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Intensive care unit 101 Use of oxygen tank holder It is not an acceptable practice to place the oxygen tank

near the bed of the patient without an appropriate tank holder. Procedure: - all oxygen cylinders must have a tank holder when placed at bedside to prevent any cause of accident. - all nurses, respiratory therapists and oxygen men must be aware of the use of the tank holder - Oxygen cylinders should not be left without tank holder. anyone who noticed that the tank holder is not being used is responsible to put the holder. - all O2 cylinders with tank holder should be placed properly in a safe and clean area. - Oxygen holder should be checked regulary.

REMOVAL OF ET OUTSIDE THE ICU Definition: It is the elective removal of breathing tube(end tracheal tube) from adult and pediatric patients outside the ICU upon the decision of the immediate relatives to discharge the patient against medical advice. Purpose: To remove the breathing tube from the patients airway when it is deemed no longer necessary. Procedure: 1. When patients relatives sign the waver for HAMA (Home Against Medical advice), the ICU Nurse informs the attending Physician about the decision. 2. The ICU Nurse explains to the relatives that once accounts are settled and an ambulance is available, the nurse will call the PCA to get the stretcher and portable oxygen ready for transport while doing a continuous ambubag. 3. When the patient is already in the vehicle, the ICU Nurse deflates The ET balloon and the relatives will be the one responsible to pull out the tube. Subsequently, the nurse connects the patient to oxygen via nasal cannula. 4. Ambulance on its way to patients home.

BEDRAILS SAFETY Introduction: Bedrails, also referred to as bed side-rails, safety sides or bed guards, are used extensively in the hospital to protect vulnerable people from falling out of bed and injuring themselves. Bed side rails are used in the ICU not to limit freedom from movement nor it to be used to restrain patients but rather to reduce the risk of falls from the bed. It is frequently used in the area because we believe that side rails cannot hurt anybody but to ensure patients safety in as much the same as parent may view the safety bars on the crib. Use of side rails: 1. Bedrails may make frail patients feel more secure. 2. Bedrails gives the patients something to hold on to when they are getting in and out of bed which adds some sort of security. 3. Bedrails can help patients reposition themselves in the bed. 4. It makes it easier to transport patients who may need to be transported for medical tests or other reasons. The rails that may prevent patients from falling thus, avoid the pain and danger associated with fall. 5. Side rails should be checked properly before and after duty, any significant source of danger must be reported. POLICY ON PATIENTS SAFETY IN TRANSFERRING TO CT SCAN Introduction: CT imaging has become an increasingly valuable diagnostic modality for intensive care unit patient. However, many clinicians may be reluctant to perform CT imaging on hemodynamically unstable patients due to the risks in transport of such patients. Ultimate goal is to provide the patient with consistent care throughout the continuum of care inclusive of the transferring process. Guidelines: 1. Pre transport coordination and communication -the nurse will provide the CT scan request form including the necessary equipment that is needed for transport (eg.O2 tank with ample supply). -contact the CT scan department and negotiate the timeline). -readiness of the equipment that will be needed. 2. A nurse will accompany the patient during the transport to CT imaging department but if the patient is intubated a respiratory therapist should accompany them.

3. Equipment is dependent on the patients condition but includesblood pressure device, a pulse oximeter, if possible a laryngoscope. 4. Emergency drugs availability. 5. Assess the patient and document before the move. Transport maintain consistent care Monitor the patient at the same level as before transportation Document the patients condition as needed during the transport.

Post transportation arrival Document the current patient assessment.

POLICIES AND PROCEDURES ON DISCHARGE OF PATIENT Discharge of patient is determined by the attending physician, and must be written in the chart as discharge order 1. Once a patient is ordered for the discharge, the nurse on duty accomplishes the discharge slip by completely filling it up with necessary data. 2. The discharge slip is brought to the pharmacy department together with the unused medicines written in red ink on a prescription pad. The pharmacy department clerk receives the unused medicines signs on a discharge slip and discharge logbook. 3. The discharge slip is brought to the billing section and the Nurse on Duty signs on the discharge logbook. 4. The Security Guard notice is given to the Security Guard on duty and signs at the discharge logbook. 5. If the Patient is a Philhealth member or dependent, the nurse on duty accomplishes the verification slip with the final diagnosis and submit it to Philhealth section. 6. If the patient is not a Philhealth member or dependent, the relatives goes directly to the billing section for payment. 7. Nurse on duty will do the home medications instructions in a clear and legible manner on the discharge instruction form. 8. If the Hospital bill has been settled by the relative, the nurse on duty signs on the clearance slip given by the billing section. 9. Nurse on duty provides a clear instruction of the home medications. 10. Date and time discharge is documented on the patients chart. 11. Nurse on duty will accompany the patient to the lobby via wheelchair or stretcher. 12. The patient or relatives presents the clearance slip to the security guard on duty and removes the same tag or id bracelet. 13. Nurse on duty will disinfect or clean all equipment used by the patient.

POLICY ON HAMA Home against medical advice or HAMA in which a relative or patient chooses to leave the hospital before the attending physician recommends discharge. 1. Once a patient is discharged against the advice of the attending physician, the patients closest kin will acknowledge that they have been informed of the risks involved and hereby release the attending physician and the hospital from the responsibility for any ill effects which may result from this action by signing and accomplishing the HAMA waiver form. 2. Upon signing the waiver form the closest kin will follow the discharge procedures but will be automatically disqualified to avail the use of the Philhealth. 3. Home instructions and medications may depend if the physician will provide such considering the HAMA. 4. All contraptions hooked to a patient will be removed before leaving the hospital premises endotracheal tube will be reamoved by the patients closest kin. Any contraptions left hooked to a patient must have a waiver signed by the patients closest kin in the chart and must be documented. POLICIES AND PROCEDURES DURING CODE 59 IN THE ICU Unlike the practice done in the ward and in other units, the ICU doesnt sound the code in case of CP arrest. This is the present practice in the unit considering that the unit has complete equipments (cardiac monitor, defibrillator, emergency medications, and an ECG machine) and the nurses are all BLS and ACLS providers. POLICIES AND PROCEDURES 1. After assessment of the patient and confirmation of CP arrest, the nurses immediately perform CPR and ambubag, following the guidelines in resuscitation of patients in the BLS training and ACLS training. 2. One of the nurses immediately notifies the ward ROD throght phone,or by paging the ROD to proceed t the ICU. 3. Then, the nurses call the pulmonary department in order to help in the resuscitation of the patient. 4. The nurses perform the rhythm strip taking using ECG machine available in the unit.

POLICIES AND PROCEDURES ON THE USE OF AMBUBAG The Ambubag is intended for patients who are in need of respiratory resuscitation. It is primarily used for patients who are on CP arrest and patients suffering from respiratory failure. POLICIES AND PROCEDURES 1. When the patient is in need of respiratory resuscitation, the nurse opens a new ambubag solely for the use of that same patient. 2. The nurse on duty charges the ambubag and senior nurse checks and the charges made. 3. The white form (used for charging) will be forwarded to the billing section. 4. The pink form will be attached to the requisition slip. the requisition slip should be properly filled up by the NOD and will be forwarded to the stockroom in order to replace the ambubag set used. 5. In such cases or respiratory resuscitation, the nurse notifies the AP of the patient. The nurse will also inform the ward ROD for initial assessment and initial medical intervention. 6. After use, the bag is kept hanged in the built in oxygen present near the head of the bed of the patient, where it can easily accessed by the nurses when needed. The ambu-mask is placed on top of the cardiac monitor table in order to provide quick access when needed. 7. When the patient expires, the nurse disposes the used ambu-set based on the Health Care Waste Management Guidelines. 8. When the patient is already for transfer out of the ICU, the ICU nurse endorses the ambu set. to the nurse of the receiving station. POLICIES AND PROCEDURES ON THE USE, MAINTAINANCE, CLEANING AND STORAGE OF BP APPARATUS The 4 manuals and BP apparatus present in the unit are used in determining and in monitoring the blood pressure of the patients. 1. Upon admission of the patient. BP is manually taken at first. If the patients BP is within normal range, the patient is attached to the NIBP cuff of the monitor. 2. The nurse uses the manual BP apparatus for patients who have abnormal blood pressure findings depending on the patients age. Patients who are attached to the NIBP cuff of the monitor, and who suddenly present low BP findings, are monitored by the nurse through the use of a manual BP. The nurses also practice the same procedure for patients who have higher BP findings. Eg. A patient who is hypertensive and is on Nicardipine drip is monitored by the nurse through manual BP apparatus every 15minutes. 3. Once the patient is for discharge or trans-out, the nurse cleans the BP cuff with warm water, using mild detergent. Then, the cuff will be rinsed thoroughly and will be allowed to air dry.

POLICIES AND PROCEDURES ON THE USE, MAINTAINANCE, CLEANING AND STORAGE OF THE INFUSION AND SYRINGE PUMPS. The infusion pump and syringe pump are used for adult and pediatric patients intended for continuous delivery of the parenteral fluids through clinically accepted routes of administration, including but not limited to IV irrigation/ablation, and enteral.the infusion pump and syringe pump are needed in the unit for accurate regulation of fluids and medications,as well as for blood products. 1. The nurse decides if a certain patient needs an infusion pump,because there are 3 infusion pumps available in the unit. Also,pumps are commonly used for fluids needing accurate regulation such as inotropics, nicardipine,cordarone, bolus administration of medications, and total parenteral nutrition (TPN).whereas, the syringe pump is commonly used for pediatric patients for blood transfusion,administration of inotropics for pediatric patients,as well as medications, where accurate regulation is needed. 2. After establishing the need to use a pump,the nurse prepares the needed pump, based on the guidelines from the manual.here are some of the instructions provided: - Ensure that the unit is properly positioned and secured. Do not position the pump above the patient. - Prior to administration, visibly inspect the pump for damage, missing parts, or contamination and check audible and visible alarms. - Position the infusion line free of kinks. 3. The nurse on duty will charge the use of such pump, and the senior nurse checks the charges made and forwards it to the billing section. 4. It the need for the pump is prolonged, the nurse charges the infusomat spaceline every 3 days (72 hours). 5. Once the patient is for transfer out or discharge, the nurse checks and cleans the equiptment as stated in the operators manual. The equiptment is checked for completeness, and damage.the outer suface of the pump is then cleansed with warm soap suds.proper disposal of the infusomat spaceline is observed. 6. After cleaning, the equiptment is allowed to vent for at least 1 minute prior to use.

POLICIES AND PROCEDURES ON THE USE, MAINTAINANCE, CLEANING AND STORAGE OF SUCTION MACHINE The suction machine is one of the primary equipments in the ICU for intubated and non intubated patients who are unable to cough out secretions. POLICIES AND PROCEDURES: 1. Once the relative of the patient signs the consent for ICU admission, the nurses prepare the equipment in the bedside including the suction machine. This is practiced in all cases of admitted patients in order to ensure that the suction machine is readily available when needed. The materials needed are just partially prepared, where the nurse places the suction tubings

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and the collecting bottle on top of the suction machine table. New suction tubings are prepared for each patient. Upon admission of non-intubated patients in the unit, the nurse assess if the patient will be able to cough out secretions. If the patient can cough out secretions, the suction machine will remain at the bedside on standby. if the patient however display inability to expel secretions the suction machine will be used, and then, will be charged. Upon admission of intubated patients, the nurse prepares the materials for suctioning (suction tubing and collecting bottle),selects the appropriate size of suction catheter for the patient, prepares the distilled water and sets the clean gloves. Before suctioning procedure, the nurse prepares the materials for suctioning. Suctioning procedure done is based on the suctioning guidelines in the ICU. Once the suction machine is used by the patient, the nurse will then charge the use of the machine. The senior nurse then check the charges then forwards it to the billing department. The suction tubings used are also charged. The white form (used in charging) will be forwarded to the billing section. the pink form will be attached to the requisition slip. the requisition slip is then properly filled up by the NOD, and this will be forwarded to the stock room in order to replace the tubings used. Additional guidelines are included based on the infection control guidelines in the prevention of nosocomial pneumonia made by the ICC committee. Here are some of the instructions included: a. Aseptic technique is strictly observed in performing suction procedures. b. Suction catheter and gloves are discarded appropriately after each use. c. Use of appropriate amount of sterile water in rinsing the suction tubing after the procedure to avoid clogging of the vacuum of the apparatus. d. Suctioning should not be applied for more than 15 seconds and ventilation and oxygenation should not be interrupted for more than 20 seconds in adults. for pediatric patients, suction should be applied for more than 5 seconds and total interruption to ventilation and oxygenation not exceeding 10 seconds. After each suctioning procedure, the nurse will then empty the collecting bottle, and the bottle will be cleansed using a disinfectant. Suction tubings will be charged every 7 days. Once the patient is for discharge or trans-out, the nurse will dispose the suction tubings of the patient. Suction machine will then be cleansed using a disinfectant, adhering the guidelines on cleaning stated in the operators manual. The outer case is wiped with lightly wet cloth soaked in disinfectant solution, and the bottle is also cleansed with a disinfectant. After cleaning, the suction machine is kept at the bedside (every bed in the unit is with its own suction machine beside it).as stated in the operators manual each suction machine is periodically checked when not in used once every 6 months.

Hooking patients to a Cardiac Monitor A nursing procedure wherein a nurse applies electrodes on patients chest and connects it to a cardiac monitor inclusive of the BP cuff and a pulse oxemeter. Purpose:it intends to monitor physiological parameters of patient within clinical care settings including waveforms (ECG tracing, breathing pattern) and numerical data (BP .heart rate, O2sat,respiration). 1. Admitting section/ER department notifies the ICU nurses regarding admission/transfer and sends patients relatives to ICU depsrtment for consent. 2. ICU Nurse explains the necessary Charges and the policies of the area and notifies adm/ER dept. once the consenting party agreed and signs the consent form. 3. The ER/ward nurse informs the ICU nurse with regards to the equptments deemed necessary for the patient(ie. Mechanical ventilator,O2 tank,suction machine). 4. If the patient is intubated, the ICU nurse informs the Respiratory Therapist to set up the mechanical ventilator. 5. ICU nurse, together with the ER/ward nurse and the PCA(patient care assistants) transfer the patient safely and comfortably on bed. 6. The ICU nurse fixes the contraptions on the patient and hooks it to a cardiac monitor, BP apparatus, pulse oxemeter, takes initial vital signs and neurovital assessment, observe the waveforms and note if there is an abnormality while further assessing subjective datas from the patient. 7. If in doubt, and if an abnormal vital signs appear on the monitor, the ICU nurse then manually re-check the vital signs. 8. The ICU nurse receives endorsements from the ER/ward nurse on duty at the BEDSIDE. 9. The ICU nurse informs and updates the Attending Physician regarding the patients initial assessment especially the abnormal findings. 10. If the Attending Physician acknowledges the message and gives orders, the ICU nurse executes the order. 11. If still waiting for the response from the AP, the ICU nurse temporarily refers the patient to the Resident on duty and executes the order if there is. 12. Then the ICU nurses continuously monitor the patients status every hour or depending on the status of the patient.

POLICIES AND PROCEDURES ON REFERRALTO APs REGARDING THE CHANGES IN PATIENTs CONDITION It is defined as a call or SMS made to the Attending Physician by the nurse on duty when a critical nursing observation/change is noted that warrants immediate nursing/medical intervention. PROCEDURES: 1. A nurse will refer a patient to the attending physician via phone call or SMS if the patient exhibits the following; Presents with a head injury and who is positive for fracture in the skull/maxilla-facial area. Epistaxis Otorrhea Facial asymmetry Alteration in level of consciousness (restlessness) Anisocoria Diplopia/ptosis Persistent head ache described as excruciating Meningeal irritation (nuchal rigidity,kernig/brudzenski sign) Mentation Decrease in level of sensorium (GCS 7 and below) Motor weakness Seizure disorder Febrile episode Dysphagia Intractable hiccups Respiratory distress (RR above or equal to 30bpm, labored breathing/gasping, chest retraction use of accessory muscle) Oxygen desaturation <90% Lung auscultation (presence of crackles/wheezes) Nausea and Vomitting Hemoptysis Frothy secretions per ET Chest pain unrelieved by nitroglycerine Referred pain (jaw pain/epigastric pain, left shoulder pain) Unstable vital signs Cyanosis (pheriperal/circumoral cyanosis) Coffee ground material per oral/NGT Melena/Hematochezia Anuria less than 50ml/day, oliguria less than 400ml/day Gross hematuria Bladder distention Independent/dependent edema (grade 1-4) Deep calf pain

Sluggish circulation on lower extremities on DM patients Diabetic foot. 2. Once a referral is made and doctors orders are carried out, the nurse on duty documents the time, nursing assessment, medical intervention done to the patient and evaluate the effectivity of the interventions and if in case the desired outcome is not met reassessment is done until the desired outcome are delivered. CARE AND USE OF DEFIBRILLATOR Defibrillators are an advanced life saving device used to correct dangerously abnormal heart rhythm, or to restart the heart by depolarizing its electrical conduction system and deliver brief measured electrical shocks to the chest wall or the heart muscle itself when its beating becomes dangerously rapid or chaotic. These shocks can restore normal heart rhythm before the malfunctioning heart suffers sudden cardiac arrest, a seizure that can lead a death within minutes. This life saving device though much beneficial, comes with a price. Thus, care and proper use of this device is therefore imperative. The ICU has newly acquired biphasic external defibrillator that can be used for both adult and pediatric patients. TECHNIQUES FOR EXTERNAL ELECTRICAL DEFIBRILLATION: 1. Ensure that the device is connected to a power source. 2. Attach the appropriate electrode cables to the appropriate location as indicated by the manufacturer. a. yellow cable left clavicular area b. red cable right clavicular area c. green cable left foot 3. Turn the main power switch on. Ensure that the synchronization switch is turned off. 4. Lubricate the paddle with a compatible electrode paste. 5. Select appropriate energy level. 6. Change paddles. 7. Interrupt chest compressions (preferably 10 seconds, maximally 20 seconds) for the defibrillation. 8. Place one paddle just to the right border of the upper sternum just below the right clavicle. Note: for patients with hairy chest, shaving the area where the paddle will be placed is necessary. 9. Place the other paddle just below and to the left nipple at the midaxillary line. 10. Apply firm pressure with paddle against the chest to reduce lung volume and electric resistance. 11. Confirm ECG diagnostic of ventricular fibrillation or pulseless ventricular tachycardia. 12. Clear the area with no one touching the patient or the bed.shout Im going to defibrillate the patient on three one, im clear. two, youre clear. three, everybody clear! 13. Fire the defibrillator by pressing the appropriate triggers.

14. Check the rhythm for conversion and proceed with CPR immediately. SPECIAL PRECAUTIONS: Do not use the defibrillator it the patient is soaked in water. If the patients chest is covered with water, quickly wipe the patients chest before applying shocks. Do not place paddles directly on top of a medication patch, medication patch may block in the transfer of the energy from the electrode pad to the heart and may cause small burns of the skin. Rempve the patch and wipe the ares clean before applying the paddles. CARE AND MAINTAINANCE: 1. Know how to use the device properly. 2. Ensure that the defibrillator is adequately charged. 3. Always remember to clean the unit after every use according to the manufacturers operators manual. 4. Ensure that the electrode wires/cables are free of tangle and properly cleansed after every use. 5. Keep the unit in cool and dry place, avoid getting the unit wet. 6. Perform routine checks on the defibrillator at least once a month according to manufacturer and institutions standards.

REQUISITION OF STOCKS It is a weekly written request for every department, requesting for a new set of supplies needed by the department provided that all the items used (empty containers) are returned to the stock room. Purpose: To be able to render quality nursing care service to all admitted patients by completely having the necessary materials that are possibly needed in the care of the patient. 1. The requisition is requested every Monday by the head/charge/senior nurse on duty. 2. The ICU head/charge/senior nurse makes a list of stocks which will be used for the week in triple copy. 3. The ICU head/charge/senior nurse gives the copy to the Nursing Service Director/NSO for checking and signing. 4. Upon approval the copies are then brought to the Stock room together with the used/empty items. 5. The requested stock will then be available for pick up every Thursday, once available the ICU head/charge/senior nurse checks for the completeness of the requested items then a PCA is requested to bring such requested items from the stock room to the unit. 6. If the requested stock is not available the ICU head/charge/senior nurse is informed by the Head of the stock room regarding the unavailability.

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