase blood pressure through vasoconstriction

Aims and indications

- Inotropes and vasopressors are used to support or enhance blood flow and organ
perfusion in hemodynamically unstable patients
- Throughout their delivery the closure of these drugs is titrated to achieve a desired
response, through increasing and decreasing the infusion rate.

Clinical Consideration
● A tachycardia produced by the B1 effects of inotropes will increases the workload
and myocardial oxygen requirement of the heart
● In patients who have heart disease, the myocardial oxygen demands may exceed the
myocardial oxygen supply and myocardial ischemia may result.
● Alpha 1 effects cause vasoconstriction and systemic vascular resistance or afterload.
● This will improve blood pressure, but it also means the heart will have to work a lot
harder in order to eject the blood from the ventricles
● Increased heart workload means increased myocardial oxygen demands
● As dobutamin exhibits minimal alpha properties, blood pressure is only supported by
increased myocardial contractility; therefore if hypotension persists an alpha agonist
may be required.

Receptor Location Primary action(s) when stimulated

Type

A1 Found primarily in ● Vasoconstriction

vascular smooth muscle
● Activation of a1, adrenergic receptors on
arterial vascular smooth muscle cells results
in smooth muscle contraction and increase in
systemic vascular resistance
● It results in peripheral vasoconstriction

B1 Found in the heart and ● Increased contractility automatically,

intestinal smooth atrioventricular conduction and heart rate
muscle ● Stimulation of B1 adrenergic receptors
results in enhanced myocardial contractility
through calcium mediated facilitation of the
actin-myosin complex binds with Troponin C
● It also enhances chronicity through calcium
channel activation
● It results in an increase in heart rate and
contractility

B2 Bronchial vascular and ● Vasodilation and bronchial dilation

uterine smooth muscle ● Stimulation of B2 adrenergic receptors on
 (lungs) vascular smooth muscle cells through a
different intracellular mechanism results in
increased calcium uptake by the
sarcoplasmic reticulum and vasodilation
● This course bronchodilation and dilation of
coronary arteries

DA Found in the renal and ● Increased blood flow to the kidneys and
mesenteric vessels mesentery
● Stimulation of dopaminergic receptors in the
kidney and splanchnic vasculature results in
renal and mesenteric vasodilation

V1 and V2 V1 - found in vascular ● Stimulation of V1 receptors in the vascular

receptors smooth muscles smooth muscle mediates constriction
V2- found in the renal ● Stimulation of V2 receptors in the renal
collecting duct collecting duct, enhances the permeability of
the collecting duct and mediates water
reabsorption
Terminology
● Cardiac Output - the amount of blood ejected from the heart each minute
● Heart rate - the number of heart beats per minute
● Stroke volume - the amount of blood ejected from the heart with each contraction
● Contractility - the force of cardiac contraction
● Preload - The amount of stretch in the cardiac muscles prior to contraction
● Afterload - The force against which the left ventricle must contract to eject blood
from the heart
● Systemic vascular resistance - the resistance in the blood vessels of the systemic
circulation
Pathophysiology

Understanding Preload, Contractility, and afterload

● Preload - is the stretching of muscle fibers in the ventricle. This stretching results
from blood volume in the ventricle at the end-diastole. According to Starling’s law, the
more the heart muscles stretch during diastole, the more forcefully they contract
during systole. Think of preload as the balloon stretching as air is blown into it. The
more air, the greater the stretch.
● Contractility - refers to the inherent ability of the myocardium to contract normally.
Contractility is influenced by preload. The greater the stretch the more forceful the
contraction - or, the more air in the balloon, the greater the stretch, and the farther
the balloon will fly when air is allowed to expel.
● Afterload - refers to the pressure that the ventricular muscles must generate to
overcome the higher pressure in the aorta to get the blood out of the heart.
Resistance is the knot on the end of the balloon, which the ballon has to work against
to get the air out.
mcg/kg/min
- Inotropes are usually measure in micrograms (mcg or ucg*) per kilogram per minutes

Use of u is generally discouraged; “micro” or “mcg”

This formula can be expressed in various other ways, e.g.
Special Consideration
- Blood pressure and ECG can be monitored continuously (or at least every five
minutes):
- Sufficient staff are available to observe monitors
- Staff have sufficient knowledge to understand significance of observations and know
how to resolve excessive or insufficient effects
- Hypovolemia should be corrected prior the institution of vasopressor therapy
- Reduce infusion rate gradually, avoid sudden discontinuation
- Vasopressors can cause severe local tissue ischemia; central line administration is
preferred. Use the distal lumen (CVP measurement, blood specimen collection and
emergency drug administration)
- In the event of extravasation, prompt local infiltration of an antidote (phentolamine)
- Inotropes and vasopressors should never be bloused or purged
- A drip meter must be used during administration
Sedation of Neuromuscular blockade

Sedation
- Is an induced state of reduced consciousness in which verbal contact with the patient
may be maintained
- It is used to reduce anxiety and stress, and to facilitate compliance with invasive
procedures such as mechanical ventilation
- Moderate sedation, previously referred to as conscious sedation, is a form of
anesthesia that involves the IV administration of sedatives or analgesic medications
to reduce patient anxiety and control pain during diagnostic or therapeutic
procedures.

Goal of Sedation
● To allow essential procedure to be carried out, including intubation
● To minimize distress to the patient
● To aid in ventilation
● To control delirium

Who Needs Sedation?

● Patients receiving neuromuscular blocking agents
● Head injury
● Certain ventilator modes
● Refractory Status epilepticus
● Patients in prone position or kinetic bed
● Patients awaiting procedures

Pharmacology
1. Opioids (morphine, fentanyl, alfentanil, remifentanil)
➔ Used primarily for analgesia
➔ Its sedation side effect is often useful in the ICU management
➔ Morphine remains widely used, but the more expensive fentanils cause less
accumulation and fewer detrimental side effects

2. Benzodiazepines (diazepam (Valium), lorazepam (Ativan), midazola (Versed))

➔ It stimulates GABA receptors (main cerebral cortex inhibitory neurotransmitter, thus
induces sedation, anciolysis and hypnosis. It has muscle relaxant and anticonvulsant
properties. IT can cause respiratory depression and ICU delirium
➔ Midozalam - the most commonly used benzo in the ICU as it acts relatively rapidly
and has the shortest half-life
➔ Antidote is Flumazenil (Romazicon)

3. Anesthetic against (propofol (Diprivan) and ketamine)

➔ Propolol is a lipid emulsion which easily crosses the BBB, giving a rapid sedation. It
also reduces cerebral metabolism so it is useful in treating status epilepticus.
➔ Cx: propofol infusion syndrome (myopathy, rhabdomyolysis, hyperkalemia and AKI)
➔ Use dedicated line and change set every 24 hours
➔ Ketamine can cause nightmare and hallucination
 4. Alpha 2 Agonist (clonidine and dexmedetomidine (Precedex)
● Can be used in controlling both hypertension and
● Enable the patient to be comfortable and awake
● Side effect (bradycardia and hypotension)

Monitoring Sedated patients

Richmond Agitation and sedation scale
Score Description

+4 Combative: overly combative, violent, immediate danger to staff

+3 Very agitated: Pulls or removes tubes or catheters: aggressive

+2 Agitated: Frequent non purposeful movement; fights ventilator

+1 Restless: Anxious but movements not aggressive or vigorous

0 Alert and calm

-1 drowsy : Not fully alert, but has sustained awakening (eye-opening/eye

contact) to voice (greater than 10 seconds)

-2 Light sedation:Briefly awaken with eye contact to voice (less than 10

seconds)

-3 Moderate sedation: Movement or eye opening to voice (but no eye contact)

-4 Deep sedation; No response to voice, but movement or eye opening to

physical stimulation

-5 Unrousable; No response to voice or physical stimulation

Sedation Hold
- Stopping the sedation daily to enable thorough assess of the neurologic state, the
effectiveness of or need for sedation and analgesia and readiness to wean

Complications
➢ Hypotension
➢ Reduce gut motility (malabsorption, constipation), especially opioids
➢ Preventing REM sleep
➢ Amnesia
➢ Delirium and post-traumatic stress disorder
Neuromuscular Blockade
● Is the reversible impairment of neuromuscular transmission resulting in skeletal
relaxation
● Blocking release of acetylcholine (a neurotransmitter) at the neuromuscular junction
causes skeletal (but not smooth) muscle relaxation
● Paralysing agents (“muscle relaxants”) cannot cross the BBB, so have no sedative or
analgesic effects

Goals and Indications

The aim of neuromuscular blockade is to relax skeletal muscle, which may be of benefit;
● In facilitating mechanical ventilation where there is ventilator dyssynchrony or poor
compliance
● In head injury to minimize surges in refractory raise intracranial pressure
● In tetany to treat severe muscle spasms, including opisthotonos (extreme rigid spasm
of the body with the back completely arched with the heels and head bent back, seen
occasionally in meningitis)
● In prolonged status epilepticus to prevent hyperthermia and rhabdomyolysis
● In reducing oxygen requirements by reducing muscle activity
● In sedation-resistant shivering during active cooling (that is, for clinical reasons)
where the shivering is counterproductive, as it is thermogenic.

Pharmacology (suxamethonium)
● Depolarizing neuromuscular blocker (DNMBs)
○ DNMBs mimic acetylcholine, causing depolarization of the neuromuscular
junction which leads to the loss of electrical excitability
○ The effects of DNMBs cannot be reversed
○ Suxamethonium is commonly used for intubation due to its rapid onset and
short duration of action
○ Causes hyperkalemia
Non-depolarizing neuromuscular blockers (NDNMBs) (atracurium, cisatracurium,
vecuronium and rocuronium)
● They may be given as either boluses or continuous infusions in ventilated, sedated
patients
● All NDNMBs, except vecuronium and to a lesser extern cisatracurium cause
histamine release suggesting caution should be exercised if muscle relaxing an
asthmatic or atopic patient
● NNMBs can be reversed by anticholinesterase such as neostigmine only after the
majority of the drug has been metabolized or diffused away from the neuromuscular
junction
● Suganmadex, a complex-forming reversal agent, can reverse rocuronium and
vecuronium at any time, although a significantly higher dose is required if immediate
reversal is required.
● Atracurium is the most widely used paralysing agent in ICU and is relatively short
acting often about half an hour following bolus intravenous injection
Nursing interventions
● Assess the level of sedation
● Monitor vital signs
● Monitor for complications
● Bed sore precaution
● Provide oral care
● Fall precaution
● Adequate nutritional support
● Ensure Safety

ACLS (Advanced Cardiac Life Support)

Approach to the Recognition of the Cardiac Rhythm

Arrhythmia recognition
● Important in any ACLS/CPR sequence
● All algorithms start with identifying the rhythm
● Cannot identify arrhythmia
➔ cannot manage correctly

Electrocardiogram
● Valuable record of the heart’s electrical activity
● Easy to understand
Tip: just recognize …
Easy as ABC or 123
or P-QRST

ECG: Clinical Applications

● Rhythm abnormalities
● Chamber enlargement (LV, RV hypertrophy, etc.)
● Ischemia/ infarction

Anatomy and physiology of Cardiac Conduction

Sinus node - the heart's natural pacemaker

- located at the right atrium
- 60-100 BPM

AV Node
- Receives impulse from SA Node
- Delivers impulse to the His-purkinje system
- 40 -60 BPM if SA Node fails to deliver an impulse

Bundle of HIS
● Begins conduction to the Ventricles
● AV Junctional Tissue
● 40-60 BPM
The Purkinje Network
● Bundle branches
● Purkinje fibers
● Moves the impulse through the ventricles for contraction
● Provides Escape Rhythm: 20-40 BPM

P-wave - represents atrial contraction

PR segment - small delay after P wave before Q wave;
monophasic
Significance of PR interval - the time it takes to travel
from atrium to ventricle? Normal PR interval 0.12 - 0.20
3-5 boxes or less than 1 big box
QRS complex - ventricular depolarization/contraction
ST segment - plateau phase of repolarization
- Normally isoelectric
T - wave - final rapid (phase 3) ventricular repolarization
(relax ventricles) - diastole
PR interval - time it takes to
- 0.12 to 0.2 secs
Deflexion - can be positive and negative
● Positive deflexion - parts of ecg is pointing upward
● Negative deflexion - parts of ecg is pointing downward
● Isoelectric line - between positive and negative deflexion
Monophasic with positive deflexion - normal
Myocardial ischemia or poor blood supply in the heart - abnormal T wave

Biphasic, notched, broad slowly, flat - decrease blood supply

Strain pattern, ischemia - myocardial ischemia
ST-segment elevation in stemi - possible myocardial injury, 2 small square signify
pathological problem
Total occlusion of coronary artery - ST elevation
Give thrombolytics - acute ST elevation and not with ST depression

Normal Sinus Rhythm

● Pacemaker impulses are initiated in the Sa node, traveling through atrial pathways,
at frequencies between 60-100 bpm
● There is the presence of a P wave, followed by QRS complex at a regular rate

P wave
● 60 - 100 bpm
● PR interval is 0.12 - 0.20 seconds, 3-5 small boxes, 1 big box and should not be
longer
● Positive deflexion
● Same contour in same lead
 ● Upright in I,II, aVF and left precordial
● Followed by QRST

Observe long lead II for accurate ECG observation

Lead I -
Lead II - P wave - positive deflexion (going above the isoelectric line), normal interval, QRS
0.8 - 0.12 greater than 3 boxes
Lead III

T waves are inverted in aVR

Lead I, II, aVF - positive deflexion of T wave
R wave - first positive deflexion of QRS wave

Steps in ECG Interpretation

1. Regularity: beat to beat interval (R to R intervals or P to P intervals) the same
(regular (the same) or irregular) count number of boxes between p-p interval or r-r interval.
1-2 variations of small boxes is still within the normal range.

During ACLS/BLS:
Patient is hooked to Cardiac Monitor/ Defibrillator
2. Rate:
To determine rhythm
- Count the number of small boxes between 2 R waves
- Divide the number of small boxes by 1500
 Ex. 1500/ 23 small boxes = 65 bpm
- If it has p wave, qrs complex, t wave, and is 60-100 bpm - Sinus normal
rhythm

Only estimated HR, not accurate

3. Rhythm? Sinus?
4. P-QRST
5. Intervals: PR, QRS, QT
6. Rhythm abnormalities?
7. Clinical Correction

Irregular Rhythm
If 3 second strip:
➔ Rate/min = Number of complexes x 20
If 6 second strip:
➔ Rate/min = number or complexes x 10
 What is an ARRHYTHMIA?
Is a group of conditions in which the heartbeat is irregular, too fast, or too slow
The term “arrhythmia” refers to any change from the normal sequence of electrical
impulses
The electrical impulses may happen too fast, too slowly, or erratically - causing the
heart to beat too fast, too slowly, or erratically

Classification of Cardiac Rhythms

Slow Rhythms Fast Rhythms Arrest Rhythms Benign ectopic rhythms

● Sinus ● Sinus ● Asystole - No

bradycardia tachycardia ● Ventricular decompensation
● Sinus pause ● Supraventri fib caused
cular ● Pulseless ● PACs
● Escape
tachycardia VT ● PVCs
Rhythms ● Atrial ● Pulseless
- Junctional fibrillation Electrical - Miscellaneous
rhythm ● Atrial flutter activity ➔ Artificial
- Idioventricular ● Ventricular pacemaker
rhythm tachycardia rhythm
● Heart blocks

Modified Empirical Approach

Approach involves answering the following questions
1. Is the rhythm regular or irregular?
2. Is the rhythm fast or slow?
3. Are the QRS complexes wide or narrow? It is wide if it's >0.12 secs. It's
narrow if it's <0.12 secs.

Benign Rhythms:

A. Sinus Bradycardia
- Regularly occurring PQRST
- Rate < 60/min
- Sinus because impulse originated from the sinoatrial node (there is contraction in
atria)
 Signs of Decompensation:
1. Chest pain - symptomatic
2. DOB - secondary to pulmonary congestion
3. Pulmonary Congestion
4. Changes in sensorium
5. Hypotension

Management for sinus bradycardia:

● Asymptomatic Bradycardia - continue monitoring, document findings (no
management)
● Symptomatic/Unstable Bradycardia - manage symptoms
- DOC: Give Atropine sulfate 1mg every 3-5 mins (max 3 mg)
- Start intotropics if atropine sulfate is maxed out, dopamine (200mg/250 ml
D5W) is given when atropine sulfate is not effective, it consist both alpha and
beta and dose dependent
- Transcutaneous Pacer if dopamine fails (only temporary)
- Permanent pacemaker (last resort for symptomatic bradycardia)A

➢ Causes of Bradycardia: Calcium Channel Blockers, Antihypertensive drugs,

Lanoxin, Digoxin
AV block - common cause

● Sinus Bradycardia - >100 bpm

● Sinus Tachycardia - <100 bpm

B. Premature Atrial Contraction

● Prematurely occurring PQRST complex
● P wave different in configuration from the sinus beat
● PR interval often long
● QRS narrow
P wave has a different morphology

C. Premature Ventricular Contraction (PVC)

● Prematurely occurring complex
● Wide, bizarre looking QRS complex
● Usually no preceding P wave
● T wave opposite in deflection to the QRS complex
 ● Complete compensatory pause of following every premature beat to give your
ventricles time to relax
T wave - negative deflection, opposite of QRS

Premature Ventricular Contraction in Couplets

- Two Premature ventricular contractions occurring consecutively

Premature Ventricular Contraction in Bigeminy

- Alternating normal sinus beat and a PVC

Premature Ventricular Contraction in Trigeminy

- PVC’s regularly occurring every third beat

Premature Ventricular Contraction in Quadrigeminy

- PVC’s regularly occurring every fourth beat

Multifocal Premature Ventricular Contraction

● PVC’s coming from different foci in the ventricle
● PVC’s assuming different polarities in a single lead
● PVC’s of different morphology and coupling interval
D. Sinus Arrest (Sinus Pause)
● Case: if the SA Node does not fire
● Period is constant from each beat
● Do you have a P wave? None
● Do you have a QRST? None
● What is the interval between the previous beat and the next beat following the
pause?
● Sinus arrest - duration of sinus arrest is constant from each beat

Sinus pause - has a variable

period of asystole
- Period of asystole is different
form each beat (inconsistent)

AV BLOCKS
1. First Degree Atrioventricular Blocks
● Normal P wave, abnormal PR segment, Prolonged PR interval >0.20 secs (> 1 big
box or > 5 small boxes), Normal QRST
● P waves present
● QRS complexes present (regular rhythm)
● One P wave to each QRS complex
● P-R interval constant

2. Second degree AV block

Normal P wave, normal PR segment, Not normal PR interval, intermittent P
waves not followed by QRS complex (dropped beats)
 a. Type I (Mobitz type I or Wenckebach)
- Progressive prolongation of PR interval until there is dropping of QRS
complex
- Irregular rhythm
b. Type II (Mobitz type II)
- No progressive prolongation of PR interval but there is dropping of QRS complex
- Irregular rhythm

Criteria for type I Second Degree Antrio-Ventricular Block (Wenckebach)

● P waves present
● QRS complexes present
● Progressive prolongation…
● Continuously monitor patient and document findings until patient develops
decompensation
● Monitor V/S

Second Degree AV Block Mobitz I

● Permanent pacing is indicated for patients with type 1 second degree AV block with
syncope, near syncope, or bradycardia that exacerbates CHF or angina
● Continuously monitor patient and document findings until patient develops
decompensation
● Monitor V/S
● Give atropine 1mg every 3-5 mins (max 3 doses)
Second Degree AV Block Mobitz II

Criteria for Type II Second Degree Atrio-Ventricular Block (Mobitz II)

● Within period of observation, one P wave is not followed by a QRS complex
● No change in PR interval before the transient failure of atrio-ventricular conduction.
● P-R interval constant for all conducted beats
● QRS complexes after the bloc have the same morphology as those preceding it.
Often progresses to complete AV block producing syncopal attacks therefore prophylactic
ventricular or Av sequential pacing is indicated in most patients, even those who initially
present without symptoms

3rd degree Av block or Complete Heart block

● No communication between the atrium and the ventricle
● Ventricular rate is not dependent on SA nodes, ventricle fires an impulse because SA
impulse does not reach ventricles

In complete heart block

- The impulse will never reach the ventricles

Third Degree AV Block

- Complete atrioventricular block
- Impulses originate at both SA nodes and at the subsidiary pacemaker below the
block.
- Do you have regularly occurring P waves and QRS complexes? Yes
- Are the P waves related to the QRST complexes? No
- Is the atrial rate < = > ventricular rate? Greater
Regularly occurring P waves and QRs complexes, not related, the rate is greater than the
ventricular rate

Criteria for Third Degree (“Complete”) Atrioventricular Block

● No recognizable consistent or meaningful relationship between atrial and ventricular
activity
● QRS complexes often abnormal in shape, duration, and axis (occasionally normal)
● QRS morphology constant
● QRS rate constant (15-60 beats/min)
● Any form of atrial activity seen (most commonly sinus initiated)
● More P waves than QRS complex
● P waves do not communicate with QRS complex

- 3rd Degree AV Block

3rd degree AV Block or Complete Heart block

● Sinus Tachycardia - <100 bpm

★ Narrow QRS complex Tachycardia - <0.12 secs or <120 msec
★ Wide QRS complex Tachycardia - >0.12 secs or >120 msec

Sinus Tachycardia
Management:
A. No specific drug treatment.
B. Identification of cause
C. Treatment of underlying cause
D. Check hemodynamics

● Characterized by tachycardia with a narrow QRS complex

● sudden onset and termination
● 150-250 beats/min (180 to 200 bpmin adults)
● regular rhythm •QRS complex is normal in contour and duration
● No P waves
● P waves are generally buried in the QRS complex
● Often, P wave is seen just prior to or just after the end of the QRS and causes
a subtle alteration in the QRS complex that results in a pseudo-S or pseudo-r
Paroxysmal Supraventricular Tachycardia
Atrial Flutter
Atrial rate = 250-350/min( P as flutter waves)
Variable degree of AV block( irregular RR interval)

Atrial Fibrillation
- No discernible P waves
- Irregular RR interval

AF with controlled ventricular

response

AF with slow ventricular response

AF with rapid ventricular response

Nonsustained Ventricular Tachycardia

Ventricular Tachycardia
● At least 3 consecutive PVC’s
● Rapid, bizarre, wide QRS
complexes (> 0.10 sec)
● No P wave (ventricular impulse
origin)

Ventricular Fibrillation
● Associated with coarse or fine chaotic undulations of the ECG baseline
 ● No P wave
● No true QRS complexes
● Indeterminate rate

Pacemaker Rhythm
● No P wave (ventricular impulse
origin)
● Wide QRS complex (>0.10 sec)
● Pacemaker spike precede the
wide QRS complexes
Important Points
KNOW THY ACLS
Review your arrhythmias
- Too fast
- Too slow
- Correlate clinically
 - Treat the patient... not the monitor

MEGACODE

Guideline on Arrest Code Training for in Hospital Cardiac Arrest Team Approach and
Emergency Treatments

Objectives:
1. Establish confidence to initiate BLS
2. Discuss equipment and medicines used during arrest
3. Return demonstration of procedures (Emergency)

When is the best time to initiate cardiac massage?

Three criteria:
1. Unresponsiveness
2. Normal breathing or absent breathing
- agonal/gasping
3. No pulse/absence of cardiac tone
- Arrest rhythms on cardiac monitor
Things to remember:
1. Secure consent from family for attachment to mechanical ventilator
2. Secure approval from the billing department (admitting section during night shift)
before attaching the patient to the mechanical ventilator.
3. Anticipate the need for the use of sedatives and muscle relaxants for patients who
are conscious and restless.

Available at the operating room

1. Anesthetic agent
- propofol
2. Muscle relaxant
- Succinylcholine
First line:
- Diazepam (0.5 mg initial)
- Midazolam

Anticipate the need for emergency kit and cardiac monitor with defibrillator and cardioverter

Anticipate the need to ask for assistance from anesthesia resident when intubation is difficult
or id with anesthesia on board (post-op patients)
Anticipate the following procedures (post intubation):
1. Arterial Blood Gas determination - repeat am and pm
2. Chest x-ray - to determine for the correct placement of the tube, follows 1 hour post
intubation
3. Use of mechanical ventilator
4. Application of physical restraints
5. Utilization of pulse oximeter
6. NGT and foley catheter insertion (attached to cardiac monitor and pulse oximeter)
- NGT - primarily for abdominal decompression
- Secondary purpose is for nutrition and medication
- Foley Catheter - French 14 (female); French 16 (male)

Intubation
Is the process of inserting a tube, called an endotracheal tube (ET), through the mouth and
then into the airway. This is done so that a patient can be placed on a ventilator to assist with
breathing during anesthesia, sedation, or severe illness.

Candidates for intubation

- ARDS patients
- GCS 3 in below
- Arrhythmias
- Pulse VTach
- Sudden loss of consciousness

Endotracheal Intubation
Purpose
● To establish and maintain the airway in patients with respiratory insufficiency or
hypoxia
● Indicated to establish an airway for a patient who cannot be adequately ventilated
with an oropharyngeal airway, bypass an upper airway obstruction, prevent
aspiration, permit connection of the patient to the resuscitation bag o mechanical
ventilator, or facilitate the removal of tracheobronchial secretions.

Indication
1. A tube is inserted through the client’s nose or mouth into the trachea. This allows for
emergency airway management of the client
2. Nasal intubation is performed when the client has facial or oral trauma. This route is not
used if the client has a clothing problem
3. Mouth intubation is the easiest and quickest form of intubation and in the emergency
department
● Respiratory arrest
● Cardiac arrest
● Inadequate ventilation
● Trauma e.g. facial injury
● Deteriorating GCS
● Maintenance of patient airway - pulmonary toilet
● Upper airway obstruction
● Prolonged apnea
 ● Hypoxia
● Inhalation Burns

Placement
● Intubation is typically performed by a nurse anesthetist, anesthesiologist, pulmonologist.
● A chest x-ray verifies correct placement of the endotracheal (ET) tube.
● ET tubes can be cuffed or uncuffed. The cuff on the tracheal end of an ET tube is inflated
to ensure proper placement and the formation of a seal between the cuff and the tracheal
wall. This prevents air from leaking around the ET tube
● The seal ensures that an adequate amount of tidal volume is delivered by the
mechanical ventilator when attached to the external end of the ET tube.
● The client is unable to talk when the cuff is inflated.

Nursing Actions
1. Have resuscitation equipment to include a manual resuscitation bag with a face
mask at the bedside at all times
2. Ensure the intubation attempts last no longer than 30 seconds and them
reoxygenate before another attempt to intubate
3. Monitor vital signs, and check tube placement.
4. Auscultate for breath sounds bilaterally after intubation (symmetric movement)
5. Observe for symmetric chest movement
6. Stabilize the endotracheal tube with a holding device or secure with tape.
7. Monitor for hypoxemia, dysrhythmias, and aspiration

Preparing patient for endotracheal intubation

Astral150 - can prevent hypoxia during transport

Mechanical Ventilation
Provides breathing support until lung function is restored, delivering warm (body temperature
37 C (98.6 F)), 100% humidified oxygen at FiO2 levels between 21% to 100%
A positive or negative-pressure breathing device that supports ventilation and oxygenation
for a prolonged period of time

Indications
- Continuous decrease in oxygenation (PaO2) - <55 mmHg
- Increase in arterial CO2 levels - > 50 mmHg
- Persistent acidosis (decreased pH) - <7.32
- Conditions that lead to respiratory failure
- Apnea that is not readily reversible

TYPES:
1. Positive-pressure ventilators
- Inflate the lungs by exerting positive pressure on the airway, pushing air in,
similar to a bellows mechanism, and forcing the alveoli to expand during
inspiration.
2. Noninvasive positive-pressure ventilation (NIPPV)
- CPAP - continuous positive airway pressure
- BiPAP - bilevel positive airway pressure
- A method of positive-pressure ventilation that can be given via face masks
that cover the nose and mouth, nasal masks, or other oral or nasal devices
such as the nasal pillow (a small nasal cannula that seals around the nares to
maintain and prescribed pressure)
- It eliminates the need for endotracheal intubation or tracheostomy and
decreases the risk of nosocomial infections such as pneumonia.

Indication:
- Acute or chronic respiratory failure
- Acute pulmonary edema
- COPD
- Chronic heart failure
- Sleep-related breathing disorders e.g. OSA

Ventilator Modes:
- Refers to how breaths are delivered to the patient
A/C mode- Assist - control mode
- Provides full ventilator support by delivering a preset tidal volume and respiratory rate
SIMV - Synchronized Intermittent Mandatory Ventilation
Delivers a preset tidal volume and number of breaths per minute between
ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from
the ventilator on those extra breaths = because the ventilator senses patient breathing
efforts and does not initiate a breath in opposition to the patient’s efforts fighting the
ventilator is reduced

Pressure support ventilation

- Applies a pressure plateau to the airway throughout the patient triggered inspiration

Ventilator settings
● Tidal volume (6-10 ml/kg or 4-8 ml for patients with ARDS)
● Mode
● FIO2 (FIO2 = 40 - candidate is candidate for weaning)
● Rate
● PEEP if applicable
● Peak inspiratory (PPIP) - Norma - 15 - 20 cm H20)

Nursing Interventions:
2 Important General Nursing Interventions:
1. Pulmonary auscultation
2. Interpretation of ABG measurements
3. Enhance gas exchange
4. Promote effective airway clearance
5. Prevent trauma and infection
6. Promote Optimal Level of Mobility
7. Promote Optimal Communication
8. Promote Coping Ability
9. Monitor and manage potential complications

FiO2: Percentage of oxygen in the air mixture that is delivered to the patient
Flow: Speed in liters per minute at which the ventilator delivers breath

Frequency (Back Up Rate) - the number of breaths per minute that is intended to provide
eucapnic ventilation (PaCO2 at patient's normal) The initial frequency is usually set between
12 and 16/min. Frequencies of 20/min or higher are associated with auto PEEP and should
be avoided

Tidal Volume is the amount of air that moves in or out of the lungs with each respiratory
cycle. It measures around 500 mL in an average healthy adult male and approximately 400
mL in a healthy female. It is a vital clinical parameter that allows for proper ventilation to take
place

Formula for FIO2:

 ➢ New FIO2 = 0.42 x BW - 103 x FIO2 upon ABG/ PO2 on ABG

Positive pressure ventilators deliver air to the lungs under pressure throughout inspiration
and/or expiration to keep the alveoli open during inspiration and to prevent alveolar collapse
during expiration → benefits include the following:
1. Forced/ enhanced lung expansion
2. Improved Ga exchange (oxygenation)
3. Decreased work of breathing

Items to Prepare:
1. Laryngoscope with different blades
2. Endotracheal tube of different sizes
➢ 7.5 cm - most commonly used
➢ 8 cm - for foreigners
Note:
- Inflate first before using
- Size usually follows the size of the pinky finger

3. Guide wire
- Malleable
- It should not overlap with the endotracheal tube
- It should be folded at the proximal part

4. 10 cc syringe
- used to inflate endotracheal tube
- pressure should be 20-30 mmhg
5. KY Jelly
- It should be applied at the tip
6. Leukoplast
- You should know how to approximately cut the leukoplast to anchor the tube in place
7. Suction machine - it must be functional; anticipate the need for suctioning upon
intubation
8. Suction Tubing (French 12 and 14) - single use
9. Suction catheter tip
10. Suction bottles - discard content
11. Sodium chloride irrigation solution
12. Bag Valve mask with reservoir
- 1 liter = deflate 2/3
- 2 liters = deflate 1/3
13. Oxygen humidifier
14. Ventilator
Considerations Preparation of the Client
- Explain the procedure to the client
- Establish a method for the client to communicate such as yes/no questions, providing
writing materials, using a dry-erase, and/or picture communication board, or lip
reading.

ENDOTRACHEAL INTUBATION
Procedure
1. Prepare all necessary equipment. Ensure that the emergency cart is accessible.
2. Prepare the laryngoscope and blades ensuring that the batteries and bulbs are
working. Ask the physician what size or type of blade is preferred.
3. Prepare the endotracheal tube ensuring that the tip is lubricated. Insert guidewire or
stylet is preferred by the physician performing the intubation.
4. Prepare the pre-medication. Administer as ordered by the physician. Most patients
are usually given 2-3 minutes prior to induction.
5. Attach the patient to a pulse oximeter for monitoring
6. Oxygenate the patient using a bag valve mask attached to the oxygen source at 10
LPM. Manual bagging with 1 breath every 5 seconds (12 breaths per minute)
7. Suction mouth secretions as needed prior to intubation
8. Position the patient and the height of bed comfortable to the physician who will insert
the tube. Alig patient’s head on a neutral position Hyperextended the head to a
comfortable degree.
9. Assist the physician during insertion. When the tube is already in place, remove the
stylet and inflate the cuff to the desired cuff pressure using a syringe. Check the tube
and the level of in the lip line
 10. Connect the bag valve mask to the ET tube and continue to manually oxygenate
patient
11. Verify the position immediately. Auscultate both lung fields. Assess if the chest is
rising. Auscultate both lung fields. Check also the pulse oximeter to assess the
patient's oxygenation.
12. If the endotracheal tube is correctly placed, secure the tube in position using a
surgical tape. Suction ET tube secretions as needed.
13. Attach the patient to a mechanical ventilator. Check the physician’s orders for the
mechanical ventilator setting.

Ongoing Care
● Maintain a patent airway
● Assess the position and placement of tube
● Document tube placement in centimeters at the client’s teeth or lips
● Use two staff members for repositioning and to resecuring the tube
● Apply protective barriers (soft wrist restraints) according to hospital protocol to
prevent self-extubation
● Use caution when moving the client
● Suction oral and tracheal secretions to maintain tube patency
● Support ventilator tubing to prevent mucosal erosion and displacement
● Have a resuscitation bag with a face mask available at the bedside at all times in
case of ventilator malfunction or accidental extubation
● Assess respiratory status every 1-2 hr: breath sounds equal bilaterally, presence of
reduced or absent breath sounds, respiratory effort, or spontaneous breaths
● Suction the tracheal tube to clear secretions form the airway
● Monitor and document ventilator settings hourly
● Rate, FiO2, and tidal volume
● Mode of ventilation
● Use of ad
● Plateau or peak inspiratory pressure (PIP)
● Alarm setting

Monitor ventilator alarms, which signal if the client is not receiving the correct ventilation.
➢ Never turn off ventilator alarms
➢ There are three types of ventilator alarms.
○ Volume (low pressure) alarms indicate a low exhaled volume due to a
disconnection, cuff leak, and/or tube displacement
○ Pressure (high pressure) alarms indicate excess secretions, client biting the
tubing, kinks in the tubing, client coughing, pulmonary edema, bronchospasm,
or pneumothorax
○ Apnea alarms indicate that the ventilator does not detect spontaneous
respiration in a preset time period.
➢ Maintain adequate (but not excessive) volume in the cuff of the endotracheal tube
➢ Assess the cuff pressure at least every 8 hr. Maintain the cuff pressure below 20
mmHg to reduce the risk of tracheal necrosis
➢ Assess for an air leak around the ciff (client speaking, air hissing, or decreasing
SaO2). Inadequate cuff pressure can result in inadequate oxygenation and/or
accidental extubation
 ➢ Administer medications as prescribed
Analgesics: Morphine and fentanyl
Sedatives: propofol, diazepam, lorazepam, midazolam, and haloperidol

Pancuronium
- Clients receiving mechanical ventilation can require sedation or paralytic agents to
prevent competition between extrinsic and intrinsic breathing and the resulting effects
of hyperventilation
Neuromuscular blocking
Agents: pancuronium, atracurium, and vecuronium are infrequently used in the clinic setting
due to their long half-life
➢ Neuromuscular blocking agents paralyze muscles, but do not sedate or relieve pain.
The use of a sedative or analgesic agent in conjunction with a neuromuscular
blocking agent is typically prescribed.
➢ Ulcer-preventing agents: famotidine or Iansoprazole
➢ Antibiotics for established infections
➢ Reposition the oral endotracheal tube every 24 hr or according to protocol. Assess
for skin breakdown.
➢ Older adult clients have fragile skin and are more prone to skin and mucous
membrane breakdown.
➢ Older adult clients have decreased oral secretions.
➢ They require frequent, gentle skin and oral care.
➢ Provide adequate nutrition
➢ Assess gastrointestinal functioning every 8 hr
➢ Monitor bowel habits
➢ Administer enteral or parenteral feedings as prescribed
➢ Continually monitor the client during the weaning process and watch for signs of
weaning intolerance. O Respirations greater than 30/min or less than 8/min
➢ Blood pressure or heart rate changes more than 20% of baseline O SaO2 less than
90%
➢ Dysrhythmias, elevated ST segment
➢ O Significant decrease in tidal volume
➢ Labored respirations, increased use of accessory muscles, and diaphoresis
➢ Restlessness, anxiety, and decreased level of consciousness
➢ Have a manual resuscitation bag with a face mask and oxygen readily available at
the client's bedside.
➢ Have reintubation equipment at the bedside.
➢ Suction the oropharynx and trachea.
➢ Deflate the cuff on the endotracheal tube, and remove the tube during peak
inspiration.
➢ Following extubation, monitor for signs of respiratory distress or airway obstruction,
such as ineffective cough, dyspnea, and stridor.
➢ Assess SpO2 and vital signs every 5 min.
➢ Encourage coughing, deep breathing, and use of the incentive spirometer.
➢ Reposition the client to promote mobility of secretions.
➢ Older adult clients have decreased respiratory muscle strength and chest wall
compliance, which makes them more susceptible to aspiration, atelectasis, and
 pulmonary infections. Older adult clients require more frequent position changes to
promote mobility of secretions.

COMPLICATIONS
Trauma
● Barotrauma(damage to the lungs by positive pressure)can occur due to a
pneumothorax, subcutaneous emphysema or pneumomediastinum.
● Volutrauma(damage to the lungs by volume delivered from one lung to the other).
Fluid retention
● Fluid retention in clients who are receiving mechanical ventilation is due to decreased
cardiac output, activation of renin-angiotensin-aldosterone system, and/or ventilator
humidification.
● NURSING ACTIONS: Monitor intake and output, weight,breath sounds, and
endotracheal secretions.
Oxygen toxicity
● Oxygen toxicity can result from high concentrations of oxygen(typically greater than
50%), long durations of oxygen therapy (typically more than 24 to 48 hr), and/or the
client's degree of lung disease.
● NURSING ACTIONS: Monitor for fatigue, restlessness, severe dyspnea, tachycardia,
tachypnea, crackles, and cyanosis.
Hemodynamic compromise
● Mechanical ventilation has a risk of increased thoracic pressure(positive pressure),
which can result in decreased venous return.
● NURSING ACTIONS: Monitor for tachycardia, hypotension,urine output less than or
equal to 30 mL/hr, cool, clammy extremities, decreased peripheral pulses, and a
decreased level of consciousness.
Aspiration
● Keep the head of the bed elevated 30°at all times to decrease the risk of aspiration.
● NURSING ACTIONS: Check residuals every 4 hrif the client is receiving enteral
feedings to decrease the risk of aspiration.
Gastrointestinal ulceration (stress ulcer)
● Gastric ulcers can be evident in clients receiving mechanical ventilation.
● NURSING ACTIONS
● Monitor gastrointestinal drainage and stools for occult blood.
● Administer ulcer prevention medications (sucralfate and histamine 2 blockers).

C. Preparing Patient for Cardioversion or Defibrillation

Always ensure a patent IV lines during intubation for sedation

Defibrillation
Usually indicated to patients with ventricular fibrillation and pulseless ventricular tachycardia
Shock is delivered 360 joules

Purpose:
● To eradicate life-threatening ventricular fibrillation or pulseless ventricular tachycardia
● To restore cardiac output lost due to dysrhythmias and reestablish tissue perfusion
and oxygenation.
Indications
● Ventricular fibrillation
● Pulseless ventricular tachycardia

When not to defibrillate?

● Non-shockable rhythms
● Asystole
● Pulseless electrical activity
● Perfusing rhythms

TRUE TO BOTH CARDIOVERSION AND DEFIBRILLATION:

1. Always apply 20 lbs weight on the paddles when shocking
2. Site: apex and sternum
3. Apply gel prior to shock - reapply after 3 shocks
4. Ensure no one is in contact with the patient before delivering a shock
5. Take away oxygen source away from the patient
6. Always set the cardiac monitor on LEAD II

Anticoagulants must be started before cardioversion in AF patients to prevent emboli.

Do not remove paddles immediately as the monitor is still looking and verifying R waves.
Always push the SYNCH button before cardioverting.

ITEMS TO PREPARE
1. Cardiac monitor with defibrillator and cardioverter
Types:
- Lifepack
- Medtronic
- Physio Control
- Mind ray

Defibrillation
● Is the definitive treatment for cardiac dysrhythmias, ventricular fibrillation and
pulseless ventricular tachycardia. This is undertaken together with Advanced Cardiac
Life Support (ACLS) procedures.
● It uses an electrical shock to reset the electrical state of the heart so that it may beat
to a rhythm controlled by its own natural pacemaker cells
● Is achieved by delivering a strong electric current through electrodes placed on the
surface of a patient’s chest wall
● Proper electrode placement ensures that the axis of the heart is directly situated
between the sources of current (defibrillator paddles)

Complications
● Patient injury: Burns
○ Arcing between electrodes may occur if pads are incorrectly placed
○ Foreign bodies (including cardiac leads) between the pads and the patient
○ Pads with insufficient or degraded conducting agent
● Transmitted shock to the operator or bystanders
Equipment
● Defibrillator
● Conducting gel
● Conductive medium-defibrillator pads
● Cardiac monitor with recorder
● Emergency cart and medications
● Electrode gel
● Electrodes
● Sedative-hypnotic - for conscious patients

Defibrillation
Procedure

4. Dopamine
- Stock: can be single 200mg/

5. Dobutamine
- To improve myocardial contractility as a vasopressor
- Better to have a central line, peripheral lines are more prone to extravasation
- Know how to compute
- Singles dose

6. Amiodarone (Cordarone/RHYTHMIA)
- Given when the patient is attached to the cardiac monitor
- Antiarrhythmic class 2
- Ensure a separate line if necessary
- Give 300 mg IV for pulseless
- HAM, give only when verified

7. Lidocaine
8. Norepinephrine

mcg/kg/min = (mcg/ml x cc/hr)/ bodyweight x 60

Sample
A patient ordered to start an IV Dopamine drip at 5mcg/kg/min
The patient weighs 180 lbs. You have a bag of Dopamine that reads 400 mg/250 ml
What will you set the iv pump rate at ml/hour
Sample 2
A patient is ordered to start

Weight = 55kg
Dose = 10mcg/kg/min
Available = 800mg/500ml

Solution:
55kg x 10 mcg/min x 1mg x 500 ml = 275000 = 0.34375mcg/min
Kg 1000mcg 800mg 800000

cc/hr: 60mins x 0.34375 ml = 20.625 → 20.6 cch/hr

1 hr min
The Intensive care unit
A culture of safety is not a casual or inevitable outcome for an Intensive Care Unit, but rather
it requires focused and constant attention and directed efforts. To improve safety and quality,
three areas should be focused:
Creating a culture of safety
Reducing complexity
Establishing independent redundancies for key processes

More specifically, successful ICUs share three main feature. As described below, the
features of successful ICUs involve the following:
Using a systems approach
Creating a specific environment
Basing changes on scientific evidence

Using a system approach

● Successful ICUs modify the conditions that contribute to errors. A system is a set of
interdependent elements interacting to achieve a common aim. The elements may be
both human and non-human (equipment, technologies, etc.).

According to the Institute for Healthcare Improvement, such a system includes:

A leadership system that assures organized systematic care
An ICU care team and executive leadership that assures continuous improvement
Efficient and timely delivery of services within a system of care
Shared decision making between the family and staff
A skilled, coordinated and collaborative care team.

Creating a specific environment

Successful ICUs work to establish work environments that embody specific characterics.

The ICU characteristics create an environment that:

Is patient focused
Is trusting and open
Is comfortable, compassionate, and caring
Has strong leadership Has everyone in the team involved in rapid cycle improvements
Has excellent communication skills
Has a scientific process of improvement

Basing changes on scientific evidence

The impetus to make changes i staff related structures and processes of care are based on
the literature

General Guidelines
● All medical personnel (including but not limited to Doctors, Nurses, Attendants, and
Auxillaries) re advised to wear appropriate personal protective equipment especially
gowns upont entry
● Practice Universal Precautions: Treat all blood and other potentially infectious body
fluids as if they are infected and take appropriate to avoid contact with these
materials
 ● To reduce the risk of infection, food is not allow anywhere with the area of the
workplace
● All ICu staff are required to wear appropriate gowns when carrying out chores
outside o the unit (e.g. patient transfers, sending specimens to the lab, etc.)
● Student Nurses are not allowed to loiter and stay in the linen room
● ICu staff nurses are required to wear the prescribed uniform only duty period. As per
infection control protocol, they are required to wear civilian attire before duty.

Nursing Care
Fundamentals of Standard Precautions
Handwashing
Gloves
Patient Placement
Limiting the movement of patients
Masks and goggles or face shields
Air filters
Gowns
Care of equipment

Transmission Based Precautions Techniques

Airborne Precautions
Droplet Pracatuions Contact Precautions

Endorsement/End of Shift Report

The importance of a good shift report cannot be underestmiated. Withoud good
communication from the previous shift, we lack the knowledge to fully assess and care for
our patients, which in turn can makes us feel anxious, disorganzed, and notwithstanding our
patients may recieve substandard care

The 4 Ps
These are the four core essentials that need to be exchanged form the outgoing staff to the
incoming staff at every shift change.

Purpose
What is the purpose? Why is the patient here?

Picture
Picture is the picture of success. What results is he looking for short term and long term?

Plan
What’s the plan?

Part
What part does each shift play?

Patient Rounds
“A patient’s perception of the quality of nursing care largely depends on the nurse’s ability to
meet the patient’s needs.”
Greetings
ICU staff are expected to be courteous and polite in their encounter with the patients and the
family

Assessment
Assessment is the first stage of the nursing process in which the nurse should carry out a
complete and holistic assessment of every patient’s needs, regardless of the reason for the
encounter. Usually, an assessment framework, based on a nursing model is used.
The purpose of assessment is to identify the patient’s nursing problems. These problems are
expressed as either actual or potential. For example, a patient who has been redered
immobile by raod traffic accident may be assessed as having the “potential for impaired skin
integrity related to immobility”

Early shift report

Early shift report is presenting the assessment done to the patient and family members in
the layman’s language. It is done during the preliminary nurse’s rounds/ Only findings that
are definite and essential should be communicated.

Medication
Medication Rights
Right patient
Right drug
Right dosage
Right timing
Right route of administration
Right documentation
right assessment
right evaluation
Right education
Right to refuse

Medication preparation/ Disposal

Always maintain aseptic technique at all times when preparing the medication. Dispose drug
packs in appropriate containers-leaving the pacts at the patient’s bedside is an unacceptable
behavior

Bedside Care
Vital sign Taking
Vital signs are measurements of the body’s most basic functions. The four main vital signs
routinely monitored by medical professionals and healthcare providers include:
Body temperature
Pulse rate
Respiration rate
Blood pressure
Vital signs are useful in detecting or monitoring medical problems. Frequency of vital signs
taking is as follows:
BP, CR, RR - EVEry HOUR
TEMP - EVERY 4 HOURS WHEN AFEBRILE EVERY HOUR WHEN FEBRILE
CVP - AS PRESCRIBED BY THE PHYSICIAN
NEURO VITAL SIGNS - EVERY HOUR

Turning
Patients, both mobile and immobile, are to be turned by ICU staff EVERY 2 HOURS. Some
situations may make changes in position difficult but are not acceptable reasons to prevent
turning.
Turning sequence is as follows:
LEFT-CENTER-RIGHT-CENTER…

Suctioning through an endotracheal or tracheostomy tube

● Ineffective cough may cause secretion collection in the artificial airway or
tracheobronchial tree, resulting in narrowing of the airway, respiratory insufficiency,
and stasis of secretions
● Assess the need for suctioning at least every 2 hours through auscultation of the
chest
● Maintain sterile technique while suctioning
● Administer supplemental 100% oxygen through the mechanical ventilator or manual
resuscitation bag before, after, and between suctioning passess to prevent
hypoxemia.
● Limit suction time to no more than 10 seconds. Discontinue if heart rate decreases by
20 beats per minute or increases by 40 beats per minute, if cardiac ectopy is
observed or if SaO2 < 90%
● Suction Tip Catheters should only be used ONCE, Dispose properly after each use
● Dry suction bottles should be replaced on due date (every 3 days)
● Suction Machine Bottle should be cleaned with disinfectant solution at the end of
every shit and PRN

Care of the patient with an endotracheal tube

Immediately after intubation
● Check symmetry of chest expansion
● Ensure high humidity; a visible mist should appear in the T-piece or ventilator tubing
● Administer O2 concentration as prescribed by the physician
● Secure the tube to the patient’s face with tape, and take note at what level the tube is
inserted.
Use sterile technique and airway care to prevent iatrogenic contamination and infection
Continue to reposition patient every 2 hours and as needed to prevent atelectasis and to
optimize lung expansion
Provide oral hygiene and suction the oropharynx before feeding and prn

Extubation
Explain Procedure
Have Bag-mask and intubation set ready in case ventilator assistance is required
immediately after extubation
Suction the tracheobronchial tree and oropharynx, remove tape, and ten defCare ate the cuff
Give oxygen for a few breaths, and then insert a new, sterile suction catheter inside tube
Have the patient inhale. At peak inspiration remove the tube, suctioning the airway through
the tube is pulled out.
Care of patient following extubation
● Give oxygen by face mask with the prescribed 02 concentration
● Monitor respiratory rate and the quality of chest excursions. Note stridor, color
change, and change in mental alertness or behavior.
● Monitor the patient's oxygen saturation through the pulse oximeter
● Keep NPO or give only ice chips for the next hour
● Provide mouth care
● Teach patients how to perform coughing and deep breathing exercises.

Care of the patient with a tracheostomy tube

Tracheostomy Care

● Tracheostomy care is done every 6 hours (3-9-3-9)

● Gather the needed equipment, including gloves, hydrogen peroxide, betadine
solution, normal saline solution or sterile water, cotton tipped applications, dressing
and twill tape(PRN).
● Provide patient and family instruction on the key points for tracheostomy care.
● Perform hand hygiene.
● Explain procedure to the patient and family as appropriate.
● Prepare supplies,including hydrogen peroxide,betadine, normal saline solution or
sterile water, cotton tipped-applicators, sterile gauze, twill tape (PRN), and the
temporary colored inner cannula.
● Hyperventilate the patient and put on gloves.
● Remove white inner cannula carefully and replace with temporary colored cannula.
Soak white cannula with Hydrogen Peroxide solution and cleanse thoroughly with
NSS or sterile water. Replace white inner cannula into tracheostomy.
● Remove and discard the soiled dressing in biohazard container
● Cleanse the wound with betadine solution. Remove and replace twill tape if soiled.

Performing tracheal suction

● Explain procedure to the patient before beginning and offer reassurance during
suctioning; the patient may be apprehensive about choking and about an ability to
communicate
● Perform hand hygiene
● Hyperventilate patient
● Insert suction catheter at least as far the end of the tube without applying suction, just
far enough to stimulate the cough reflex
● Apply intermittent suction while withdrawing and gently rotating the catheter 360’ (noi
longer than 10 seconds, because hypoxia and dysrthythmias may develop, leading to
cardiac arrest)
● Hyperventilate patient
● Repeat previous three steps until the airway is clear
● Suction oropharyngeal cavity after completing tracheal suctioning
Bed Bath
● Done every PM shift.
● If bath is refused due to gender issues (e.g. female patient refuses male nurse to
give bath), male staff should switch patient bath assignment with Female Staff.

Patients requesting bed bath during the AM shift should always be accommodated (even if
patient was bathed during thr previous PM shift). If for staff nurse could not in any means
grant the request, the Accounts supervisor will take charge. ICU staff nurse should use the
following checklist to evaluate completeness of care (PM shift)
● Patient is haved
● ET tape is replaced (If with ET TUBE)
● IV site is newly dressed and newly taped

Feeding
Appropriate and timely delivery of nutrition is essential for fast recovery. There are two
prerequisites before feeding regardless of the frequency:
Patient is suctioned (tracheally, endotracheally, and /or orall)
Oral Care

Doctor’s Rounds
As the bedside care provider, nurse’s interaction during doctor’s rounds is not only essential
for increased care coordination but is vital for the patient’s safety and well being.

Charts
Patients chart holders are scrubbed with disinfectant solution every after trans-out or
discharge.

Special Engagements
Special engagements are patient activities that require a multidisciplinary approach.
Guidelines have been established to ensure quality care and patient safety

Admission/Trans-in
After patient has been received, properly placed in a comfortable position, and necessary
interventions have been given, ORIENTATION regarding the ICU guidelines and protocols
should be given.
During transport
● ICU staff should bring the following:
○ Emergency Kit
○ Syringes
○ Patients chart
○ Smock gown

Post transport
Patient comfort and safety prior to endorsement is the ICU staff’s main priority
For Trans outs, terminal cleaning is strictly observed

CODE MANAGEMENT

“Treat the patient, not the monitor.”

Code management is the organization and direction of resuscitation. Many things seem to
be happening all at once. For the resuscitation to be effective there must be a systematic
approcah to the delivery of care.

Roles
In Charge Nurse
● Is the main reference concerning the patient’s status
● Should disseminate tasks
● Should stay at the patient’s bedside at all times

Staff Nurse
All ICU staff nurses can perform these functions:
Managing the airway (e.g. ambubagging)
Performing chest compressions
Giving medications
Handling the monitor, E-cart and defibrillator
Documenting the events that occurred
Referring and coordinating patient care with staffs from various fields
Support for the family and control the number of people observing the resuscitation

Emergency cart/Kit

● All ICU shifts are obliged to inform the E-cart assigned ICU staff (EAIS) when using
supplies from the E-cart.
● EAIS should check completeness of stocks AFTER THE SHIFT
● EAIS is not allowed to leave the nif if used E cart stocks are not replaced.
● EAIS will be held responsible for lacking stocks during his shift. Receiving EAIS
should not tolerate endorsement of stock replacements.
 ● ICU head nurse should check expiry dates of all medical supplies in the Ecart every
Tuesday of the week. Near expiry stocks will be labeled.
● Labeled medical supplies should be USED FIRST.
● All E kits should be sealed every after shift. ICU staff used supplies from the E-kit is
responsible for its replacement and sealing. E-kit user will be held responsible for
unreplaced and unsealed kits.

Physical Management
“Cleanliness and orderliness should be observed at all times”

Station
Food is not allowed at the station
All station desks should be cleaned every PM shift

Washing Area
All medications should be never left unattended
Mortar and Pestle should be cleaned immediately after use
No medicine cups, feeding glass, and asyringes should be left in the area-it should be
returned properly at the patient’s bedside table.

Medication Area
● Maintain aseptic technique at all times
● It is the outgoing ICU staff’s responsibility to have meds available for the next shift in
patients who have closed accounts
● Area should be clean and orderly at all times
● No used syringes should be found in the area with exception of 50cc syringes used
for mannitol. Mannitol syringes should be changed every 3 days and properly labeled
with due dates

Patients Room
Due to the limited space, folding beds are not allowed

SUCTION TABLE
This table should only hold the following items:
● Suction machine
● PNSS for irrigation/sterile water
● Dry suction bottle
● Suction catheter tip
Since suctioning is a STERILE procedure, connecting tube tips should be covered with
sterile cover and properly looped and anchored.

Bedside Table
This table holds the following items:
Gloves
Medicine cups and syringes
Feeding glass and syringe
Personal Hygienic Necessities (e.g. tissue, lotion, etc.)
Alcohol
Oral Care Essentials (.eg. mouthwash, kidney basin, etc.)
Dressing Materials (e.g. gauze, cottonballs, etc.)

IV MANAGEMENT

Insertion
● Strict aseptic technique should be observed

Line management
● IV sites and IV tubings are to be changed every 3 days during the PM shift and have
due date labels
● Be dressed and tapes
● Peripheral IV sites should be changed during the PM shift preferably after bed bath
● Central lines(e.g. Subclavian, femoral, and intrajugular catheters, IV cutdowns)
should be dressed every other day during the AM shift and Have due date labels.
● All Iv bottles should be labeled and calibrated appropriately
● Iv line needles should be recapped properly. Recapping of needles into the Y-port is
not allowed

Central Lines should be flushed every shift (6am-6pm).

Steps are as follows:
● After prot scrubbing, withdraw 5 cc and discard
● Give/instill medication or IV solution
● Flush with 10cc PNSS
● Give Pure Heparin (1:5000 IU) 1.5cc bolus for large bore catheters (e.g. Mahurkar)
and 1cc for small bore catheters (e.g. Certofix).
● Recap aseptically.

Port Scrubbing
● Scrubbing the ports (e.g. Y-port, central line ports, etc.) with alcohol swabs for atleast
10 seconds before giving meds.

Apparatus Management
All apparatus should be disinfected with umonium solution after use by accounts supervisor

Defibrillators
All defibrillators should be charged after use.

Bedside Monitor
● Use of digital BP apparatus is encouraged; but ICU staff is required to take BP
manually using sphygmomanometer as baseline
 ● Change chest leads every 3 days during PM shift preferably after bed bath and PRN.
Due date labels are to be placed on Left Lower lead
● All BP cuffs on Beds 1-4 will be washed every Monday, Beds 5-8 every Wednesdays,
and on ICU extension every Friday by Account supervisor
Infusion pumps
● Due to the inevitable turn of events in the ICU, all infusion pumps should stay within
the unit. Borrowing of other stations is not allowed.

Syringe Pumps
● Borrowing of syringe pumps should be properly documented
● Returned syringe pumps should be disinfected with umonium solution by Accounts
Supervisors

Suction machines
● Suction bottles should be washed every after shift or when it is two thirds (⅔) full-
whichever comes first and PRN
● All suction machines should be disinfected with umonium solution upon patients
discharge or trans out from the unit.

Garbage Disposal
● All sharps should be properly disposed in puncture free sharps container
● No syringes and medication packages should be found inside the patient’s room
● Waste basket plastics in the unit are colored Yellow- which indicates that wastes
contained are highly infections
● Two waste containers are found in the utility room:
Green-non-infectious wastes
Red-infectious wastes

WORK ETHICS

Professionalism
● Three major roles = comprehensive care
● Furthermore, these roles are designed to meet the immediate and future health care
and nursing needs of consumers who are the recipients of nursing care

Practitioner Role
● Involves actions that the nurse takes when assuming responsibility for meeting the
health care and nursing needs of the individual patients, their families, and significant
others.
● This is a role that can only be achieved through use of the nursing process, the basis
for all nursing practice.
● The ICU staffs help patients meet their needs through direct intervention, by teaching
patients and family members to perform carem and by coordinating and collaborating
with other disciplines to provide needed services

Leadership Role
● This role is inherent in ALL nursing positions
 ● Basic to the entire process is effective communication, which determines the
accomplishment of the process
● A manager does things right, a leader does the right thing

Research role
● Is a responsibility of all nurses including those in clinical practice.
● Two ways;
○ Contribute to research
○ Apply research in current practice

On calls
● On call schedule should be reported by the ICU staff when needed
● An explanation via an incident report will be required for non compliance

Synergy
“The name in your uniform is more important than the name in your ID.”

The collaborative model is the primary goal of ICU nursing - a venture that promotes shared
participation, responsibility, and accountability in a health care environment that is striving to
meet the complex health care needs of the public.

Work Relationships
● Private Duty Nurse (PDN)
● All PDNs are considered watchers. They are not exempted from the One Watcher
visiting policing.
● All PDNs are not allowed to scan patient’s charts
● PDNs are required to use the Watcher’s Gown provided in each room.

Volunteer Nurses (VN)

● VNs are considered nurse trainees of the ICU staff.
● ICU staffs are solely liable and accountable for VN’s actions

Student Nurses (SNs) and Clinical Instructors (CIs)

 ● SNs and CIs are considered part of the working team

Account Supervisor
Charges
● All procedures (e.g. Central Catheter insertion, intubation, extubation, etc.) and
special services (e.g. JMS drip meters, Defibrillators, etc.), and stocks should be
charged COMPLETELY and accordingly.

Other Responsibilities:
● Preparation of feeding
● Aftercare of all procedures
● Disinfection of equipments (e.g. Monitor and monitor cables, infusion pumps, BP
apparatus, Suction Machines, etc.) upon patient discharge/trans-out
● All BP cuffs on Beds 1-4 will be washed every Monday,Beds 5-8 every Wednesday,
and on ICU Extension every Friday.
● Returned syringe pumps should be disinfected with umonium
● Distribution and replacement of Watcher’s Growns, mask, and cap ath the end PM
shift.
● All stocks should be complete and accounted for
● Updating of patient’s diet list
● Log refrigerator’s temperature at start of shift

What is a Bundle?
A grouping of best practices that individually improve care, but when applied together result
in substantially greater improvement
Science behind the bundle elements is well established - the standard care
Bundle element compliance can be measured as “yes/no”
“All or non” approach

Institute for healthcare improvement (IHI) recommendations

Implement the Ventilator Bundle
● By definition, ventilator-associated pneumonia (VAP) is an airways infection that must
have developed more than 48 hours after the patient was intubated.
Preventing pneumonia of any variety seems at first blush to be a laudable goal
However, there are some reasons to particularly concerned about the impact of
pneumonia associated with ventilator use
● VAP is the leading cause of death amongst hospital acquired infections, severe
sepsis, and respiratory tract infections in the non-intubated patient. Perhaps the most
concerning aspect of VAP is the high associated mortality. Hospital mortality of
ventilated patients who develop VAP is 46% compared to 32% for ventilated patients
who do not develop VAP
● In addition, VAP prolongs time spent on the ventilator, length of ICU stay, and length
of hospital stay after discharge from the ICU. Strikingly, VAP adds an estimated cost
of $40,000 to a typical hospital admission.
 ● Reducing mortality due to ventilator associated pneumonia requires an organized
process that guarantees early recognition of pneumonia and consistent application of
the best evidence based practices,
● The ventilator bundle is a series of interventions related to ventilator care that when
implemented together, will achieve significantly better outcomes than when
implemented individually.

The key components of the ventilator bundle are:

● Elevation of the head of the bed
● Daily “sedation vacations” and assessment of readiness to extubate
● Peptic ulcer disease prophylaxis
● Deep venous thrombosis prophylaxis

Elevation of the head of the bed

● Elevation of the head of the bed is an integral part of the ventilator bundle and has
been correlated with reduction in the rate of ventilator associated pneumonia. The
recommended elevation is 30 to 45 degrees
● Drakulovic et al. conducted a randomized controlled trial in 86 mechanically
ventilated patients assigned to semi-recumbent or supine body position. The trial
demonstrated that suspected cases of ventilator-associated pneumonia had an
incidence of 34 percent while in the semi-recumbent position suspected cases had
an incidence of 8 percent (p=0.003). Similarly, confirmed cases were 23 percent and
5 percent respectively (p=0.018).
● While it is not immediately clear whether the intervention aids in the prevention of
ventilator-associated pneumonia by decreasing the risk of aspiration of
gastrointestinal contents or oropharyngeal and nasopharyngeal secretions, this was
the ostensible reason for the initial recommendation.
● Another reason that the intervention was suggested was to improve patients’
ventilation. For example, patients in the supine position will have lower spontaneous
tidal volumes on pressure support ventilation that those seated in an upright position.
Although patients may be on mandatory modes of ventilation, the improvement in
position may aid ventilatory efforts and minimize atelectasis.
● Some concerns with regard to this position have included patients sliding down in
bed and, if skin integrity is compromised, shearing of skin. Others have commented
on the possibility of patient discomfort. Although it is difficult to assess these
concerns in a controlled manner, anecdotal experience is that neither care providers
nor patients (when off the ventilator and able to speak) have had this complaint.
Tips
● Implement a mechanism to ensure head-of-the-bed elevation, such as
including this intervention on nursing flow sheets and as a topic at
multidisciplinary round
● Create an environment where respiratory therapists work collaboratively with
nursing to maintain head-of-the-bed elevation.
● Involve families in the process by educating them about the importance of
head-of-the-bed elevation and encourage them to notify clinical personnel
when the bed does not appear to be in the proper position.
 ● Use visual cues so it is easy to identify when the bed is in the proper position,
such as a line on the wall that can only be seen if the bed is below a
30-degree angle.
● Include this intervention on order sets for initiation and weaning of mechanical
ventilation, delivery of tube feedings, and provision of oral care.
● Post compliance with the intervention in a prominent place in your ICU to
encourage change and motivate staff.

2. Daily "Sedation Vacations" and Assessment of Readiness to Extubate

● Using daily "sedation vacations" and assessing the patient’s readiness to extubate is
an integral part of the Ventilator Bundle and has been correlated with reduction in the
rate of ventilator-acquired pneumonia.
● Kress et al. conducted a randomized controlled trial in 128 adult patients on
mechanical ventilation, randomized to daily interruption of sedation irrespective of
clinical state or interruption at the clinician’s discretion. Daily interruption resulted in a
marked and highly significant reduction in time on mechanical ventilation. The
duration of mechanical ventilation decreased from 7.3 days to 4.9 days (p=0.004).
● It appears that lightening sedation decreases the amount of time spent on
mechanical ventilation and therefore the risk of ventilator-acquired pneumonia. In
addition, weaning patients from ventilators becomes easier when patients are able to
assist themselves at extubation with coughing and control of secretions.
● Sedation vacations are not without risks, however. Patients who are not sedated as
deeply will have an increased potential for self-extubation. Therefore, the maneuver
must be conducted in a careful fashion. In addition, there may be an increased
potential for pain and anxiety associated with lightening sedation. Lastly, increased
tone and poor synchrony with the ventilator during the maneuver may risk episodes
of desaturation.
Tips
● Implement a protocol to lighten sedation daily at an appropriate time to
assess for neurological readiness to extubate. Include precautions to prevent
self-extubation such as increased monitoring and vigilance during the trial.
● Include a sedation vacation strategy in your overall plan to wean the patient
from the ventilator; if you have a weaning protocol, add "sedation vacation" to
that strategy.
● Assess that compliance is occurring each day on multidisciplinary rounds.
● Consider implementation of a sedation scale such as the Riker scale to avoid
oversedation.
● Post compliance with the intervention in a prominent place in your ICU to
encourage change and motivate staff.

3. Peptic Ulcer Disease Prophylaxis

● Applying peptic ulcer disease prophylaxis is an appropriate intervention in all patients
who are sedentary, however the higher incidence of stress ulceration in critical illness
justifies greater vigilance. In addition, decreasing the pH of gastric contents may
protect against a greater pulmonary inflammatory response to aspiration of
gastrointestinal contents.
● Aspiration causes either pneumonitis or pneumonia and can be prevented. The
effects of aspirating acidic contents may be less severe than those with a higher pH.
 Although some studies have shown increased risks of VAP with certain agents, such
a sucralfate, others have not shown this association. In addition, the extent to which
reflux of gastric contents and secretions occurs even in healthy individuals suggests
that these critically-ill patients are susceptible to aspiration events. Critically-ill
intubated patients lack the ability to defend their airway.
● The Surviving Sepsis Campaign Guidelines were produced after a thorough review of
the literature including peptic ulcer disease prophylaxis. They conclude, “H2 receptor
inhibitors are more efficacious than sucralfate and are the preferred agents. Proton
pump inhibitors have not been assessed in a direct comparison with H2 receptor
antagonists and, therefore, their relative efficacy is unknown. They do demonstrate
equivalency in the ability to increase gastric pH.”
● While it is unclear if there is any association with decreasing rates of ventilator
acquired pneumonia, our experience is that when applied as a package of
interventions for ventilator care, the rate of pneumonia decreases precipitously. The
intervention remains excellent practice in the general care of ventilated patients.
Tips
● Include peptic ulcer disease prophylaxis as part of your ICU order admission
set and ventilator order set. Make application of prophylaxis the default value
on the form.
● Include peptic ulcer disease prophylaxis as an item for discussion on daily
multidisciplinary rounds.
● Empower pharmacy to review orders for patients in the ICU to ensure that
some form of peptic ulcer disease prophylaxis is in place at all times on ICU
patients.
● Post compliance with the intervention in a prominent place in your ICU to
encourage change and motivate staff.

Deep Venous Thrombosis Prophylaxis

● Applying deep venous thrombosis prophylaxis is an appropriate intervention in all
patients who are sedentary, however the higher incidence of deep venous
thrombosis in critical illness justifies greater vigilance.
● The risk of venous thromboembolism is reduced if prophylaxis is consistently applied.
A clinical practice guideline issued as part of the Seventh American College of Chest
Physicians Conference on Antithrombotic and Thrombolytic Therapy recommends
prophylaxis for patients undergoing surgery, trauma patients, acutely ill medical
patients, and patients admitted to the intensive care unit. The level of cited evidence
was that of several randomized control trials.
● While it is unclear if there is any association with decreasing rates of ventilator
acquired pneumonia, our experience is that when applied as a package of
interventions for ventilator care, the rate of pneumonia decreases precipitously. The
intervention remains excellent practice in the general care of ventilated patients.
● Important considerations include that the risk of bleeding may increase if
anticoagulants are used to accomplish prophylaxis. Oftentimes, sequential
compression devices (a.k.a. ‘venodynes,’ or ‘pneumoboots’) are not applied to
patients when they go to or return from procedures.
Tips
 ● Include deep venous prophylaxis as part of your ICU order admission set and
ventilator order set. Make application of prophylaxis the default value on the
form.
● Include deep venous prophylaxis as an item for discussion on daily
multidisciplinary rounds.
● Empower pharmacy to review orders for patients in the ICU to ensure that
some form of deep venous prophylaxis is in place at all times on ICU patients.
● Post compliance with the intervention in a prominent place in your ICU to
encourage change and motivate staff.

Implement the Central Line Bundle

● Central venous catheters (CVCs) are being increasingly used in the inpatient and
outpatient settings to provide long-term venous access. CVCs disrupt the integrity of
the skin, making infection with bacteria and/or fungi possible. Infection may spread
to the bloodstream (bacteremia) and hemodynamic changes and organ dysfunction
(severe sepsis) may ensue, possibly leading to death. Approximately 90 percent of
the catheter-related bloodstream infections (BSIs) occur with CVCs.
● 48% of ICU patients have central venous catheters, accounting for 15 million central
venous catheter-days per year in ICUs. Studies of catheter-related bloodstream
infections that control for the underlying severity of illness suggest that attributable
mortality for these infections is between 4 and 20 percent. Thus, it is estimated that
between 500 and 4,000 US patients die annually due to bloodstream infections.
● In addition, nosocomial bloodstream infections prolong hospitalization by a mean
of 7 days. Estimates of attributable cost per bloodstream infection are estimated to
be between $3,700 to $29,000 (Php185,000 – 1,450,000).
● Care bundles, in general, are groupings of best practices with respect to a disease
process that individually improve care, but when applied together result in
substantially greater improvement. The science supporting the bundle components
is sufficiently established to be considered standard of care.
● The Central Line Bundle is a group of evidence-based interventions for patients with
intravascular central catheters that, when implemented together, result in better
outcomes than when implemented individually.
The key components of the Central Line Bundle are:
○ Hand Hygiene
○ Maximal Barrier Precautions Upon Insertion
○ Chlorhexidine Skin Antisepsis
○ Optimal Catheter Site Selection, with Avoidance of the Femoral Vein for
Central Venous Access in Adult Patients
○ Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines

Hand Hygiene
One way to decrease the likelihood of central line infections is to use proper hand hygiene.
Washing hands or using an alcohol-based waterless hand cleaner can help to prevent
contamination of central line sites and bloodstream infections.

Some appropriate times for handwashing include:

● When they are obviously soiled
● Before and after invasive procedures
 ● Between patients
● After removing gloves
● Before eating
● After using the bathroom
● If contamination is suspected

Tips
● Empower nursing to enforce use of a central line checklist to be sure all processes
related to central line placement are executed for each line placement.
● Include hand hygiene as part of your checklist for central line placement.
● Keep soap/alcohol-based hand washing dispensers prominently placed and make
universal precautions equipment, such as gloves, only available near hand sanitation
equipment.
● Post signs at the entry and exits to the patient room as reminders.

● Initiate a campaign using posters including photos of celebrated hospital

doctors/employees recommending handwashing.
● Create an environment where reminding each other about handwashing is
encouraged.
● Signs often become "invisible" after just a few days. Try to alter them weekly or
monthly (color, shape size).

Maximal Barrier Precautions Upon Insertion

● One way to decrease the likelihood of central line infections is to apply maximal
barrier precautions in preparation for line insertion.
● For the operator placing the central line and for those assisting in the procedure,
maximal barrier precautions means strict compliance with handwashing, wearing a
cap, mask, sterile gown and gloves. The cap should cover all hair and the mask
should cover the nose and mouth tightly. These precautions are the same as for any
other surgical procedure that carries a risk of infection.
● For the patient, maximal barrier precautions means covering the patient from head to
toe with a sterile drape with a small opening for the site of insertion.
● Maximal barrier precautions clearly decrease the odds of developing catheter-related
bloodstream infections. Two studies show that the odds of developing a central line
infection were higher if maximal barrier precautions were not used. For pulmonary
artery catheters, the odds ratio of developing infection were more than two times
greater for placement without maximal barrier precautions. A study of similar design
found that this rate was six times higher for placement of central line catheters.
Tips:
● Empower nursing to enforce use of a central line checklist to be sure all
processes related to central line placement are executed for each line
placement.
● Include maximal barrier precautions as part of your checklist for central line
placement.
● Keep equipment ready stocked in a cart for central line placement to avoid
the difficulty of finding necessary equipment to institute maximal barrier
precautions.
Chlorhexidine Skin Antisepsis
● Chlorhexidine skin antisepsis has been proven to provide better skin antisepsis than
other antiseptic agents such as povidone-iodine solutions.
● The technique, for most kits, is as follows:
○ Prepare skin with antiseptic/detergent chlorhexidine 2% in 70% isopropyl
alcohol.
○ Pinch wings on the chlorhexidine applicator to break open the ampule. Hold
the applicator down to allow the solution to saturate the pad.
○ Press sponge against skin, apply chlorhexidine solution using a back and
forth friction scrub for at least 30 seconds. Do not wipe or blot.
○ Allow antiseptic solution time to dry completely before puncturing the site (~
2 minutes).
● Tips:
○ Empower nursing to enforce use of a central line checklist to be sure all
processes related to central line placement are executed for each line
placement.
○ Include chlorhexidine antisepsis as part of your checklist for central line
placement.
○ Include chlorhexidine antisepsis kits in carts storing central line equipment.
Many central line kits include povidone-iodine kits and these must be avoided.
○ Ensure that solution dries completely before an attempted line insertion.

Optimal Catheter Site Selection, with Avoidance of the Femoral Vein for Central
Venous Access in Adult Patients
➢ Percutaneously inserted catheters are the most commonly used central catheters. In
a prospective observational study assessing catheters placed by a critical care
medicine department in a university teaching hospital, the site of insertion did not
alter the risk of infection. The authors concluded that the site of insertion was not a
risk factor for infection when experienced physicians insert the catheters, strict sterile
technique is used, and trained intensive care unit nursing staff perform catheter care.

➢ Other studies have shown that in less controlled environments, the site of insertion is
a risk factor for infection. Mermel and colleagues were able to demonstrate that the
great majority of infections develop at the insertion site. Another risk factor was use
of the jugular insertion site over the subclavian site. In addition, for use of total
parenteral nutrition, McCarthy demonstrated a similar effect.

➢ Several non-randomized studies show that the subclavian vein site is associated with
a lower risk of central line-associated bloodstream infection than the internal jugular
vein, but the risk and benefit of infectious and non-infectious complications must be
considered on an individual basis when determining which insertion site to use. The
femoral site is associated with greater risk of infection in adults, however may be
limited to overweight adult patients.

➢ The core aspect of site selection is the risk/benefit analysis by a physician as to

whether the subclavian vein is most appropriate for the patient. There will be
occasions when the physician determines that the risks and benefits of using the
subclavian vein outweigh the benefits, and a different vessel is selected. For the
 purposes of bundle compliance, if there is dialogue among the clinical team members
as to the selection site and rationale, and there is documentation as to the reasons
for selecting a specific different vessel, this aspect of the bundle should be
considered as in compliance. It is not the intent of the bundle to force a physician to
take an action that he or she feels is not clinically appropriate.
Tips:
● Empower nursing to enforce use of a central line checklist to be sure all processes
related to central line placement are executed for each line placement.
● Include optimal site selection as part of your checklist for central line placement with
room for appropriate contraindications (e.g., bleeding risks).

Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines

Daily review of central line necessity will prevent unnecessary delays in removing lines that
are no longer clearly necessary in the care of the patient. Many times, central lines remain
in place simply because of their reliable access and because personnel have not considered
removing the line. However, it is clear that the risk of infection increases over time as the
line remains in place and that the risk of infection is decreased if removed.

Tips:
● Empower nursing to enforce use of a central line checklist to be sure all processes
related to central line placement are executed for each line placement.
● Include daily review of line necessity as part of your multidisciplinary rounds.
● Include assessment for removal of central lines as part of your daily goal sheets.
● Record time and date of line placement for record keeping purposes and evaluation
by staff to aid in decision making

VISITOR INFORMATION
➢ Because of the complex care and rest needed for critical care patients, only ONE (1)
WATCHER is allowed at the bedside. Only members of the immediate family can
enter.
➢ All watchers are REQUIRED TO WEAR GOWNS upon entry to the ICU.
➢ To protect patients as well as children, no one is allowed to visit ICU patients under
the age of 7. Special considerations are given under certain circumstances.
➢ Food, flowers, and balloons are not allowed inside the patient’s room.
➢ To provide the best possible care to the patient, visitors are asked to leave the unit
when patients are being admitted, during critical situations or when certain
procedures are being performed. The unit maybe closed to visitors at any time due to
emergency situations.

PARA SA MGA BISITA

● Para makapahuway sang mayo ang aton pasyente, ISA (1) LANG KA BANTAY ang
pwede kasulod. Kung damu ang bisita, palihog lang bulos-bulos. Ang pamilya lang
ang pwede makabisita.
● Tanan nga watcher kiNanGlan magsuksuk sang GOWN kung magsulod sa ICU.
● Para sa proteksyon sang pasyente kag bata, indi pwede makasulod ang may edad
nubo sa 7. Pero ginatagaan man konsiderasyon kaso por kaso.
● Ginadili-an ang pagdala sang pagka-on, bulak, kag balloon sa sulod sang ICU.
 ● Ginapangabay nga maghulat lang ang pamilya sang pasyente sa gwa kung may mga
procedure nga gina-ubra kag kung ga-emergency.

REMINDER
The ICU is a locked unit. To gain access, press the button beside the door. Someone will
respond to your request as soon as possible. Please be patient. If the nurses are busy
caring for your loved ones, the response maybe briefly delayed.

TERMINAL CLEANING DURATION

Patient’s rooms are to be disinfected after discharge or trans-out and will have a fixed
“curing period” where the room is vacated and the disinfectant is given time to exterminate
the present microorganism.

Curing durations are as follows:

Non-infectious -2 hours
Infectious -6 hours
Heavily Infectious (e.g. tubercle bacilli) -24 hours

Intensive Care Unit

A specialized section of the hospital containing the equipment, medical….

ICU Milieu
● 8 Bed capacity (4 sing rooms and 2 double rooms)
● ICU Extension can accommodate 3 patients
● Each room has its own Bedside Milieu
➔ Cardiac monitor
➔ Respiratory Monitor
➔ Pulse Oximeter
➔ Thermometer

Nurse to patient ratio is 1:2

Nurse’s responsibilities, among others are:
● v/s q hour
● Hourly urine output
● Ongoing assessment
● Complete bedside care

Nurse’s Outfit
● Scrub suit
● Surgical cap
● Surgical mask
● Use gown and gloves when handling soiled materials

Policy
● No name policy
● Data privacy act and confidentiality

Patient’s Folk’s Outfit

 ● Gown
● Surgical mask - optional
● 1 watcher policy!

Emergency Preparedness

Be prepared:
➢ Suction
➢ Oxygen
➢ Airway adjunct
➢ Pharmaceutical
➢ Cardiac monitor
➢ Others

Neuro Vital signs:

Gcs is scored between 3 and 15
3 being the worst and 15 being the best

● Eye response
● Verbal response
● Motor response

Best eye response

No eye opening
eye

Best verbal response

1. No verbal response
2. Incomprehensible sounds
3. Inappropriate words
4. Confused
5. Oriented
Best motor response
1. No motor response
2. Extension to pain
3. Flexion to pain
4. Withdrawal from pain
5. Localizing pain

Glasgow Coma Scale

Note that the phrase “GCS of 11” is essentially meaningless, it is important to break the
figure down into its components, such as E3V3M5 = GCS11.

Coma scores
13-14= mild brain injury
9 to 12= moderate injury
8 or less= severe brain injury (initial action: refer to physician for intubation, check
hemodynamics)
Emergency nursing
Preparing patient intubation

Things to prepare for intubation:

1. Oxygen tank with gauge
2. Oxygen cannula
3. Ambu bag
4. Suction apparatus that works
5. Suction tip
6. Endotracheal tube(diff.sizes)
7. Stylet
8. Laryngoscope with blade (3 sizes of blade)
9. Lubricant
10. Stethoscope
11. Disp. syringe

Sign to watch out after intubation

1. Hypotension
2. Desaturation
3. Cyanosis
4. Vomiting

Caring for intubated patient

1. Provide a suction machine that works
2. Suction tip each for mouth,et, and nose
3. Provide dry bottle for each suction tip (moist areas are medium for the multiplication
of bacteria)
4. Provide separate rinser for each suction tip
5. Provide clean gloves
6. Suction PRN. (<10sec per suction)
7. Keep tubes clean at all times with the least manipulation
8. Ensure that surrounding area of the bottle and tip is clean

With ET to MV, TV, BUR, FIO2, AC mode assist control; simv for weaning
Maximum 14 days attached to ET tube
Change to tracheostomy tube after 14 days of ET
ET tube → Tracheostomy

If it's FIO2 100% gauge 1500, monitor remaining O2 from time to time. It will be depleted in 4
hours
FIO2 40%, gauge 1500 → 2 days

Ideal mechanical Ventilation Set-up

 - ALL patients with mech vent should have a standby O2 tank with gauge, attached to
an ambu bag via an aqua pack - in case the ventilator malfunctions or other untoward
events take place

Signs to watch out after extubation

1. Cyanosis
2. Dyspnea
3. Laryngeal spasm

COMMON EMERGENCY DRUGS

Potassium chloride 40 meq

Lidocaine - 3
Epinephrine - 7 or more administration, there is only 1% of survival; ampule, red label
Atropine
Dopamine

Dilantin 100mg/2ml
Lasix 20mg/2ml
Solu-cortef 100mg/2ml
Valium 10mg/2ml

Dopa -200/250
Dobu

SALAD - same alike look alike drugs

HAM - high alert medications
- Verify with another nurse before administering HAM drugs

Inotropics Titration
Inotropes are delivered to patients in very sensitive and specific doses
Inotropics are not permanent. They are only supportive..

MD’s order
- Titrate dopamine by increments/decrements of 2cc/hr as long as SBP >= 100mmHg
- To aid in titration, we use drip meters for accurate delivery of inotropics.

Ano kuno?
Mahatag ka inotrope, dapat 90/60 and BP, ang bp sng patient 80/50, ano obrahon mo?
Titrate +2; if order is 70, give 72
TPN
Good handwashing
Sterile technique

TPN Solution:
 ➢ Strat combiflex or nutriflex, central or peripheral line for TPN
1920 cc x 48 hr
1900 Kcal

1920cc = 40 cc/hr
48 hrs

Mechanical ventilators
Set-up
● Tidal volume - amount of air that goes in and out of the patient’s lungs (in cc)
● Fraction of inspired oxygen (FIO2) - amount of O2 being delivered by the machine to
the patient (in %)
● Back up rate - number of respi the ventilator supports (incpm)

CARDIAC MONITORS
● Double set-up - a term used to describe a patient attached to a bedside monitor at
the same time attached to cardiac monitor with defibrillators.

Which of the following stat

NG tube silicon expiration = 6 months

Foley catheter = 14 days
Et tube = 14 days
Tubings IV = 3 days
IG Cath = 6months
Dressing = PRN or 7 days
Tapes = every shift or when soiled

Einthoven’s Law

3rd degree av block - transcutaneous pacing

School uniform

Medication cards, yellow, blue, green, and white

30 pesos for photocopy

What is ECG?
Recording (“gram”)
Electrical activity (“electro”)
Generated by heart cells (“cardio”)
That reach the body surface
REMINDERS:

➢ Kardexing
➢ IV insertion
 ➢ PPE Doffing and Donning
➢ Handwashing
➢ Medications (Prepare cartolina)

THINGS TO BRING:
● Pens (red, blue, black)
● Pencil, sharpener, ruler, calculator
● Checklist
● Endorsement notebook
● Booklet
● Green apple notebook
● Uniform (scrubs, regular, nightingale)
● PCR test
● Vaccine card
● Backtrack