Nursing Guidelines ( Draft)

GUIDELINES FOR NURSING PRACTICE

Nursing department IGMH 2006

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CONTENTS

Foreword...............................................................................................................6

SECTION ONE - General guidelines................................................................7

Admission............................................................................................................8

Know your patient..............................................................................................9

Recording of vital signs....................................................................................10

Administration of medication..........................................................................11

Intake & output................................................................................................13

Communication.................................................................................................14

Pre-operative management..............................................................................15

Post –operative management...........................................................................16

Documentation..................................................................................................17

Telephone/ verbal order guideline:.................................................................20

Transfering patients.........................................................................................21

Discharge...........................................................................................................22

Leaving aginst medical advice.........................................................................23

Death care..........................................................................................................24

Care of dead foetus/ baby................................................................................25

Filling death forms and delivery forms……………………………………………………26

Vaccination........................................................................................................26

Appendix-A / orientation on admission..........................................................27

Appendix- B / patient’s record /chart arrangement......................................28

Appendix – C / filling death forms and delivery forms.................................30

Appendix – D -checklist for ward sisters........................................................31

SECTION TWO (ward specific guidelines)

Daily tasks of nurses of private wards............................................................36

Daily tasks of pediatric ward nurses...............................................................41

Daily tasks of medical ward nurses.................................................................48

Daily tasks of gynae ward nurses....................................................................54

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Daily tasks of ENT ward nurses......................................................................60

Shift routines for surgical ward nurses..........................................................64

Daily tasks of isolation ward nurses................................................................69

Daily tasks of accidents and emergency department nurses........................75

Daily task of ICCU nurses...............................................................................77

Daily tasks of O.P.D nurses.............................................................................93

Daily task for staff working in the dialysis unit.............................................95

Theatre guidelines............................................................................................99

theatre lists...........................................................................................................................99

preparation of the theater...................................................................................................100

points to be remembered by the scrub nurse and the circulating / floor nurse..................101

protocols to be followed in the operating rooms...............................................................102

protocols to be followed while in operation theatre complex............................................103

routine cleaning of operation theatre.................................................................................104

daily tasks of nurses working in operation theatre.............................................................105

daily tasks of attendants working in operation theatre.......................................................108

Acknowledgement...........................................................................................113

Admission protocol for labour patients........................................................114

On going care during first stage of labour...................................................116

Care of patients with foetal distress..............................................................120

Care of patients with previous lscs in labour...............................................121

Care of patient during second stage of labour.............................................122

Assisting a vacuum delivery..........................................................................126

Management of third stage of labour...........................................................127

Expectant management of third stage: (is not encouraged).......................128

Retained placenta...........................................................................................128

Manual removal of placenta..........................................................................129

Management of fourth stage of labour.........................................................130

Management of PPH......................................................................................131

Performing an episiotomy..............................................................................132

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Repair of an episiotomy.................................................................................133

Care of new born............................................................................................135

Neonatal resuscitation....................................................................................137

preparation for delivery......................................................................................................137

post resuscitation:..................................………………………………………………….137

Transferring newborn babies to nursery.....................................................138

Nursing care of patients with ante partum hemorrhage............................138

Management of patients with pih in labour.................................................139

Use of magnesium sulphate for pre- eclampsia and eclampsia..................140

Care of patients with malpresentations........................................................142

Management of cord prolapse.......................................................................143

Administration of oxytocin for induction and augmentation of labour....144

Cerviprime instillation for induction of labour...........................................145

Extra amniotic saline instillation..................................................................146

Care of patients with infectious disease in labour.......................................147

Infection control practices in labour room..................................................149

Care of the patient after abortion.................................................................151

Routine investigation checklist......................................................................153

Admission checklist........................................................................................154

Emergency pre- operative checklist..............................................................155

Documentation checklist................................................................................156

Appendix A: patient unit preparation..........................................................158

for first stage of labour:..............................................................................................……158

for second stage of labour:.................................................................................................158

for severe PIH / eclampsia:................................................................................................159

Appendix B / orientation to labour room.....................................................160

Appendix C: articles/ equipments needed for procedures performed in

labour room

normal delivery:.................................................................................................................161

equipments needed for resuscitation in delivery room:.....................................................162

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medications needed for new born resuscitation:................................................................162

urinary catheterization:......................................................................................................163

cerviprime instillation:.......................................................................................................163

culdocentesis:.....................................................................................................................163

extra amniotic saline instillation:.......................................................................................164

episiotomy suturing:...........................................................................................................164

dilatation and curettage (d & c):........................................................................................165

Appendix D: check list for ward sister / ward incharge

(labour room)..................................................................................................166

Appendix E: responsibilities of shift in-charges (labour room).................170

Appendix F: daily tasks of nurses working in labour room.......................171

Appendix G: daily tasks of attendants working in labour room................177

Rhc-routines....................................................................................................182

Quality & maintenance of work & working environment..........................187

Infection controll guideline for rhc staff......................................................196

Shift routines for Rhc staff...............................................................................203

FOREWORD

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Improving & strengthening nursing care is an element of nursing profession. Nursing

department is proud to produce a Manual of Practical Guidelines to be used by the nurses of

IGMH. These guidelines are developed mainly aiming to standardize & improve the quality

of nursing care. Most of the procedures, protocols, & standards included in these guidelines

are already in practice. However, these guidelines will help in standardizing the practice of

these procedures in all the areas of the hospital.

Nursing Department greatly acknowledges the contribution of all nurses who were involved

in developing these Guidelines. I am sure these guidelines will serve as a valuable reference

manual for all the nurses and students working in IGMH.

Aminath Saeed Firaq

Director of Nursing

Nursing Department

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SECTION ONE

GENERAL GUIDELINES

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ADMISSION1. Make the unit ready with all the necessary equipments depending on the condition /

type of patient.

2. Receive & greet the patient with a warm welcoming smile.

3. Check the patient’s folder for correct name, address (temporary & permanent), treating

doctor, date & time of admission, and details (name, address, contact number) of the

guardian or relative.

4. Call him/her by name and introduce yourself in a pleasant manner.

5. Check doctor’s orders, prioritize and implement care accordingly. e.g.:

a) Carry out emergency orders immediately.

b) Make necessary arrangements to do urgent investigations.

c) When necessary give special instructions such as NPO, bed rest, without

delay.

6. Check all necessary documents. All admissions should have the following documents.

a) Admission slip / Doctors prescriptions

b) Nurses notes/observation chart /treatment chart (casualty admissions)

c) Other documents if any e.g. Referral letters

7. Take a detail report if the patient is accompanied by a nurse.

8. Assess the patient:

a) Observe for conditions such as restless, confused, level of consciousness etc.

b) Record Bp, pulse, respirations and check weight.

c) Check FHS for obstetric patients.

d) Take history of present complaint, past medical and surgical problems,

ongoing treatment if any, and other relevant histories.

e) Take obstetric and gynea history for relevant conditions.

9. Inform the medical officer or consultant.

10. Enter the admission in the daily census & relevant registers.

11. Orient the patient and relatives to the ward / room and hospital (refer Appendix-A).

12. Inform about the necessary items required during the hospital stay.

13. Instruct the relative / patient to be responsible for their own valuable items such as

money and mobile phones.

14. Inform coordinator about critically ill patients.

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KNOW YOUR PATIENT

All nurses should know the following information of all patients under their care.

1. Identification (name, age, sex, bed number, address, diagnosis (provisional & final).

2. Past & present medical / surgical /obstetric & gynaecological history.

3. Status such as allergies, G6PD & chronic problems.

4. Stability of vital signs & investigation reports

5. General condition, present complaints & prognosis of illness.

6. Treating & other referral doctors.

7. Previous & ongoing treatment as well as response to medications.

8. Type of diet required.

9. Urinary & bowel habits.

10. Mobility (walking, walk with support, wheel chair, stretcher)

11. Position to be maintained ( e.g. lateral/supine position, leg or arm elevation etc)

12. Socio-economic status (e.g. family support, welfare assistance etc)

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RECORDING OF VITAL SIGNS

1. Record vital signs every 4th hourly for all the patients & then according to the

condition & necessity.

2. Follow the standard procedure for checking the vital signs, (Refer the procedure

manual).

3. Take immediate actions & inform the doctor for any deviations from normal.

4. Record of vital signs under special conditions:

e.g.

- Before administering indicated drugs such as antihypertensive drugs, digoxin etc

- Before performing certain procedures such as blood transfusion, before transferring

the patient to the theater, endoscopy or any other major invasive procedures.

5. Document vital signs correctly and legibly in the appropriate charts in time.

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ADMINISTRATION OF MEDICATION

1. Right Patient:

1. Check the patient by name, age, address and bed number.

2. Check the patient if he/she is ready or in a stable condition to receive the particular

prescribed medicine.

E.g. condition of vital signs, food intake, bowel movements, urine output etc

2. Right Medicine:

*Check the name, dosage, route, & expiry date

1. Check & compare the prescribed medication order in the folder (name, dosage,

route & timings) and the treatment chart.

2. Check & compare the medicine (name, dosage, and route & expiry date) & the

written order.

3. Clarify from the concerned doctor in any doubtful situation.

3. Right Dose:

1. Check & take or prepare the right dose of medicine.

2. Get counter checked by another nurse for indicated drugs such as insulin & narcotics

etc.

3. Prepare the medication according to the instructions e.g. correct dilution, aseptic

technique etc.

4. Always label the IV fluids prepared with other medications, with the added drug’s

name, amount, dosage, date & time.

4. Right Route

1. Check the advised route of medication.

2. Check the site – IV / IM / SC, eye, ear, skin, tubings etc, for condition & patency to

administer the drug.

5. Right Time:

1. Check the time & timings for medication.

2. Check the time of last dose of the particular medicine administered.

3. All medications to be administered in time.

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After Medication Administration:

1. Check relevant Vital signs for indicated drugs.

2. Observe the condition & immediate response to drug. If unusual symptoms are

observed check vital signs.

3. When needed give necessary instructions to the patient about the desired action of the

drug and its possible side effects.

Eg. Drowsines s/ sleepiness after narcotic administration

Symptoms of hypoglycemia after insulin dose.

Urine out put after diuretics. Etc.

4. Provide immediate care & inform to the doctor for any adverse side affects.

5. Document & sign in the appropriate charts /record books accurately & clearly in

time.

6. Replace & store the balance (if any) medicine properly labeled with name, dosage,

date and time of use (if required).

Points to Remember:

1. All prescription must be written by the doctors.

2. Check the name, age, and sex and bed number before handing over a prescription.

3. Explain to the relative/patient when handing over the prescription to buy the

medicine.

4. Check the prescription & medicine after receiving them.

5. All medications must be taken by the patient in the presence of a nurse. Do not

leave the medicine at bedside for the patient to take at a later time.

6. Avoid administering medications prepared or taken by another nurse.

7. Hand over the balance prepared medication to the next shift nurses.

8. All medication errors of any kind must be reported to the senior nurse & the doctor

in the shift.

9. All medication errors must be written in detail in the incident book & reported to the

ward in charge.

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INTAKE & OUTPUT

1. Maintain Intake /Output chart for all indicated patients from 7.00am to 7.00am.

2. Explain & instruct the patient and relatives about maintaining intake & output chart.

3. Provide a graduated measuring cup & a measuring jar to all necessary patients.

4. Intake should include the total amount of oral intake (foods/fluids) and parental

infusions.

5. Out put should include the total amount of urine passed, aspirations, vomitus and

drainages along with the total number of bowel movements.

6. Observe or ask & record the total amount, color, & consistency of output.

7. All the measurements should be seen by a nurse.

8. Take action for any abnormal observations/measurement.

e.g. heamaturia, hematemisis, Poor oral intake, less urine out put, constipation,

loose motion etc.

9. Record the intake & output in time & complete at the end of each shift.

10. Calculate the total Intake and Output /24hours at the end of night shift.

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COMMUNICATION

Nurse - Patient

1. In each shift after taking over visit all the patients.

2. Greet, smile, address by name & introduce yourself.

Enquire how he/she is feeling or doing.

Enquire about pain, sleep, diet, bowel movements or whatsoever related to his /her

problems.

3. Explain the condition (progress / deterioration) during the doctors’ rounds.

4. In high risk cases keep a written record of the explanations provided for the patient/

relatives.

5. Explain to the patient and relatives about starting /discontinuing / withholding any

treatment.

6. Explain prior to performing each procedure / investigation.

7. Communicate with patient and provide health education according to their needs

(time can be given while performing procedures).

8. Explain any delay in carrying out an expected procedure e.g. cleaning, bath,

handing over the discharge summery etc.

Nurses & other members of the health care team

1. Respect each other & other members of the health care team.

2. Acknowledge & greet to each other & other senior members of the team.

3. Conversations should be polite, understanding & professional.

4. Do not use mobile phones & do not share personal conversations at the time of

patient care and during the ward rounds

5. Follow the telephone manners during telephone conversations.

6. Resolve conflicts according to the protocols..

7. Help each other & other wards when they are in need.

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PRE-OPERATIVE MANAGEMENT

1. Check patient’s identity (name, age, sex, address, bed/room number)

2. Check the type & nature of posted surgery

3. Check if instructions of anesthetists and surgeon’s instructions are carried out

4. Recheck validity of consent & signature by the relative/guardian

5. Check investigation results & informed to the concerned people

6. Instruct & explain the importance of the concerned relative/guardian to stay near by

the theatre throughout the surgery.

7. Enquire about the donor & instruct the donor should be available in the hospital (in

front of theatre) at the time of surgery

8. Check if any of the medication of ongoing treatment to be administered before shifting

to Theater.

9. Check patient preparation for surgery

Skin or part preparation,

Fasting status

Bowel /preparation & results

Pre medication

Catheterization, IV cannula or IV fluids (if required)

Changing clothes & removing jewelries, nail polish etc.

Removal of dentures, contact lenses or other appliances that needs to be

removed.

Personal hygiene (bath taken /sponge given)

10 Make sure if bladder is emptied just before shifting to the theater

11. Check vital signs

12. Complete all documents

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POST –OPERATIVE MANAGEMENT

1. Prepare the unit according to the type of case to be received.

2. At the time of taking over from the OT nurse check the following.

Level of consciousness

Operation site

Post-operative orders (surgeons & anesthetist)

3. After transferring the patient to the unit, carry out the following

Position the patient according to the instructions.

Position & secure the drainages, catheters, IV fluids etc.

4. Check vital signs once in every 15 minutes for 1 hour, if stable for half hourly for 2

hours, & then routinely.

5. Explain the condition & provide necessary instruction to the relatives.

NPO hours,

Maintenance of patient position & mobility.

Purpose of catheters, drainages etc.

6. Observe & take actions for any possible complications & inform the doctor.

7. Prioritize & carry out orders.

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DOCUMENTATION

Nursing documentation should have the following principles:

Principle 1: Nursing documentation is aimed at serving the interests of the

patients.

- The record should contain relevant and patient focused information only.

- Nursing records should not be used as a forum for criticizing other professionals nor

should it be used as route for complaints.

- Avoid bias and describe observations of behavior rather than labeling the patient.

(E.g. Instead of writing as patient being uncooperative document the exact behavior

of the patient).

Principles 2: Frequency of documentation:

- Frequency of documentation is ultimately a professional judgment. The frequency of

entries depends on several factors. These include

- The physical and mental condition of the patient

- The method of documentation used by the organization

- Any other obligations (legal or other wise) that the health record must fulfill.

- Nursing documentation should contain the initial assessment of the patient when

taking over as well as the assessment done before handing over

- In circumstances where a client is in unstable health, it is necessary to document more

frequently than in circumstances where the client is more stable condition.

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

manner.

- Entries should be chronological sequence, with time, date, name, signature and

designation of the staff.

- All entries must be made as close as possible to the care or treatment provided.

Waiting until the end of a shift to write the report should be avoided as it increases the

possibility of errors and omissions.

- Documentation should never be done ahead of time.

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- While using electronic monitors and if the time on the printouts is not the exact time,

make sure that the correct time is written on the printouts.

- Space should not be left in a client’s record for documentation to be completed at a

later time.

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

date.

- All entries should be brief, complete and clear-cut.

- All entries should be made in black or blue ink and any blank areas must be ruled

out.

- All the entries must include a date, time of documentation.

- A person making any documentation in a patient record must be identified. Therefore

all entries in the health records including signatures should be legible. Nurses should

enter their name (not the initials) and designation clearly in the space provided for the

purpose.

- When writing drug doses, as a legibility caution use leading zeros for decimals (e.g.

0.5 units of syntocinon) and avoid terminal zeros (e.g. do not write 10 units of

syntocinon instead of 1 unit).

- The most common reason for drug errors is illegible or questionable handwriting.

Therefore, to avoid errors care should be taken to write neatly and to avoid spelling

mistakes. Grammar and cleanliness are also worthwhile.

- Duplication of information should be avoided. It is not necessary to repeat

information that is recorded else where in the patients health record. (E.g. when

medications are entered in the treatment sheet it need not be repeated in the nurses

notes).

- Document specific information: Don’t state, “Patient’s condition informed to

doctor”. Document exactly what was informed to the doctor?

- Avoid use of generalized phrases such as “wound improved”. State in objective

terms: size, drainage odour.

Principle 5: Errors should be corrected accurately.

- Correct errors openly and honestly. The content in question must remain visible so

that the purpose of correction is understood.

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- Errors should be corrected by drawing a line through the incorrect information. But

the time, date and signature of the person altering the record should be clearly

written. It is also advisable to record the reason for alteration.

- Correcting, modifying or altering someone else’s document is illegal and is

considered as professional misconduct.

- Under no circumstance should correction ink be used or scribble over an entry

or tear off an entry. This will be considered as tampering.

Tampering: Tampering is not only the willful act of destroying the record. Crossing out

incorrectly or wiping out information and squeezing a little information are also forms of

tampering. Leaving blank lines can help the subsequent users to tamper the records by

altering them. Therefore a line should be drawn through empty spaces.

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

- Nurses should ensure that the documentation is done in a language approved by the

organization.

- Ensure that patients name and inpatient number is written in all forms.

- Internationally acceptable abbreviations should be used in the document and no

abbreviation should be used unless it has a clear meaning.

- All entries must be signed. A () mark indicates correct or right and it cannot be

considered acceptable as a substitute for a signature.

- Each entry must begin with a date, time and should end with a signature, name and

title.

Principle 7: The documentation should contain entries recorded by the

individual nurse who provided the care.

Nurses should not document on behalf of others.

All persons who provide care for the patient should make entries of their observations

and interventions in the records.

Principle 8: documentation should demonstrate that the nurse has fulfilled

her duty of care to the patient.

- All care, advice and any specific nursing management plans should be documented

clearly.

- Any refusal for treatment or advice should be noted.

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Late entries:

Late entries can be done for information that was not recorded in a timely fashion and if

omission of the information would impact the care. When a late entry is needed, the

following needs to be documented:

- current date/time

- entry for date and time of happening

- Signature/name

e.g. 2/3/2006, 9 a.m. late entry for March 1, 2006, 10 a.m.

A late entry must be made within 24 hours with the authorization from the ward incharge.

Telephone/ verbal order guideline:- Clearly determine the clients name room/ bed number and diagnosis.

- Write down the order exactly as stated by the physician

- Repeat the prescribed orders back to the physician.

- Use clarification questions to avoid misunderstanding

- Document in the nurses’ notes as a telephone order or a verbal order including date,

time and name of the physician giving the order.

- Ensure that the physician writes the order in the patient’s folder later.

- Verbal orders should be double checked when appropriate.

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POINTS TO REMEMBER- Write nurses notes after taking over, in-between after care or

performing a procedure and at the end of each shift.

- Record the attending doctor’s visit whenever the nurse sends a call or

special visit done by the doctor

- Write the condition, complaints, progress and other observations

E.g. after a wound dressing, write if the wound is healing, bleeding, not

improving or other conditions of the wound observed during the procedure.

- Do not write pending works, & investigations to be done in the nurse’s

note, but pending works can be written and hand over to the next shift

- Recording should be done by the responsible nurse only

- Complete nurses notes & other records before leaving hospital/HC

TRANSFERING PATIENTS

While transferring patients from ward to ward or to other hospitals the following steps

should be carried out.

1. Check fitness and doctor’s order for transfer.

2. Check and arrange a staff to accompany the patient if required.

3. Check if bed or room is available / ready with the necessary items or equipments.

4. Make transfer memo.

5. Complete & prepare all the records and other belongings.

6. Arrange means of transport.

7. Document in the census & and other registers.

8. Inform to the ward or to the concerned department / hospital (when possible) just

before shifting

9. Continue IV & oxygen during the transfer if on flow.

10. Observe condition during the transfer.

11. Provide a complete report (from the time of admission till date & time) to the

receiving nurse and handover all the documents, medications, investigations such as

scan, X-rays etc.

12. Inform to the patient, relatives, and to the respective ward if there is any delay.

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DISCHARGE

When discharging a patient from the hospital ensure that the following steps are carried

out.

1. Check discharge order.

2. Enquire if medical certificate is required.

3. Collect investigation results or result collecting slips.

4. Check the discharge summary for compete information (name age, address,

diagnosis etc

Check discharge summary for special information such as final diagnosis, treatment

tubal ligations, IUFD, neonatal deaths etc.

5. Settle the payment.

a) Write the date & time of discharge in the folder cover.

b) Complete service notification including operation slips.

c) Stamp “discharge” & mark the type of discharge.

d) Hand over the folder cover to the concerned person after explaining to bring back

the folder cover & the bill.

e) Receive & enter the information to the concerned records (census & registers)

6. Discharge advice.

a) Check the discharge medicine; label the drugs with the timings & dosage.

b) Explain how to take drugs with proper instructions.

c) Provide health education on diet, activity & exercise for all patients.

d) Explain about exclusive breastfeeding for all breastfeeding mothers.

e) Provide special information for clients like diabetes, hypertension, CRF, post-

operative etc.

f) Teach procedures like, dressing, cleaning, catheter care, sitz bath etc.

g) Demonstrate & get return demonstration of procedures like Ryles tube feeding,

Etc. This need to be done from the time of discharge planning.

7. Explain and handover discharge summary, investigations reports, x-rays, pending result

collecting slips etc.

8. Explain about the follow up visits & appointments.

9. File the chart in order (refer Appendix B)

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LEAVING AGINST MEDICAL ADVICE

1. Ensure if the risks of leaving against medial advice is clearly informed by the doctor.

2. Complete LAMA form, explains & take signature from the concerned relative or

guardian.

3. Remove the appliance such as IV cannulas.

4. Complete bill settlements according to the discharge procedure.

5. Check the discharge summary if it indicates “Leaving Against Medical Advice”.

6. Check the discharge summary for the stated risks & brief them to the patient &

relatives.

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DEATH CARE

1. Inform to the relatives / guardian immediately after death declaration (these

information & explanation should be given by the concerned doctor).

2. Inform to the consultant, nurse – coordinator, and to other concerned people.

3. Complete death form & hand over to the relatives/guardian to make necessary

arrangements for funeral.

4. Provide brief information about the procedure to take the dead body home or

cemetery.

5. Inform to the public relation coordinator & direct the relative /guardian to the public –

relation counter for further assistance & to arrange ambulance and for further

assistance.

6. Handover the folder cover (after completing & stamping [death & discharge]) with

service notification for bill settlement.

Cleaning the dead body:

1. Inform to the relatives about cleaning the dead body

2. Remove the IV fluids and other tubing.

3. A Maldivian nurse should guide or accompany during the cleaning procedure.

Respect the religious and cultural values during the procedure.

4. Dead body must be handled carefully & provide special attention not to expose the

dead body.

5. Clean the dead body & dress any wound.

6. Perform the procedure according to the procedure manual.

Documentation:

1. Complete nurses notes, and other charts clearly with all the details of the process.

2. Document the details in the census, admission & death register.

3. Hand over the investigation reports & x-rays.

4. Order the file according to the chart arrangement protocols (refer Appendix B).

Transferring the dead body

1. Confirm if ambulance is ready

2. Inform to public relation counter just before transferring.

3. A nurse should accompany to the ambulance.

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CARE OF DEAD FOETUS/ BABY

Inform the mother and the relatives about the death as soon as possible.

Death care should be given according to the Muslim tradition regardless of the

gestational age.

Clean the foetus/ baby gently with warm water and olive oil. If the baby is macerated

give special attention as the skin may get peeled off while cleaning.

If there is bleeding from the cord tie the cord with silk or any type of thread. Do not

use a cord clamp.

If possible the baby’s chin should be supported firmly with a bandage and the knot

should be placed over the head.

Fold the arms with the right hand over the left and keep over the abdomen. Tie on the

wrist with a bandage.

Put the legs together and tie over the ankle with a bandage.

If there is excessive secretions plug the nostrils with cotton.

Show the baby/ foetus to the mother and the relatives

Always cover the baby/foetus with a sheet and never expose the body unnecessarily.

Fill delivery form and death form and hand over to the relatives (refer Appendix C).

The relatives should be told to give a name to fetus and the name should be entered in

the death form. When sex cannot be identified it should be taken as a male.

Enter in the delivery register if the baby is more than 28 weeks of gestation and enter

in the abortion register if less than 28 weeks.

When the formalities for burying the baby is over and when transport is ready hand

over the baby to the relatives (a nurse should accompany).

FILLING DEATH FORMS AND DELIVERY FORMS

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Delivery forms and death forms should be filled in the following conditions:

A delivery form and a death form should be given to each aborted fetus. All delivery

forms and death forms should be filled completely before handing over to relatives.

If there is no fetus, a delivery form need not be given, but a death form has to be

issued with the identification of the product of conception along with mother’s name.

eg. Name: Aishath’s (aborted membrane)

If sex of the fetus is not identified, it should be taken as a male fetus.

VACCINATION

Prior to vaccination of a baby confirm the following.

1. Check identity of the baby (check & compare the identity of the mother with the

baby’s name tag)

2. Assess the baby & ensure that the baby is fit for vaccination

3. Reconfirm the vaccination status of the baby from the nursing records & double

check with another staff.

4. Inform & give detail information to the parents about vaccinating the baby

5. Take the baby along with necessary records for vaccination

6. A bystander who could give correct information needed to complete the vaccine

card should accompany the baby.

After vaccination:

1. Assess the baby’s condition after vaccination

2. Show the BCG site to the parent (s) and give instruction related to post

vaccination care

3. Ensure that the necessary documentation has been completed.

4. Hand over the vaccination card & explain the vaccination schedule to the parent(s)

APPENDIX-A / ORIENTATION ON ADMISSION

Greet & smile to the patient & relatives

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Tell that you will be looking after the patient in your shift.

Explain that nurses will be working in four shifts

Tell the patient /relatives to inform nurses regarding any problem with the patient and other

problems related patient care.

Orientation to place: Show the location of toilet, hot water, fridge and drinking water

Explain location of the pharmacy & canteen

Explain about the day room, activities and closing timings

Advice the relatives to inform the nurses if any of the facilities provided by the

hospital is not in working condition e.g. fan, electricity etc

Explain about the rules of the hospital: Patients are not allowed to go out of the hospital

Explain about the visiting hours

Explain that other than visiting hours only one responsible bystander can stay with the

patient. If the patient is sick it will be necessary for two people to stay with the

patient.

Advice to bring the necessary toilettries & cutleries

Smoking is not allowed in the hospital premises. Explain them about the danger of

smoking in close proximity to oxygen sources`

Explain about the doctor’s visiting trimmings depending upon the consultant and departments

Explain that doctor’s will be visiting usually daily once & then depending upon the condition

of the patient

Explain that the medical officer of the department will be visiting for any complaints

Room Orientation:

Hand over the AC /TV remote & show other items in the room

Explain about the bell-calling systems

Explain how to use telephone

Tell them politely to use the slippers for going to toilet

Take special consent for admission of psychiatric patient

APPENDIX- B / PATIENT’S RECORD /CHART ARRANGEMENT

1 History sheet

27

2 Progress and management sheets

3 Investigation reports (Lab, scan, ct, X-ray

4 Nurses notes

5 Observation and special sheets (diabetic /neurological)

6 Input and output charts

7 TPR sheets

DEATH CHART

- Death summary

- Death certificate /Form

- Then 1-8

DISCHARCH CHARTS

- First, discharge summary

- Then 1-8

SURGICAL PATIENTS

After progress sheet

- PAC notes

- Consent

- Surgery notes

- Anaesthesia notes

- Then 3-8

OBSTETRIC PATIENT’S CHART

- After progress sheet

- Partogaph

- Labour progress

- Then 3-8

- Service notification form

- Prescription – in case of death

- Nursing assessment form

- Investigation result forms

28

- IV orders

- Personal hygiene plan

- Condition explain form

- Operation slip

- Referral letters

- Casualty prescription

- Transfer slip

- Admission slip

- Communicable disease notification form

Checking of death forms

Coversheet

Patient details

Admission coversheet

Time of death

Date of death

Death stamp

Discharge stamp

Summary filled

Inside folder

Death certificate with stamp

APPENDIX – C / FILLING DEATH FORMS AND DELIVERY FORMS

Delivery forms and death forms should be filled in the following conditions:

29

A delivery form and a death form should be given to each aborted fetus. All delivery

forms and death forms should be filled completely before handing over to relatives.

If there is no fetus, a delivery form need not be given, but a death form has to be

issued with the identification of the product of conception along with mother’s name.

eg. Name: Aishath’s (aborted membrane)

If sex of the fetus is not identified, it should be taken as a male fetus.

APPENDIX – D -CHECKLIST FOR WARD SISTERS

DAILY (Section-A)

1. Check whether- daily inventory taken.

30

- missing/borrowed items replaced.

2. ” - census (transfer in/transfer out/discharge).

3. ” - narcotics inventory taken.

- narcotics cupboard locked.

- narcotics register maintained regularly.

- narcotics cupboard key with senior staff nurse.

4. - emergency trolley (drugs/equipments/instruments).

5. ” - store room locked at all times.

6. ” - temperature/intake & output chart/files filled/updated

(during ward rounds and report giving)

7. ” - all medication sheets filled accurately

8. ” - all special investigations (USG, CT scan, ECG)

appointments, reports etc.)

9. ” - all operation slips entered on OR day/latest by the first post op-day.

10. ” - PAC’s done, consent taken (by the appropriate person)

11. ” - welfare letters are given

12. ” - linen checked, sent & returned

13. ” - infection control practices

- Waste disposal/sharp disposal

- Cleanliness/disinfection of equipments & instruments

Nursing Department 2005

14. ” - patient care components – according to the care plan.

- patient allocation

- allocated nurses go on round with doctor

- all doctor’s orders are carried out properly

- daily care given

31

- all records completed

- all registers completed.

- maintenance of intake/output chart for whom all required

(even if no doctor’s order)

15. ” - all ward equipments in working order.

16. ” - overall cleanliness /tidiness of ward

17. ” - communication between shifts

18. ” - follow up when things go wrong /broken items/missing items in the ward

19. ” - attendants handover to next shift attendants (mops dry, buckets emptied,

- dustbins emptied, kidney trays washed, dirty utility in clean state)

” - nurses and attendants report before going off duty (other shifts to the senior staff on duty)

20. ” - update the changes in the duty register in the nursing department.

21. ” - tidiness of the ward.

22. Reporting- Incidents that need immediate reporting.


WEEKLY (Section-B)

WARD STOCK

- Identifying consumables required for the next week.

- Write & send indent book to Nsg Dept.on the previous day before 12.00nn.

32

DUTY ROTA

- Send Duty Rota on Tuesday before 12.00nn to Nsg Dept.

- To be made by ward sister/in-charge nurse only

CLEANLINESS (thorough cleaning/disinfection/deep cleaning)

- treatment room

- patient unit

- clean utility room

- dirty utility room etc.

- fans, windows, etc.)

EQUIPMENT

- disinfection (trolleys/suction machine/IV stand etc.)

- serving of all equipments- oiling of trolley wheels et.

- order/replace broken items

CASE SHEETS -DISPATCH

- Charts arranged in order

- Death case sheets stamped and documents filed in order/death summary filled.

- Dispatch weekly or biweekly

CHECK AUTOCLAVED ITEMS

- Re-autoclaving after 2 weeks

(Please allocate to senior nurses/junior nurses accordingly and do over all check).

REPORTING - Necessary information (patient care/staff progress/additional requirements etc. to

the Nursing Department).


MONTHLY (Section –C)

- Reviewing a nursing procedure of a case presentation

- C/S of treatment rooms

CHECK INVENTORY (3-6 monthly) of ward stock, Equipments / machinery

33

DISPATCH equipments/instruments which cannot be repaired

EXPIRY DATE drugs and emergency medications

RECORDS & REPORTS maintenance of ward registers and files

REVIEW CLASS identifying weakest area – (present in the ward)

MONITORING staff progress/patient care (appraisal review after 6 months)

REPORTING necessary information (patient care/staff progress/additional requirements

etc. to the Nursing Department).

- Ward linen - Check total linen count

- Maintenance of paint, lights, curtains.

- Ward meetings – the special events of the month.

ANNUALLY (Section-D)

FULL INVENTORY OF WARD

NEW IMPROVEMENTS TO THE WARD –suggestions and ideas etc.

BUDGET-items required for the following year budget

LEAVE SCHEDULE OF THE STAFF

COMPLETING STAFF APPRAISAL

34

SECTION TWO

WARD SPECIFIC GUIDELINES

DAILY TASKS OF NURSES OF PRIVATE WARDS

Morning shift:

Report to the ward at 7:30 am

35

Checking inventory, emergency trolley, Narcotics

Send autoclaving items to CSSD/ collect linen from laundry

Take handover from the night shift nurses

Check the treatment charts, vital charts, Intake output charts and diabetic chart and

kick count chart

Visit patients, talk with the patients, ask how they are feeling, about patient diet,

bowel habits

Giving morning care.

Prepare patients going for surgery and labour room.

Check IV fluids and drainages, remove if there is any empty IV bottle/

Check the cannula site and operation site, wounds, for soakage

Check fetal heart

Ask mothers about breast feeding, / passed urine/me conium

Check baby’s skin for colour and dehydration

Prepare the trolley for doctor’s rounds

Collect pending investigation reports before rounds

Bed making

Check and prepare for special investigations/get appointments for (Scan, CT, X-ray,

endoscopy, audiometry, echo,)

Assist doctors to the ward round

Carry out morning orders

Administer morning medications if any

Check vital signs, if any alteration give SOS medications/other required interventions

(tepid sponging, hot water bag) / inform to doctor

Documentation

Check the overall cleanliness of the ward.

Give baby bath/ cord care/eye care/baby’s weight

Give bed baths if any/ hair wash/ any other necessary interventions (back

care/position changing)

Wound Dressings and Episiotomy care

Collect autoclaved things

Visit patients and check the present conditions

Complete the discharges as soon as possible

Vaccination of babies before 1:00 pm

36

Empty urinary drainages and measure/ maintain intake out put

Complete documentation

Hand over to the next shift

Check overall cleanliness of the ward

Go through the reading materials/message book/work assignment book

Carry out special work assignments

Report to shift in charge before leaving the ward

Second Shift:

Report to the ward at 1:00 pm

Check inventory, emergency trolley, narcotics

Take over from the previous shift


kick count chart

Visit patients, talk with the patients, ask how they are feeling, about patient diet,

bowel habits



Check fetal heart

Ask mothers about breast feeding, / passed urine/meconium

Provide breast feeding counseling


Administer afternoon medication after lunch

Check vital signs

Make the patient comfortable, put off the lights, draw the curtains, make the room

cozy for the patients, allow them to rest

Send autoclaving items to CSSD/ collect linen from laundry

Back care/change positions


Carry out special nursing interventions like, nebulization, steam inhalation, provide

hot water bag

Make the patient ready for the visiting hour

Check the cleanliness and tidiness of the ward

Complete Documentation

37


Check overall cleanliness of the ward




Evening shift:

Report to the ward at 6:00pm


Take handover from the second shift nurses


kick count chart

Visit patients, talk with the patients, ask how they are feeling, about patient meals,

bowel movements



Check fetal heart



Skin preparation/ give enema

Advise and explain about NPO for surgery and other investigations



Vital signs

Administer medication


hot water bag

Make the patient ready for sleep, draw curtains, put off the lights,



Check overall cleanliness and tidiness of the ward




38

Night duty:

Report to the ward at 11:45pm


Take handover from the second shift nurses


kick count chart

Visit patients, see whether patients are comfortable and settled for night’s sleep.



Check fetal heart



Make census/ arrange case sheets

Documentation

Wash injection trays/carbolize the trolleys/arrange the treatment room/ utility rooms

Give enema/prepare the patient for surgery/check skin preparation

Ensure about NPO status, keep patient prepared for special investigation/surgery

Morning care/bed baths


Vital signs

Administer morning medication/pre-anesthetic medications



hot water bag

Check baby’s weight and document

Check the cleanliness and tidiness of the ward



39

DAILY TASKS OF PEDIATRIC WARD NURSES

Morning shift

Report to ward on time

Check ward inventory of all biomedical equipments and stationeries

Check narcotics inventory (Should be checked by the shift in-charge: amount &

expiry date)

Check emergency trolley (check drugs for the correct amount & expiry dates,

equipments and other items for good working condition. Immediate action has to be

taken for replacing missing drugs from emergency trolley & repairing of any

equipments not in good working condition)

(IF ANYTHING IS MISSING ON INVENTORY CHECKS, IT SHOULD BE

WRITTEN IN THE MISSING BOOK AND REPLACED BEFORE SHIFT IS

OVER)

40

Take report from the previous shift nurse

Shift in-charge should check with the previous shift in-charge for any

special handover

Visit patients after report

- Communicate with patients and parents; ask regarding their condition, oral

intake, whether breakfast taken or not and regarding comfort and

inquire about their queries

- Touch the patient and feel the skin for hyperthermia or hypothermia (if felt

hyperthermia check temperature, if skin is cold cover the child

with sheet)

- Check the bedside records for correct entry of patients’ name, diagnosis,

check the temperature sheet, observation sheets and intake out

put charts for correct entry.

- If patients are on intravenous fluids check the IV site for any swelling,

phlebitis or induration. And check the IV fluid for correct

amount of drop rate

- For all dengue patients, pulses on dorsales pedis should be checked for

volume. (If you feel that the pulses are weak or not felt, check

the blood pressure immediately)

Shift in charge should allocate patients and assign work for each staff

Check the allocation book for your assigned patients and work

Visit patients and introduce yourself as their shift nurse

Make the bed and give morning care for patients as required

Prepare for doctors rounds (round trolley should be prepared with patients chart,

treatment sheets, required investigation slips and tray with torch & tongue

depressor and calculator)

Check for any pending investigations and collect the report before the rounds

Take rounds with doctors ( Ensure that report regarding patient is given to doctors on

round, all new reports are shown, show the treatment sheet and inquire about

all the medications whether to continue or discontinue or for any other

changes, ensure that parents enquiries are answered and condition is explained

by the doctors)

If investigations are ordered make memo and send samples to laboratory

41

If patients are posted for any special investigations ensure that patient is prepared and

sent to the concerned department on time

After rounds give prescription for all medications

Give morning medications and injections

Take vitals, blood pressure, temperature, pulse and respiration and if required O2

saturation.

Give midday medication and injections

Make the patient comfortable

Check the cleanliness and tidiness of unit

Receive new admissions and carry out the admission procedure

Check and supervise attendants work and whereabouts

Complete documentation (service notifications should be filled, all medications

marked, intake output and observations should be entered, write the nurses

notes as well.)

Give 2pm medication as required, inquire and assess for any new symptoms

If patients are discharged

- Inform the medical officer for preparation of discharge summary

- Explain the discharge procedure and the time it will take for discharge

preparation

- Remove IV cannula and prepare patient for discharge

- Give for payment and ensure that operation slip is attached

- Explain discharge medications, review dates and if any pending reports are

there for collection very clearly.

Handover to next shift

Check the missing book, replace any items taken in your shift

Report to ward in-charge or shift in-charge before going of

Second shift




expiry date)



42





OVER)



special handover



intake, whether lunch taken or not and regarding comfort and




with sheet)






amount of drop rate







Check for any pending reports and collect the reports and inform the reports to doctor

Check cleanliness and tidiness of ward

Prepare the unit and patient for an afternoon nap and plan nursing care so that patient

is not disturbed during this period

If pending or evening discharges are there attend to this immediately

- Inform the medical officer for preparation of discharge summary

43

- Explain the discharge procedure and the time it will take for discharge

preparation

- Remove IV cannula and prepare patient for discharge

- Give for payment and ensure that operation slip is attached

- Explain discharge medication and review dates and if any pending reports are

there for collection very clearly.

- Check the patients charts & compare the treatment sheet with the doctors

orders for the latest changes/double check whether orders are carried out

Assess patient in-between and provide nursing care accordingly

Check and supervise attendants work and whereabouts

Take vital signs and give medications or injections at evening time


marked, intake output and observations should be entered, & write the

nurses notes)



Shift in-charge should fill their checklist

Report to ward in-charge or shift in-charge before going off duty

Third shift




expiry date)







OVER)



special handover

44



intake, regarding comfort and inquire about their queries



with sheet)





phlebitis or in-duration. And check the IV fluid for correct

amount of drop rate







Check the patients charts compare the treatment sheet with the doctors orders for the

latest changes or to double check whether orders are carried out

Prepare the patient and unit for visitors visit

Give 10pm medication and injections

Identify and confirm patients who need to be fasting for investigations, surgery etc.

Check for any pending reports and collect the reports and inform the reports to doctor

Prepare the unit for night sleep and ensure that patients are not disturbed

unnecessarily

Assess patient in-between and provide nursing care accordingly ( check especially for

drop rate of IV fluids and IV check site for any inflammation)

Check and supervise the work of attendants work and whereabouts


marked, intake output and observations should be entered, write the nurses

notes as well.)



45


Night shift




expiry date)







OVER)



special handover



intake, whether breakfast taken or not and regarding comfort and



hyperthermic check temperature, if skin is cold cover the child

with sheet)






amount of drop rate




46




Explain nil per oral orders to parents as required

Prepare the patient and complete everything for morning

Plan nursing care so that patient is not disturbed during sleep

Visit patients frequently and observe the IV sites for disconnections, swelling and IV

drop rates

Ask the attendant to clean all areas of ward, wash trays and supervise their work

Ensure that patient take a feed before morning medication

Check vitals and give 6am medication/injections as required, inquire and assess for

any new symptoms

Send early morning investigations and collect the reports before rounds

If patients are posted for any special investigations ensure that patient is prepared

Check the cleanliness and tidiness of unit

Receive new admissions and carry out the admission procedure


marked, observations entered, and intake output calculated for 24 hours and

nurses notes written.)




DAILY TASKS OF MEDICAL WARD NURSES

FIRST SHIFT

Report to ward on time.

Check ward inventory (check whether all the equipments are in working condition

and if there are any thing missing get it replaced by the previous shift nurses).

Check narcotics inventory. (Check whether any narcotics have been used in the

previous shift and see that it is entered in the narcotics register).

47

Check the emergency trolley (check whether all equipments are in working

condition).

Check the daily census

Check the general cleanliness of the ward

Send linen to laundry/ Send Physio referral book and CSSD items

Take report from the previous shift

Visit patients after report and check patient’s condition (sleep, breakfast, comfort,

e.t.c.)

Check IV fluids/drainages/catheters)

Check vital signs for necessary patients & document

Prepare for doctors rounds.

Collect all due investigation results from the concerned departments

Give any due medications/feeding etc.

Do rounds with doctors & make sure that patient’s condition is explained to the

relatives

Check & identify the necessary medications that are over

Carry out due orders.

Send notification for cases with communicable diseases

Send required investigations and take appointments from other departments as needed

Check, prepare patients going for special investigations (USG, CT scan, X- ray,

endoscopy e.t.c)

Check preparation & send patients for the above investigations on time

See that autoclaved items are collected from the CSSD.

Report any unusual incidence to the shift coordinator.

Complete documentation.

Sponge bath & morning care

Monitor the morning care (senior nurses)

Change dressing

Change of tubes, catheter etc

Check vitals

Maintain I/O charts

Carrying out doctors orders

Do a round to check the patient’s condition

48

Make patients comfortable

12.00 n. change of position of bed ridden patients (change nappy)

Complete documentations

Pack used trays and clean/disinfect the treatment room

Check if all the above is done

Make necessary preparations to send the discharged patients home

Handing over to the next shift

Take / assist in the special treatments (nebulizations, dressings, Ambulations, sit up

on chair

Check cleanliness of the ward / unit

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

SECOND SHIFT







condition).

Check the census



Visit patients after report and check patient’s condition (about rest / sleep, lunch,

comfort, e.g.)



Prepare for doctors rounds if necessary

Do rounds & carry out orders prioritizing them



49



Make the patients comfortable


Prepare patients for afternoon rest (draw curtains)

Check & prepare patients going for special investigations not completed in the

morning (scan, CT, X-ray, endoscopy)

Giving injections, nebulizations

Administering medications, giving NG feeds

Back care /change of nappy & positioning of bedridden patients

Send used linen / used trays to Laundry & CSSD

Collected items from the CSSD & laundry


Maintain I/O charts and check vital signs

Re-check doctors orders

Complete documentations & hand over to the next shift

Check the cleanliness of the ward / unit


THIRD SHIFT Report to ward on time






condition).




Visit patients after report and check patient’s condition (about rest & comfort, e.g.)

Check IV fluids/drainages/catheters



50


Carry out any due orders

Do a round & check patient’s condition



Check, prepare & give specific instructions for patients going for special

investigations in the next morning (e.g: fasting, full bladder )

Administer medications, and carry out procedures e.g dressing, feeding etc.


Prepare patients / unit for sleep (draw curtains / switch off necessary lights)

Send used linen to laundry


Maintaining I/O charts / observation chart / vitals chart / Diabetic chart

Check cleanliness & tidiness of the ward



NIGHT SHIFT Report to ward on time






condition).

Complete the daily census








51



Inform the concerned doctors about any deterioration in the patient’s condition



Check, prepare & ensure that the instructions are understood by the patients going for

special investigations in the next morning (e.g: fasting, full bladder )




Complete I/O charts / observation chart / vitals chart / Diabetic chart


Check the routine cleaning of the ward (washing of all the medication cups and all the

trays).

Check and arrange patient files

Check & prepare the registers & books in the ward

Identify medical patients in other wards & update the notice board

Give early morning care, back care & change position

Check vital signs

Give early morning injections & medications

Collect lab. samples make memos & send them to lab

Pack used articles & keep them ready for autoclaving

Check general cleanliness of the ward



52

DAILY TASKS OF GYNAE WARD NURSES

Morning shift


Check ward inventory and emergency trolley

Check narcotics inventory

Check FHS of the antenatal patients and whether the patient has maintained kick

count chart by the allocated staff

Check the treatment charts and baby charts whether medication had been given

Take report form the previous shift nurses (targeted time is before 7:45am)

Visit patients after report and check patient’s condition (about sleep, comfort,

contraction, bleeding, feeding, etc.)

Give morning care

Assess the patients who are having contractions and inform SOS by the allocated staff

Check for blood investigation reports, and get them from the lab, before rounds.


Check and prepare patients going for special investigations (scan, CT, X-ray,

endoscopy, NST).

Check, prepare and send patients for the above investigations/ surgeries on time.

Give morning medications

Check vitals, FHS and kick count chart

Give perineal care and check for bleeding PV for cases like post natal mothers, post

operative cases, threatened abortion cases etc

53

Check IV fluids and drainages.

Do rounds with Doctors.

Carry out orders.

Do a round and check the patients’ condition.


Give health education for the patients

Check the cleanliness and tidiness of the ward.


Complete the discharges as soon as possible.

Give bath for babies

Take babies for vaccination

Send blood investigations.

Send patients for other investigations.( scan, NST, BPP and surgeries as required)

Take/ assist in the special treatments (nebulizations, dressings, patient activity, sit up

on chair, ambulation)

Give perineal care for the postnatal mothers

Make patient comfortable.

Give SOS medication if necessary.

Maintain intake output chart

Check whether back care and positions are changed as required.


Check the cleanliness and tidiness of the ward/ unit.

Hand over to next shift.

Report to ward in charge or shift in charge before going off duty.

Write the leaving time in the over time sheet if stayed after 2:30pm by the shift in

charge

Afternoon shift




Check FHS of the antenatal patients and whether maintained kick count charts by the

allocated staff

54


Take report form the previous shift nurses.

Visit patients after report and check patient’s condition (about rest, lunch,

comfort – repositioning, room temperature, quietness of the room, sleep

etc)

Prepare patients for afternoon rest (draw curtains).

Check and prepare patients going for special investigations and surgeries not

completed in the morning (scan, CT, X-ray, endoscopy).

Check whether any patient has to be prepared for special investigation or surgeries for

next day.

Check, prepare patients for the above investigations.

Check for blood investigation reports, and get them from the lab.

Give afternoon medications

Check vital signs, FHS and kick count chart




Do a round and check the patients’ condition.

Make patients comfortable.


Give sos pain killers and keep patient ready for visitors.




Take/ assist in the special treatments (nebulizations, dressings etc.)

Take/ assist in checking the vitals.


Make patients comfortable, and tidy the ward.




Report to ward in charge or shift in charge before going off duty

Write the time of leaving if stayed after 8:00pm by the shift inchrge

55

Evening shift






allocated staff


Visit patients after report and check patient’s condition (about rest, comfort –

repositioning, room temperature, quietness of the room, sleep medication, pain

medication, etc.)

Check for urgent blood investigation reports, and get them from the lab..

Give evening medications and injections.

Make patient comfortable for dinner.






Do a round in the ward and check patients’ condition.

Explain the procedure about IOL for the posted patients

Patients who are posted for surgeries, fasting to be explained

Make sure all surgery patients has done PAC, Local preparation, all routine

investigation, cross match, consent etc


Carry out any emergency orders.

Take/ assist in the special treatments (nebulizations, dressings, patient activity like

ambulation, sit up on chair etc.)


Check and make patient comfortable for the night.

Give SOS medication if necessary.


56




Write the time of leaving if stayed later than 1pm by the shift incharge

Night Shift





allocated staff



Visit patients after report and check patient’s condition (sleep, comfort –

repositioning, room temperature, quietness of the room, sleep medication, pain

medication, etc.)

Complete the census.


Check the routine cleaning of the ward for the previous day (washing of all the

medication cups, all the trays like IV tray, mouth care tray, injection tray etc.).

Check IV fluids, drainages etc.

Do a round in the ward and check patients’ condition.


Identify and confirm patients who need to be fasting for investigations, operations etc.

Complete the documentation.





Check weight for PIH patients as required

Check urine sugar and urine albumin for patients with PIH and GDM

Start IV fluids for all surgery cases by 6am.

Give enema for patients who are posted for surgeries and IOL

57

for major surgeries like LSCS, Hysterectomy, do catheterization

Give early morning care, back care and change of positions as required.

Give early morning injections and medication.


Send things for autoclaving


Shift the first case to OT by the allocated staff when OT informs

Start shifting IOL patient to the L/R by the allocated staff



Record going off time if exceed after 8:00am by the shift in charge

Special points to remember

All the un usual incidents to be reported to the coordinator

Any case of MLC admitted to the ward should be informed to the coordinator and

MLC form should be completed by the GMO and send it to CEO office on the

following day

Send all the charts for dispatching to medical records when the patient is discharged

All unmarried mothers should be informed to counseling coordinator

Any IUFD, high risk patients, sick patients should be informed to coordinator

Gynae ward standing order to be followed by all the staff (eg, checking FHS 2 hourly)

Vaccination protocol should be followed

Work as a team and build good relationship between coworkers

58

DAILY TASKS OF ENT WARD NURSES

Morning shift


Check ward inventory.

Check narcotics inventory.

Take report from the previous shift nurses.


Visit patients after report and check patient’s condition (about sleep, breakfast,

comfort, etc.)

Check prepare patient’s going for surgery.

Give morning care.

Check soakage of dressing color of finger of pop hand /leg.

Check and prepare patients going for special investigations (scan, CT, X-ray,

endoscopy).

Check, prepare and send patients for the above investigations on time.

Check for blood investigation reports, and get them from the lab, before rounds.

Give morning medications and injections.

Monitor the morning care (senior nurses).

Check IV fluids and drainages. positions, tractions

Do ward rounds with Doctors.

Carry out orders.

Do a rounds check the patients’ condition


59




Send blood investigation.

Send patients for other investigations.

Take/assist in the special treatments (nebulizations, dressings, ambulations, sit up on

chair), exercises of finger pop hand / leg.

Take/ assist in checking the vitals pulse of pop hand.

Make patient comfortable.

Give sos medication I check soakage of dressing necessary.



Check the cleanliness and tidiness of the ward/unit.


Report to ward in charge or shift in charge going off duty,

Doctors round start at 7:45am

Afternoon shift


Check ward inventory


Take report from the previous shift nurses.

Visit patients after report and check patient’s condition (about rest, lunch, comfort-

repositioning, room temperature, quietness of the room, sleep etc.)

Check soakage of dressing.


Check and prepare patients going for special investigations not completed in the

morning (scan, CT, X-ray, endoscopy.)

Check whether any patient has to be prepared for special investigation for next day.

Check, prepare patients for the above investigations.

Check for blood investigation reports, and get them from the lab.

Give afternoon medications and injections.

Check IV fluids and drainages positions of tractions

60

Do a round and check the patient’s condition.

Check soakage of dressing.



Give sos pain killers and keep patient ready for visitors.

Complete the discharge as soon as possible



Give and /assist in the special treatments (nebulizations, dressings etc), Exercise of

finger of pop hand leg.


Make patients comfortable, and tidy the ward.

Check soakage of dressings




Preparation of patients for surgery (shaving consent etc).

Evening shift



Check narcotic inventory

Take report from the previous shift nurses,

Visit patients after report and check patient’s condition (about rest, lunch, comfort-

repositioning, room temperature, quietness of the room, sleep etc.)

Check soakage of dressing and color of finger of pop hand /leg.

Check for urgent blood investigation reports, and get them from the lab..

Give evening medications and injections

Make patient comfortable for dinner.





61



Check whether back care and positions are changed as required

Take/assist in the special treatments (nebulizations, dressings, Exercises of finger pop

hand / leg.

Give/ assist in checking the vitals and check pulse of pop hand/leg

Give sos medication if necessary.

Check and make patients comfortable for the night.





Night Shift




Take report from the previous shift nurses,

Visit patients after report and check patient’s condition (sleep comfort-repositioning,

room temperature, quietness of the room, sleep medication sos.)

Check soakage of dressing and color of fingers of pop hand /leg.

Complete the census.


Check the routine cleaning of the ward for the previous day (washing of all the

medication cups, all the trays like IV tray, mouth care tray, injection tray etc.

Check IV fluids and drainages position and tractions.



Identify and conform patients who need to be fasting for investigations, operations.


Take/ assist in checking the vitals and pulse of pop hand/leg

Give Early morning care, back care and change of positions as required,

Give early morning injections and medication.


62




SHIFT ROUTINES FOR SURGICAL WARD NURSES

FIRST SHIFT






Check the emergency trolley (check if all equipments are in working condition).





Visit patients after report & check patient’s condition (sleep, breakfast, comfort, e.t.c.)


Check & prepare patients going for surgery

Send patients for surgery as per request from OT

Give morning care

Check soakage of dressings


Receive patients from OT

Monitor the immediate post operative cases



Give due medications


relatives


63




Check, prepare patients going for special investigations (USG, CT scan, X- ray,

endoscopy e.t.c)







Change dressing


Check vitals

Maintain I/O charts




12.00 nn. change of position of bed ridden patients (change nappy)


Pack used trays and clean/disinfect the treatment room / dressing trolleys




Take / assist in the special treatments (nebulization, dressings, Ambulation, sit up on

chair)

Check cleanliness & tidiness of the ward / unit


SECOND SHIFT




64




condition).

Check the census




comfort-repositioning, room temperature, quietness of the place e.t.c)

Monitor the immediate post-operative cases

Check IV fluids/drainages/catheters/soakage ofdrssings)


Prepare for doctors rounds if necessary if needed











Prepare patients posted for surgery (shaving, consent etc)

Administer medications (SOS /routine), give NG feeds

Check IV fluids/drainages/catheters/soakage of drssings)









65

Handover to the next shift








condition).















Give specific instructions to patients posted for surgery








66









condition).





Check IV fluids/drainages/catheters/soakage of dressings






Check immediate post operative cases







Give early morning care , back care and change of positions as required





trays).

67




Check vital signs







DAILY TASKS OF ISOLATION WARD NURSES

FIRST SHIFT







condition).





Visit patients after report and check patient’s condition (sleep, breakfast, comfort,

e.t.c.)

Take appropriate infection control measures while visiting patients

Ensure if all personal protective equipments are available for the day




68




relatives





Check, prepare patients going for special investigations (USG, CT scan, X- ray, e.t.c)







Change dressing


Check vitals

Maintain I/O charts




12.00 n. change of position of bed ridden patients (change nappy)


Pack used trays and clean/disinfect the treatment room trolleys



Disinfect cubicles after patients leave the room


Take / assist in the special treatments (nebulizations, dressings, Ambulations, sit up

on chair

Check cleanliness of the ward / unit

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

69

SECOND SHIFT







condition).

Check the census




comfort, e.g.)

Take appropriate infection control measures while visiting patients



Prepare for doctors rounds if necessary









Remind to mimize visitors during the visiting hours



Giving injections, nebulizations

Administering medications, giving NG feeds




Disinfect cubicles after patients leave the room

70













condition).




















71











condition).





















72


trays).



Identify medical patients in other wards & update the notice board


Check vital signs







73

DAILY TASKS OF ACCIDENTS AND EMERGENCY DEPARTMENT NURSES Morning (1 st shift), Afternoon (2 nd shift) & Evening (3 rd shift);


Check inventory (ER, narcotics, dressing room, procedure room)

Take report from the previous shift nurses

Visit patients during taking over and check patients’ condition

Receive the new patients and accompany/direct them to the bed

Make patients comfortable; ask the patient’s complaints

Take/assist in checking vitals, procedures

Inform the concerned doctor and attend patients along with doctors

Carry out doctor’s orders

Administer stat medications immediately

Monitor patients’ conditions frequently till stable

Check IV fluids, drainages (if any)

Send lab investigations on time and collect reports on time

Take /assist in the special treatments (nebulizations, dressings, etc)

Do a round and check patients' condition from time to time

Complete documentations of all procedures (maintain the census register properly)

Try and shift all admissions to the respective wards as soon as possible


Inform all incidences (minor/ major) to shift-in-charge at all times

Keep ER ready at all times

Maintain the cleanliness and tidiness of the casualty complex

Keep casualty complex (dressing room, procedure room, blood bank,) ready at all

times

Maintain a professional relationship with other team members

Report to shift-in-charge when ever leaving ER

Hand over to next shift staff

Report to next shift-in-charge before going off duty

Night (4 th shift);

74


Check inventory (ER, narcotics, dressing room, procedure room)

Take report from the previous shift nurses

Visit patients during taking over and check patients’ condition

Receive the new patients and accompany/direct them to the bed

Make patients comfortable; ask the patient’s complaints

Take/assist in checking vitals, procedures

Inform the concerned doctor and attend patients along with doctors


Administer stat medications immediately

Monitor patients’ conditions frequently till stable

Check IV fluids, drainages (if any)

Send lab investigations on time and collect reports on time

Take /assist in the special treatments (nebulizations, dressings, etc)

Do a round and check patients' condition from time to time

Complete documentations of all procedures (maintain the census register properly)

Try and shift all admissions to the respective wards as soon as possible


Inform all incidences (minor/ major) to shift-in-charge at all times

Clean and maintain the tidiness the casualty complex (dressing room, procedure

room, blood bank) and keep ready for morning shift

Keep casualty complex (dressing room, procedure room, blood bank, ER) ready at all

times

Maintain a professional relationship with the other team members

Report to shift-in-charge when ever leaving ER

Hand over to morning shift staff

Report to morning shift-in-charge / ward sister before going off duty

DAILY TASK OF ICCU NURSES

75

7.30 am – Report for duty

7.30 am to 7.45am

Check inventories (narcotics, daily drug inventory, daily inventory, emergency trolley

etc). Replace if anything is missing from emergency trolley

Enquire about missing items, broken things and clear all doubts before taking the

report

Count and enter laundry linen

Count and send CSSD things

7.45am to 8.15am – Take patient report from previous shift nurses

8.15am to 8.30am - Take over special instructions and check allocated patients

8.30am 8.45 am – Bedside take over of individual assigned patients

Check at bedside

All allocated patient’s chart whether it is completed or not

All IV lines / IV sites / IVF balance and labels / any drugs added / CVP lines / dialysis

catheter (if any) in situ.

If urine catheter in situ check urine bag (colour and amount if any urine present)

Loaded injections balance and labels (if any)

Unit cleanliness and left over food containers

If patient on ventilator – check whether tubings are connected properly and water

collection in the tubings and drain cups / check humidifier if water to be filled

Check current settings of the ventilator

Check whether test lung and test tube are on the ventilator and nebuliser is attached to

the ventilator

Check bedside oxygen cylinder whether it is full, ambu bag with oxygen connection

and reservoir bag is ready in good working condition

Cardiac monitor for rhythm and whether chest leads are properly connected or not and

whether finger pulse probe is connected or not

76

Whether bedside equipments (suction machine / infusion pumps / cardiac monitor etc)

are in good working conditions

Whether all nursing interventions are recorded legibly / any investigations pending /

any reports to be collected

Specific interventions like I/O of the patient / vital signs / saturation / oxygen intake /

CVP ( if on ventilator) / sleep pattern / personal hygiene / bowel

8.45am to 9.00am

Check vital signs and record

Assess patient’s conscious level and pupil reaction

Assess GCS for relevant patients

Endotracheal suctioning and oral suctioning (for ventilator patients) – observe

secretion (amount and color)

Flush arterial line (if present) every hourly or as ordered

Check patient’s file ( read nurses notes and doctors orders)

Compare treatment chart with doctors orders

Attend ward round


Make sure the relatives are explained about the patient condition by the treating

doctor

Check all medicines and get prescription from the doctors

Receive laundry items and CSSD items, count and replace

Inform shift in-charge if any balance remaining

9.00am to 10.00am


Inform any abnormalities and carry out orders

Do suctioning if necessary

If patient is getting RT feeding Q3hrly, give the feed list and explain the relatives (if

not done previously)

Give feeding and record

If patient is on normal diet request the relatives to bring food and serve to the patient

77

Empty and wash the food containers. Do not leave unfinished food in the locker

For patients on ventilator, give back care and observe the skin for skin laceration,

bedsores, edema, and any other skin problems

Give sponge bath or toilet bath for other patients

While giving mouth care check whether patient has loose teeth, bleeding gums, dry

and cracked lips, tongue if coated etc

While giving back care and turning the patient, check whether the air mattress is

working or not (if it is there)

While giving catheter and perineal care observe the perineum and catheter site for any

abnormalities. Inform the duty medical officer and carry out orders

Give catheter care with betadine solution by using aseptic technique

Clean perineal area with soap and water

Give hair wash every Saturday

Flush CVP line and measure CVP (if on ventilator) and record

Maintain hygiene chart

Check, prepare and send patients for special investigations on time

Assist in physiotherapy sos

Change position as advised

Start writing nurses notes

10.00am to 11.00am

ET and oral suctioning if necessary


Any abnormalities inform to duty medical officer and carry out orders

Re-check vitals after carrying out orders (eg: if temperature is high)

Keep all the patients ready for visitors

Check the cubicles and make the patient neat

11.00am to 12.00pm

78


Allow one relative at a time to visit the patient

Spend time to talk with them and clarify their doubts

Give prescription if any

If any other items like toiletries or drinking water is finished, ask the relatives to get it

Receive the CSSD things, count and replace all items

Take a break of 10 -15 minutes during this time (two staff can go together)

12pm to 1.15 pm


Inform and carry out orders if any abnormalities

Administer due medication if any

RT feed if patient is on Nasogastric feeds

Serve lunch for those on normal diet

Record in I/O chart

Check ventilator tubings again. If water is collected empty drain cups and tubings

Refill humidifier with sterile water (if necessary)

Complete nurses notes and re-check whether the chart is complete or not

Go through page by page and check whether all information is complete or not

Keep patient and cubicle clean

If any bed is vacant prepare the cubicle and keep ready to receive another patient

Check if any equipment or any place needs a repair work and inform

If any item is borrowed make sure it is returned or else report it to the next shift

nurses

Report if any item is given to another ward. Try to get it back before you hand over to

next shift nurses

Check whether patient has to replace any drugs. If so, replace it before you hand over

Check the emergency trolley and make sure it is ready to use

Check all ventilators not in use and keep it ready for next use

Check defibrillator and ECG machine and keep it ready for next use

Check and keep the standing wreck ready. Replace all the items

79

Check whether attendants have completed their work (sweeping, mopping, cleaning

toilets, changing sodium hypochlorite, emptying dustbin, laundry, CSSD things,

washing slippers, gloves washed and packing, changing rubber sheets etc)

Check the over all cleanliness of the ward is maintained or not

Be ready to handle any emergencies in the ward. Do not neglect other patients while

you attend emergencies

If patient is on ventilator, check the timings for medications and administer

accordingly

Collect all reports of investigations sent and enter where appropriate

Complete your work and chart including round order book

Complete the registers as appropriate

Enter all services rendered in the service notification book

1.15 pm to 1.45 pm

Give a detail report of your patients and handover to the next shift nurses

Allow the next shift nurse to check patient’s bedside and charts

Give her time to clarify her doubts before you leave

1.45 pm to 2.30 pm

Wash and pack all the trays used

Write your name and date legibly while keeping trays for autoclave

Arrange nurses counter

Attend any emergencies during that shift

Report to shift in-charge of the next shift before leaving the ward

SECOND SHIFT

80

1.00 pm – Report for duty

1.00 pm to 1.15 pm




report

1.15 pm to 1.45 pm – Take patient report from previous shift nurses

1.45 pm to 2.00 pm - Take over special instructions and check allocated patients

2.00 pm to 2.15 pm – Bedside take over of individual assigned patients

Check at bedside









Check for whether test lung and test tube are on the ventilator and nebuliser is

attached to the ventilator


Bedside oxygen cylinder whether it is full and whether ambu bag with oxygen

connection and reservoir bag is ready and in good working condition







81



2.15pm to 2.30pm


Assess patient’s conscious level and pupil reaction (SOS)



Flush arterial line (if present) every hourly or as ordered



Attend ward round (sos)


Make sure the relatives are explained about the patient condition by the treating

doctor

Check all medicines and get prescription from the doctors (if any)

2.30 pm to 3.30 pm





not done previously)




For patients on ventilator give back care and observe the skin for skin laceration,

bedsores, edema, and any other skin problems








82


Change position as advised

Check, prepare and send patients for special investigations on time (if not sent in the

morning)

Prepare patients for afternoon rest


3.30 pm to 4.30 pm





Check the cubicles and make the cubicle and patient neat

Check and count the laundry things and CSSD things with the attendants

Send laundry and CSSD things

4.30 pm to 5.30 pm


Keep all the patients ready for visitors



Receive laundry things, count and replace


Take a break of 10 -15 minutes during this time (maximum two staff can go together)

5.30 pm to 6.15 pm




RT feed if patient is on Naso-gastric feeds

Serve a snack if on normal diet

Record in I/O chart

83

Allow one relative at a time to visit the patient

Spend time to talk with them and clarify their doubts

Check ventilator tubing again. If water is collected empty drain cups and tubing








nurses


next shift nurses





Check and keep the standing rack ready. Replace all the items







Communicate with the shift in-charge always

If patient is on ventilator, check the timings for mediations and administer

accordingly





6.15 pm to 6.45 pm

84




6.45 pm to 8.00 pm

Wash and pack all the trays used

Write your name and date legibly while sending trays for autoclave



THIRD SHIFT


6.00 pm to 6.15 pm




report

6.15 pm to 6.45 pm – Take patient report from previous shift nurses

6.45 pm to 7.00 pm - Take over special instructions and check allocated patients

7.00 pm to 7.15 pm – Bedside take over of individual assigned patients

Check at bedside






85















7.15 pm to 7.30 pm





Flush arterial line (if any) every hourly or as ordered




Check all medicines and get prescription from the doctors (sos)

a. pm to 8.30 pm





not given previously)




86

Give back care and observe the skin for skin laceration, bedsores, edema, and any

other skin problems



Give back care and catheter care





Flush and measure CVP (if on ventilator) and record


Change position as required


8.30 pm to 9.30 pm





Check the cubicles and make the patient neat

Receive CSSD things (if ready), count and replace all items

Inform shift in-charge if not received or if any balance remaining

9.30 pm to 10.30 pm




Administer medications if any

Take a break of 10 -15 minutes during this time (maximum two staff can go together)

10.30 pm to 12 midnight




87

RT feed if patient is on Naso-gastric feeds

Serve dinner for those on normal diet


Record in I/O chart

Check ventilator tubing again. If water is collected, empty drain cups and tubing








nurses


next shift nurses





Check and keep the standing rack ready. Replace all the items




Check and count the laundry things and send to laundry




Supervise attendants at all times


12 midnight to 1.00 am

88



Administer any due medications


accordingly


Receive laundry things, count and replace all linen








Pack all the trays used and send it for autoclave




NIGHT DUTY


11.45 pm to 12.00 am




report

Arrange to send the service notification book to counter

Make the midnight census

Prepare the shift in-charge book and ward round book

89

12.00 am to 12.30 am – Take patient report from previous shift nurses

12.30 am to 12.45 am - Take over special instructions and check allocated patients

12.45 am to 1.00 am – Bedside take over of individual assigned patients

Check at bedside




















1.00 am to 1.15 am






Arrange patient file

Replace necessary sheets and file extra sheets from the chart board


90

Carry out doctor’s orders (if any)

Check all medicines and get prescription from the doctors (SOS)

1.15 am to 3.15 am








Check ventilator tubing again. If water is collected empty drain cups and tubing






If any item is borrowed make sure it is returned or report it to the next shift nurses


next shift nurses





Check and keep the standing wreck ready. Replace all the items




Check and count the laundry things and CSSD things with the attendants





91

12 midnight to 1.00 am



Administer any due medications


accordingly








Pack all the trays used and send it for autoclave



Attend any emergencies during that shift



DAILY TASKS OF O.P.D NURSES

Morning Shift



Arrange the consulting rooms for morning shifts doctors.

Send and receive items from C.S.S.D.

Check the temperature of fridge and record.

Check the laundry linen.

Start the dressings and injections on time.

Sending samples to laboratory.

Assisting the cases with the doctors in minor O.T.

Preparing for the vaccination for the new born and routine vaccination.

Inspection the conditions of the patients wounds.

92

Check the cleanliness and tidiness of the rooms and area.

Washing and packing the instruments.

Giving of I /V and I/M injections.

Carbonizing of the beds and trolleys.

Cleaning the rooms for the 2nd shift.

Handing over to the 2nd shift.

Afternoon shift

Report to the ward on time.


Taking over from the 1st shift.

Continue vaccination.

Continue dressings and injections.

Sending specimens to laboratory.

Assisting cases in minor O.T.

Sending and collecting things from C.S.S.D.

Cleanliness of the rooms.

Carbonizing of the beds and rooms.

Check the cleanliness and tidiness of the rooms and area.

Hand over to the 3rd shift.

Evening Shift ( 3 rd Shift)

Report to the ward on time.


Taking over from the 2nd shift.

Arranging the rooms.

Continue of the dressings and injections.

Assisting of minor cases in minor O.T.

Check the cleanliness of the rooms and area.

Carbonizing of rooms.

Prepare for closing the rooms.

93

DAILY TASK FOR STAFF WORKING IN THE DIALYSIS UNIT

MORNING SHIFT

Report ward on time

Check the ward inventory


Rinse the RO machine

Disinfection of dialysis machine

Check pre-dialysis weight and vital signs of the patient


Check and send pre-dialysis investigations if necessary

Check fistula /catheter site

Start dialysis

Monitor vital signs ½ hourly

Observe complications like hypotension,,nausea,vomiting,headache etc

Collect blood reports

Inform the doctor if necessary

Carry out any emergency orders


Check the cleanliness and tidiness of the ward / centre

Prepare disinfectant solution ( clear surf )

Terminate the dialysis after completion

Check and send post dialysis investigation if necessary

Do pressure dressing to access site

Disinfection of the dialysis machine

94

Clean the dialysis machine with clear surf and carbolize the bed

Keep the patient for observation( at least for 15 mnts)

Send the patient home with the relative

Hand over to next shift


AFTERNOON SHIFT

Report ward on time



Take report from previous shift nurses

Visit patients after report and check patients’conditions

Check pre-dialysis investigation, weight and vital signs of the patient



Start dialysis


Observe for any complications like hypotension,nausea,vomiting,headache etc


Inform doctor if necessary





Check and send send post dialysis investigation if necessary

95






Hand over to next shift


EVENING SHIFT

Report ward on time



Take report from previous shift nurses

Visit patients after report and check patient’s conditions

Check pre-dialysis investigations, weight and vital signs of the patient



Start dialysis


Observe complications like hypotension, nausea, vomiting, headache etc


Inform doctor if necessary




96


Check and send post dialysis investigation if necessary






Check the routine cleaning of ward for the next day (washing of all the medicine cups,

trays and clean trolleys etc.)

Write down in communication book if anything special happens

THEATRE GUIDELINES

THEATRE LISTS

1. Theatre list should be sent on the previous day before 17:00 hrs to theatre and wards

97

2. Cases with co-morbidity, (e.g. Diabetes, HTN,COPD) should be well prepared and

well communicated with concern anaesthetist and concern staff, in order to avoid last

minute cancellations of the case

3. Anaesthetist should do a preliminary check up of PAC workup on the night before

surgery

4. The theatre list should mention any special needs the case might have (e.g. C-arm,

change of or table, instruments, ICU bed)

5. Theatre list would accommodate cases such that the list should finish on time at the

end of the OT day. The emergency team (anaesthetist/theatre staff) should not be

over burdened with routine cases

6. If an emergency list was brought forward it should be entertained first in spite of

the nature /type of surgery (there is no emergency/semi emergency or less

emergency cases).

7. In case if there is an LSCS and another emergency then preference will be given to

the LSCS

8. No operating department should take advantage and utilize other department

OR’s saying they have an emergency. i.e. they should accommodate emergency list

in their ongoing list. If an emergency occupies another departments OR on their

Operation day then the respective department to be given the OR which empties first.

9. The time taken by the emergency would be compensated at the end of the list (i.e. if

an hour taken by the emergency case, then the theatre will function till 15:00 hrs

instead of 14:hrs)

10. If any one wants to use the theatre on days which are not theirs then permission

must be obtained from the sister in-charge of the theatre and the surgeon concerned

11. In the event of a procedure has to be changed or done by the surgeon for which

consent has not been obtained, this must be immediately informed by the responsible

staff in that OR to the relative who had signed the consent form. After the surgery is

over it is the duty of the attending surgeon to call the relative and explain the reason

for the procedure.

PREPARATION OF THE THEATER

1. Cleanliness

Check whether the theatre is clean enough to start surgery.

98

2. Sterility status

Check whether the theatre is carbolized thoroughly, if it is the first case in the

morning.

Carbolize the bed, mayo stand instrument trolleys in between cases.

3. Anaesthesia machine

Check whether the machine is functioning properly. All necessary connections are

working.

Check the colour of soda lime, no leakage from any tubing’s or breathing bag.

Laryngoscope and other necessary items are available and working.

4. Drugs

Keep all the necessary drugs ready and check the expiry date. Make sure the drug

was stored at the correct temperature.

5. Sets and bundles

Check the label for correct set, the autoclave tape for sterility and date of

autoclaving.

Arrange the sets and bundles in the correct places.

6. Consumables

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

7. Equipments

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

8. Lighting

Check the light whether it is working and adjust them

99

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

FLOOR NURSE

1. Make sure that you strictly follow the instructions which are placed on the walls of

scrub area.

2. Make sure that all the aseptic procedures are followed during and after scrubbing

3. If the circulating/ floor nurse find you unsterile please change your gown & gloves.

4. Do not open the second layer of the bundle or the set unless you are scrubbed,

gowned and gloved.

5. Scrub nurse’s gloves has to be open and given to her/his hand by the floor nurse once

he /she is scrubbed & gowned

6. Do not open gloves, sutures or any sterile item straight to the operating table or field.

Give them to the scrubbed nurse instead.

7. Make sure that all surgical appliances (cautry machines, suction machine, incubator,

warmer, extension boards, and instruments) are in proper order.

8. Make sure that you are properly covered through out the surgery.

9. Make sure that the sterile field is maintained.

10. Be aware that you are sterile at all times.

11. When ever you or team finds that some thing is unsterile please correct it then and

there.

12. Do not let unscrubbed staff to enter the sterile field.

13. Maintain proper count and documentation.

14. Scrub nurse and circulating/floor nurse should take count together.

Thank you for your cooperation .it’s the patient who will benefit and it is us who will be

satisfied at the end of the day.

100

100

PROTOCOLS TO BE FOLLOWED IN THE OPERATING ROOMS

1. Protective gloves are to be worn at all times when working with potentially

contaminated materials.

2. The major door to the operation room is just being used for bringing and taking the

patient only.

3. Go to the operation room when it is really necessary.

4. Use one small door for getting in and out of the operating room when cases are

going on.

5. The doors to the operating rooms should always remain closed.

6. The number of staff present in OT and the staff movement should be limited to

minimum.

7. Sterile gowns are to be worn after scrubbing.

8. Discussions / conversations between theatre staff during an operation should be

limited.

9. The surgical hand disinfection (scrubbing) is to be followed according to the

instructions which are placed on the walls of scrub area.

10. After every surgical case, the operating team must dispose their gloves and gowns in

the allocated areas.

101

101

PROTOCOLS TO BE FOLLOWED WHILE IN OPERATION THEATRE COMPLEX

1. All personnel should change into theatre clothes in the allocated changing rooms.

2. Under garments (like petticoat and baniyan) should not be visible.

3. The hair must be completely covered by the theatre caps.

4. Jewelries on the hands and forearms, as well as wrist watches are not permitted.

5. Nail polish (colored and colorless) is not permitted.

6. Before entering all operating areas, a face mask must be worn. this must cover the mouth

the nose and all facial hair (e.g. beards moustaches).

7. To leave the operating theatre with surgical attire is prohibited.

8. The OT staffs must change their facial mask when ever necessary ( e.g. when moist)

9. Face mask should not be kept hanging at the neck, instead should be removed and kept in

pocket if not wearing.

10. Used theater attire must be disposed off properly to the allocated hampers in the

respective change rooms.

11. A hygienic hand disinfection is necessary before entering and leaving the operating theatre

before sterile procedures

after possible contamination (cleaning the nose,visiting the toilet)

Before and after cleaning the patient.

12. Only the theatre staff and the surgical team can enter theatre.

13. Outside staffs should get permission from the theatre in-charge before entering the theatre at all times.

14. Foot wear is to be changed whenever soiled with body fluid

15. Eating or drinking is prohibited out side tearoom.

(Pay attention to change of plans).

102

102

ROUTINE CLEANING OF OPERATION THEATRE

Daily cleaning

Carbolize with carbolic solution after every case and with hypochlorite solution every morning

OT 1/2/3

Scrub room 1/2/3

Clean utility 1/2

Dirty utility 1/2/3

Sterile corridor

Sterile store

Equipment store

Weekly cleaning

Wash with washing detergent and water and clean with hypochlorite solution.

OT 1/2/3

Scrub room 1/2/3

Clean room 1/2

Sterile corridor

Dirty utility

Clean store

Packing room

Equipment store

Sterile store

Monthly cleaningWash with washing detergent and water and clean with hypochlorite solution.

Pre-op room

Post-op room

Outside area

103

103

DAILY TASKS OF NURSES WORKING IN OPERATION THEATRE

Morning Shift

Report to OT on time

Check inventory

Take report

Check the daily posting

Check the O T list

Bring patient

Check blood investigations reports PAC and consent.

Prepare their respective OT/place


Check the cleanliness and the tidiness of the OT

Make sure first patient for each OT is in OT by 7:50 am

Start scrubbing as soon as the doctors(anaesthetists and surgeons) enter the theater

Pack instrument sets and bundles whenever possible

Hand over to the next shift staff before going off duty

Complete documentations (report book)

Report to in charge before leaving at 2:30 pm

Second shift

Report to OT time

Check inventory


Take handover of their respective places and relieve the morning staff

Packing of equipments, bundles sets gowns etc

Replace items before packing

Wash and Carbolize the OT s

104

104

Clean and tidy the other areas

Carbolize the stretcher and accessory stand

Complete documentations and registers

Check the next day OT lists and confirm the cases and their wards


Confirm the necessary items for next days surgery are packed and autoclaved

Check the machines whether in working order

Wash up all items and keep ready for the next day

Prepare items like gauze, D/pads packs etc

Hand over to next shift staffs

Report to shift in charge before leaving

Third shift

Report to OT time

Check inventory


Take handover of their respective places and relieve the staff




Receive linen, fold(properly) and packing bundles

Arrange the changing rooms (male and female) and cleaning the stores

Carbolize packing rooms and clean stores



Night shift

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Report to ward time

Check inventory


Take handover of their respective places and relieve the staff

Complete documentations and registers




Arrange the theaters

Check the Anaesthesia machine and laryngoscope

Keep the theater ready for the morning shift (routine cases)

Arrange the changing rooms (male and female) and cleaning the stores

Inform the wards to bring first cases by 7:40 am

Patients for all theaters to be inside OT by 7:50 am

Complete documentations (report book)


Check the sterility of the OT (carbolize)

FRIDAYS

Check the sets and bundles and sent for autoclaving those that require re autoclaving

Wash the whole OT complex

Clean with sodium hypo chloride solution

Replace items in sets e.g. ortho implants

NOTE During all shifts keep the whole theater clean this includes the pre op and post op with the

corridor area and where we keep our gas cylinders too

Replace items in sets before packing e.g. ortho implants to be replaced

DAILY TASKS OF ATTENDANTS WORKING IN OPERATION THEATRE

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Morning shift

Report to OT on time

Take over from the night shift attendant

Check the general cleanliness of OT complex

Do not keep hypo chloride solution in basin for more than 30minutes

Take instruments to CSSD and collect it when autoclaved

Keep equipment inside OR’s e.g. Suction /Cautry and check the table

Check whether dirty utility rooms are closed/locked

Check paper towel dispenser and keep it filled

Clean the stretchers

Clean/mop OR’s properly and quickly in between cases

Keep stretchers ready all time with the pillows and rubber sheet

Check for sharp disposals and change it when it is 2/3rd full

Keep the counter slippers properly and wash it whenever dirty

Give urinals to patients if asked by a nurse

Assist patients to the toilet if required (ONLY WHEN ASKED BY A NURSE)

Answer the bell, but DO NOT give any information regarding patients. call a nurse to

give any information to the relatives

Cut gauze

Check patients toilet frequently and clean as needed

Wash kidney trays and disinfect them if used (keep in 0.5%sodium hypochlorite

solution for 10mins. DO NOT LEAVE THEM FOR MORE THAN THE

SPECIFIED TIME)

Wash all the toilets thoroughly

Clean doors, windows and other furniture’s

Wash suction bottle and suction tubing after each case

Clean and disinfect pre and post operative thoroughly when patients are transferred

Take dirty linen to laundry DO NOT TAKE DIRTY LINEN ALONG WITH ANY

THING CLEAN(STICK BIOHAZARDABLE)

Take things to CSSD

Wash the slippers.

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Out side attendant has to go to wards to bring patients to OT as well as to shift patients

out when ever asked.

Do not enter OR during surgery unless asked

Be present outside the OR’s

Take linen to laundry and collect clean linen

Be prompt whenever called to anyone


Report and get permission from the shift in charge before leaving the OT or going off

duty.

Keep drinking water in tea room

Evening shift Report to OT on time

Take over from the morning shift attendant

Check the general cleanliness of the OT complex

Take instruments to CSSD and collect it when autoclaved

Collect clean linen from laundry(count them properly and inform to the shift in charge if

there is any problem)

Clean stretchers


Answer the bell, but DO NOT give any information regarding patients. Call a nurse to



Wash kidney trays and disinfect them if used (keep in 0.5%sodium hypochlorite

solution for 10 minutes. DO NOT LEAVE THEM FOR MORE THAN THE

SPECIFIED TIME)



Oxygen tubing and change water in the humidifier


THING CLEAN(STICK BIOHAZARDABLE)

Keep the store room clean

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Wash the slippers

Keep the counter slippers properly and wash it whenever asked by a nurse



duty.


Night shift

Report to the OT on time

Take over from the evening shift attendant

Check the general cleanliness of the OT complex




Cut gauze


Wash all kidney trays and disinfect them if used (keep in 0.5%sodium hypochlorite

solution for 10 minutes. DO NOT LEAVE THEM FOR MORE THAN THE

SPECIFIED TIME)



(change water in the humidifier)

Assist the nurses in cleaning and disinfecting the OR’s


THING CLEAN(KEEP BIOHAZARDABLE)

Wash the slippers

Keep the counter slippers properly and wash it whenever asked by a nurse



duty.

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`

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Midwifery guidelines

Acknowledgement

These guidelines have been prepared with the aim of providing guidance for the proper

management of patients admitted to labour room. They are based on the interventions described

in the manual “Integrated Management of Pregnancy and Childbirth (IMPAC)” published by

WHO. In addition, protocols prepared by Dr. Jumailath Begam in 1995 were also used as a

reference in preparing these guidelines. Nursing department greatly acknowledges Dr. Jabeen Ali

Shareef and Dr. Mohamed Aseel Jaleel who gave their advice and opinion to complete these

guidelines. In addition, contributions given by the doctors in the department of obstetrics and

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gynaecology are appreciated. Our thanks are also due to Dr. Abdullah Niyaf for his contributions

on newborn care. Furthermore, nurses working in labour room have contributed immensely to

make these guidelines. Nursing department wishes to thank all those who have helped to prepare

them.

It is hoped that these guidelines will be useful not only for the staff of IGMH but also to the

students and nursing staff working throughout Maldives.

Nursing department

IGMH

ADMISSION PROTOCOL FOR LABOUR PATIENTS

Confirm identity of the patient (check the patient’s name, age and address on the folder).

Make sure all ANC records are available. These records should be attached to the inpatient

folder.

ANC card

Scan reports

Blood investigation reports

Urine reports

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Referral letters (if any)

On admission take a brief history with emphasis on the following.

Gravida/para

LMP and EDD as per dates and scan

Problems with previous pregnancies/deliveries.

Rh status

Allergies

History of medical problems

Onset of labor

Membranes-ruptured or intact.

The following documents must be completed for all labour patients:

Labour ward admission

Daily census

Partograph (when the cervical dilatation is 4cms or more.)

New born sheet.

If investigations are not available send for all routine investigation. This includes: urine R/E,

Hb, PCV, blood grouping and Rh typing, RBS, G6PD, VDRL, HbsAg and HIV screening.

For all patients in labour have one pint of blood cross matched. If the patient’s Hb is low or

gives history of severe PPH in last deliveries arrange for 2 donors.

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

the foetal movements are felt.

Record temperature, BP, pulse and FHS and uterine contraction. Note the frequency and

intensity of uterine contractions. Normal fetal heart rate ranges from 120 to 160 beats per

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minute. The rate may increase or decrease during a contraction, hence foetal heart should be

checked only when the uterus is relaxed.

P/V examination should be done unless contraindicated, to assess if the patient is in labour. A

vaginal examination should be performed only following adequate explanation.

DO NOT DO P/V in the following conditions:

Ante partum hemorrhage

Low lying placenta.

All patients in labour should have perineum shaved and a disposable enema should be given

unless contraindicated. (Contra indications include severe PIH, cervix fully dilated, APH

abnormal presentations).

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

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

sponge bath.

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

relatives.

While caring for the woman in labour give special emphasis to the principles in the

ethical and professional code of conduct for nurses. This includes:

Respecting the woman’s right to privacy and modesty while doing procedures.

Draw curtains and drape the patient while performing a vaginal examination.

Maintain confidentiality.

Show empathy.

Provide sufficient information before performing any procedures (If language is a

barrier ask some one for help).

Recognize professional accountability borne for actions and omission

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ON GOING CARE DURING FIRST STAGE OF LABOUR

If there are no problems/ risk factors, for all patients in labour with term gestation and vertex

presentation the following care is to be followed.

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

hydration.

Record blood pressure on admission and 4 hourly if normal. If the diastolic is more than 90

record BP every half hourly or as per the doctor’s advice. Notify any abnormal recordings to

the duty doctor (BP is not to be taken during contraction).

Check temperature on admission and every 4-6th hourly unless otherwise indicated. If the

patient is febrile notify the doctor.

Record pulse on admission and half hourly. Notify the doctor if tachycardia is there (pulse

should not be taken during a contraction).

Record FHS on admission and every half hourly or more frequently if indicated. FHS should be

checked following a contraction and in between contractions. It should be counted for ONE

FULL MINUTE. If there is any foetal tachycardia (>160 bpm), foetal bradycardia (<120 bpm)

or irregular foetal heart rate notify the doctor immediately. (For additional care refer to care of

patients with foetal distress).

Assess the uterine contractions on admission and every hourly in the latent phase (upto 3cm)

and every half hourly in the active phase (from 4-10cm). Contractions should be checked for its

frequency and duration. Frequency of contractions is assessed by the number of contractions in

a 10-minute period. Duration is measured in seconds from the time the contraction is first felt

abdominally, to the time the contraction phases off. In the active phase contractions should

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occur at least three times every ten minutes each lasting > 40 seconds with adequate relaxation

in between. If contractions are not satisfactory inform the doctor.

If there is no contra indications a P/V examination should be performed every 4 hourly in the

first stage to assess the progress of labour.

Follow aseptic techniques while performing a P/v examination and be as gentle as possible.

Ensure patients privacy during the procedure. The following findings should be recorded:

o Position, dilatation and effacement of the cervix

o Presenting part and its level

o Presence of caput or moulding

o Membranes: presence or absence of membranes and the colour of liquor if

membranes are ruptured.

o Liquor: present or absent, colour

o Ensure that no cord is felt

If the membranes are ruptured liquor should be carefully examined for meconium if the fetus

is in the vertex presentation. A slight degree of meconium without foetal heart abnormality is

a warning for the need for caution. Thick meconium may indicate the need to speed up

delivery hence if meconium is present in the liquor inform the doctor.

Slight green color. Thin meconium.

Green to dark color Moderate meconium.

Dark green with flakes of meconium Thick meconium.

After each vaginal examination FHS should be recorded.

A partograph should be filled for all patients in the active phase of labour. Dilation of the

cervix is plotted with an X, descent of the fetal head is plotted with an O, and uterine

contractions are plotted with differential shading. The first recording on the partograph should

be on the alert line and if the progress of labor is normal, plotting of cervical dilatation should

remain on the Alert Line or to left of it.

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Descent of the head should always be assessed by abdominal examination (by Rule of

Fifths felt above the pelvic brim) immediately before doing a vaginal examination. When

2/5 or less of the fetal head is felt above the level of symphysis pubis, the head is engaged,

and by vaginal examination, vertex is at the level of ischial spines (0 station).

Recording of the condition of the membranes and liquor in the partograph should be as

follows:

Intact membranes - I

Ruptured membranes + Clear liquor- C

Ruptured membranes + Meconium-stained liquor - M

Ruptured membranes + Blood-stained liquor- B

Ruptured membranes + Absent liquor- A

Presence of moulding should be recorded in the partograph as follows:

1: Sutures opposed.

2: Sutures overlapped but reducible

3: Sutures overlapped and not reducible.

Encourage oral fluids during labour unless otherwise indicated.

Encourage regular 2 hourly voiding and record when urine is passed. A full bladder is

uncomfortable and may inhibit the progress of labour by inhibiting the decent of the

presenting part. Where there is a palpable bladder and the woman is unable to void, consider

urinary catheterization.

Attend to the patients’ personal hygiene as required. Provide oral care every 4 hourly or as

required. Provide early morning care for all patients. Perineal care should be given according

to the needs of the patient.

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Encourage the woman to move about freely when in early labour unless contraindicated. Eg if

the patient is leaking or bleeding.

Teach breathing exercises for coping with labour pains. Encourage the patients not to push

before full dilatation of cervix.

The patients’ condition should be explained to the relative’s atleast twice in each shift and at

any events or changes in the treatment line.

Allow the patients to talk to the relatives over phone if they wish to. If they are in labour

room for too long they should be taken out to meet the relatives.

Complete documentation and give proper handover when the shift changes.

CARE OF PATIENTS WITH FOETAL DISTRESS

Foetal brady cardia in the absence of contraction or persisting after a contraction and foetal

tachycardia in the absence maternal tachycardia is suggestive of foetal distress. Thick

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meconium stained liquor in vertex presentation may also be suggestive foetal distress. If any

of these conditions are observed inform a gynecologist immediately

General management:

Place the woman on left lateral position

Administer oxygen 4-6 liters per minute.

Stop oxytocin if being administered (with advice from a doctor)

Record the foetal heart rate every 10- 15 minutes.

Start a plain pint of ringer lactate.

Explain to the patient and the relatives about the baby’s condition.

Check for explanatory signs of foetal distress:

Bleeding

If vaginal examination is done feel for the cord pulsation. If felt, manage as cord

prolapse.

Observe the colour of liquor if the membranes are ruptured

Record the findings.

CARE OF PATIENTS WITH PREVIOUS LSCS IN LABOUR

On admission collect the history and find out the indication for LSCS. Inform the

gynaecologist or the medical officer as soon as possible.

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If the woman is in labour monitor the progress of labour using a partograph. If the cervical

dilatation crosses the alert line inform a gynaecologist.

Monitor the maternal pulse, foetal heart rate and uterine contractions every half hourly.

Monitor the woman’s blood pressure every hourly and temperature every 4th hourly

Encourage the woman to void every 2 hourly and observe the colour of urine. When the

woman is in active labour catheterize her. If hematuria is observed inform a gynaecologist.

Watch for signs of impending rupture.If any of these findings are observed inform a

gynaecologist or a medical officer immediately:

Rapid maternal pulse

Persistant abdominal pain and scar tenderness

Foetal distress.

Record all the findings.

CARE OF PATIENT DURING SECOND STAGE OF LABOUR

When possible all the deliveries must be conducted in the second stage room and the following

steps should be ensured.

When the cervix is fully dilated, shift the patient to the second stage room.

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Paediatric medical officer should be informed for all the deliveries.

A pediatrician must be notified in cases of

Severe foetal distress

Thick meconium stained liquor

Instrumental deliveries

Premature deliveries

Undue delay

Fot patients at risk (PIH, DM, IUGR, postdated pregnancy)

Gynaecologist on call must be notified in cases of

Foetal distress

Thick meconium stained liquor with or without foetal heart abnormalities

Prolonged second stage of labour (more than 1 hour in primis and more than half

an hour in multis)

Heart disease

Multiple gestation

Breech presentations

Patients with bad obstetric history

Undue delay

patients at risk (PIH, DM, IUGR, postdated pregnancy)

Prepare the delivery room. (Refer to appendix C for articles/equipments needed

for delivery)

Prepare the baby receiving area. The following things should be available:

Baby warmer (should be kept ON)

Ambu bag and mask in working condition

Laryngoscope

Suction machine in working condition

Oxygen

Meconium aspirator

ET tubes, suction tubes no: 8 & 10, nasogastric tubes.

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Emergency drugs (Inj. Adrenalin, Inj. naloxone if the mother has received a

narcotic, Inj. soda bicarb, normal saline)

Warm baby sheets and sterile pads.

Nursing observations:

Assess the patient for signs suggestive of satisfactory progress in the second stage

of labour. This includes steady descend of the presenting part and the onset of

expulsive phase.

Monitor the uterine contractions. If contractions are not adequate inform a

gynecologist.

Observe the color of liquor. If meconium is present inform the gynecologist.

Record FHS every 5 minutes. If there is any foetal heart abnormalities inform a

gynecologist.

Perform a vaginal examination once every hour.

The following things should be avoided.

Premature positioning

Uterine manipulation

Stretching of perineum

Unnecessary frequent PV

Catheterization unless indicated.

Maintain adequate hydration by encouraging adequate oral fluids if not contra

indicated.

Encourage the patient to empty her bladder at the beginning of the second

stage.

Teach pushing techniques to the patient

If the presenting part is high keep the patient on left lateral position and

encourage her to push with contractions. Do not put the patient on lithotomy position

too early

Ensure cleanliness of the patient and the birthing area.

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Provide a supportive and an encouraging atmosphere and ensure patient’s

privacy and confidentiality. Do not allow unnecessary visitors inside delivery room

while the patient is giving birth. Only staff and doctors on duty are allowed in

second stage room.

While conducting delivery the following steps should be followed:

Wash hands and wear personal protective equipments.

Talk to the patient and explain every procedure throughout the second stage.

If the patient is to be delivered in lithotomy position while positioning put both

legs together on the stirrups. Ask the patient if she is comfortable and adjust the

level accordingly.

Clean the patient’s perineum and inner thighs with an antiseptic solution

(betadine).

Drape the patient (with lithotomy sheet and leggings).

Encourage the woman to push with contractions.

If an episiotomy is needed infiltrate the perineum with 1% lignocaine and perform

an episiotomy with a contraction when the foetal head crowns.(refer to guideline

for performing episiotomy).

Ensure the following steps during the delivery of the head:

Place the fingers over the foetal head to maintain flexion.

Support the perineum as foetal head is delivered.

Once the head is delivered ask the woman not to push.

If meconium is present suction the baby’s mouth and nose.

Feel around the baby’s neck for the umbilical cord. If the cord is around the neck

but loose, slip it over the baby’s head. If the cord is tight doubly clamp and cut it

before unwinding from the neck.

Ensure the following steps during the delivery of shoulders.

Wait for the external rotation of the head.

Place a hand on each side of the baby’s head and ask the woman to

push with contraction.

Apply downward traction to deliver the anterior shoulder. Avoid

excessive tracton as this may result in brachial plexus injury.

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Lift the baby’s head anteriorly to deliver the posterior shoulder.

Support the perinium during the delivery of the shoulders.

In case of shoulder dystocia:

Call for a gynaecologist.

Ask the woman to flex both thighs bringing her knees as far a apart

as possible toward her chest.

Have an assistant apply suprapubic pressure downwards to assist the

delivery of shoulders. Do not apply fundal pressure as it can

further impact the shoulders.

Clamp and cut the cord and hand over the baby to an assistant.

If the mother is Rh –ve collect cord blood for Hb, PCV, blood grouping and Rh typing,

reticulocyte count, direct coomb’s test, serum bilirubin total and direct serum bilirubin.

Palpate the abdomen to rule out the presence of any additional baby(s), if not already

confirmed by USG.

Proceed to do active management of third stage or do the expectant management.

ASSISTING A VACUUM DELIVERY

A vacuum extraction may be needed in when there is

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Foetal distress

Delay in second stage of labour

Maternal exhaustion

Maternal heart disease

Explain to the women and the relatives about the need for a vacuum extraction.

Assemble all equipments / instruments needed for a vacuum extraction.

All instruments needed for a vaginal delivery (delivery bundle)

Vacuum cup

Rubber tubing

Vacuum extractor

Check the connections of the vacuum extractor and ensure that it is functioning well.

When the vacuum cup is applied to the foetal head ask an assistant to create a vacuum of

0.8kg/cm2 negative pressure by using the pump (up to the red mark on the vaccum

apparatus).

Contimnue to monitor foetal heart rate in between contractions.

Maintain asepsis throughout the procedure.

At the delivery of the foetal head release the pressure of vacuum.

After the birth of the baby assess the maternal and foetal complications:

Maternal:

Tears in the genital tract may be present. Examine the woman for any tears in the

vagina or the cervix (The doctor who performs the vacuum will usually do this).

Foetal:

All babies born by a vacuum will have a caput. Explain to the mother that it harmless.

Examine for scalp abrasions. If any abrasions are there clean and determine the extent

of the abrasion.

Inform a pediatric medical officer and carry out any orders given.

Show the baby to the mother and the relatives and explain abut the laceration.

MANAGEMENT OF THIRD STAGE OF LABOUR

Active management of third stage:

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Active management of third stage is encouraged as it helps to prevent PPH. This includes:

Administration of oxytocin

Controlled cord traction

Uterine massage.

The following steps must be followed in the active management of third stage:

Administration of 10 units of oxytocin I.M or 5 units I.V within one minute of

delivery of the baby.

Clamp the cord close to the perineum.

Apply controlled cord traction along with counter traction. Never

pull the cord with out counter traction as it can cause uterine in version.

Keep slight tension on the cord and wait for a uterine contraction.

With a contraction gently pull the cord downwards to deliver the

placenta while continuing to apply counter traction.

If the placenta does not descend with 30- 40 seconds of controlled

cord traction do not continue to pull. But gently hold the cord and wait for another

contraction.

As the placenta is delivered hold it in two hands and gently turn it

until the membranes are twisted.

Once the placenta is delivered carefully examine it for

completeness

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EXPECTANT MANAGEMENT OF THIRD STAGE: (IS NOT ENCOURAGED)

Wait for signs of placental separation. This includes:

Gush of blood

Lenghthening of the cord

Uterine contraction.

Deliver the placenta using controlled cord traction.

As the placenta is delivered hold it in two hands and gently turn it until the membranes

are twisted.

If not contra indicated, administer injection ergometrine when the

placenta is delivered. Contra indications include: PIH & heart disease. Check the blood

pressure before giving ergometrine.

Once the placenta is delivered carefully examine it for completeness.

RETAINED PLACENTA

Inform a gynecologist

Catheterize the bladder or ensure that the bladder is empty.

Start an IV line. (oxytocin infusion may be started).

Explain to the woman and the relatives about her condition.

Watch for any undue bleeding.

Accurately document the interventions carried out.

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MANUAL REMOVAL OF PLACENTA Explain to the woman and her relatives and get their consent for the procedure.

Provide emotional support for the woman.

Carryout any advice given by the doctors.

Prepare the articles necessary for manual removal of placenta:

sterile gloves

sterile lithotomy sheet

leggings

antiseptic solution

dettol cream

Post procedure:

Administer IV ergometrine if not contraindicated.

Continue oxytocin infusion as per doctor’s advice.

Examine the placenta

Monitor vital signs every half hourly or as advised.

Palpate the uterine fundus to ensure that it is well contracted.

watch for any undue bleeding

Accurately document the interventions carried out.

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MANAGEMENT OF FOURTH STAGE OF LABOUR

Remove the drapes and soiled linen. Give a clean gown to the patient

Remove both legs from the stirrups at the same time and then lower both legs down at the

same time to prevent cramping

Provide care of the perineum. Evaluate the perineal area for signs of developing edema

and/or hematoma. Predisposing conditions includes prolonged second stage, delivery of

a large infant, rapid delivery, forceps delivery.

An ice pack may be applied to the perineum to reduce swelling from episiotomy and

manual manipulation of the perineum during labor.

Apply a clean perineal pad between the legs.

Obtain a complete set of vital signs, evaluated the fundal height and firmness, and

evaluate the lochia. Keep the patient in labour room for 2 hours under observation.

Following observations should be made.

Record blood pressure and pulse and uterine contraction every half hourly.

Inform the doctor if the fundus remains boggy. Encourage the patient to massage

the uterus over the abdomen.

Observe for signs of hemorrhage. Causes of PPH may include

Uterine atony.

Vaginal or cervical lacerations.

Retained placental fragments.

Bladder distention.

Observe patient's urinary bladder for distention. Full bladders may actually

cause postpartum hemorrhage because it prevents the uterus from contracting appropriately.

Assessment for perineal hematoma.

Look for discoloration of the perineum.

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Listen for the patient's complaints or expression of severe perineal

pain.

Observe for edema of the area.

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

rectal pressure.

Inform the doctor of abnormal findings.

Discontinue IV on a normal patient once she is stable

Complete notes and transfer the stable patient to the ward

MANAGEMENT OF PPH All post partum women must be monitored closely to determine PPH.

In cases of PPH the priorities in managing the patient are as follows.

Call for help (call for a gynecologist or a medical officer)

Start an IV line.

Perform a rapid assessment of the woman’s general condition which should

include blood pressure, pulse, respiration and temperature.

Find the cause for bleeding: To find out the cause examine the cervix, vagina and

perineum for tears. Check if the placenta is complete or not.

Stop the bleeding: If the cause of PPH is trauma to cervix, vagina or perineum, repair it under

aseptic precautions.

If the cause of PPH is uterine atony, follow these steps:

catheterize the bladder

Massage the uterus to expel the blood clots.

Start an IV infusion as per the doctor’s advice.

Give oxytocin as per doctor’s order

Monitor the blood pressure and pulse closely and watch for signs of shock.

Explain the patient’s condition to the relatives.

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Anticipate the need for blood transfusion and arrange blood.

Keep an accurate record of the blood loss and interventions carried out.

If bleeding continues, check the placenta for completeness and if there are signs of retained

placental fragments inform a gynecologist.

PERFORMING AN EPISIOTOMY

Apply an antiseptic solution to perineum before performing episiotomy.

Infiltrate perineum with 1% xylocaine

Infiltrate beneath the vaginal mucosa, beneath the skin of perineum and deeply into

the perinial muscle.

Aspirate to be sure that no vessel has been penetrated. The woman can suffer

convulsion and death if IV xylocain is given.

Xylocain should be injected continuously while the needle is slowly withdrawn.

Anesthesia is more effective when one third of the injection is given first and two

further injections are made one on either side of the incision line. The needle must be

redirected just before the tip is withdrawn to avoid a second prick. Xylocain takes 3-4

minutes t o take effect.

Episiotomy should be performed only when crowning takes place (When the perineum is

thinned out and 3-4 cm of the baby’s head is visible during a contraction).

If episiotomy is given too early it will fail to release the presenting part and cause hemorrhage

from the cut vessels. In addition the levator ani muscles will not have time to be displaced

laterally and may be incised.

If episiotomy is performed too late there will not be time to infiltrate the prineum with

anesthetic.

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The incision is best made during a contraction when the tissues are stretched so that there is

clear view of the area and bleeding is less likely to be severe.

A single deliberate cut of 2-3 cm is made while inserting two fingers into the vagina to

protect the baby’s head. Medio-lateral is best, as it avoids danger of damage to anal

sphincture. This begins at the mid point of fourchette and is directed at 45 degree angle to the

midline.

The baby’s head and shoulders should be controlled as they deliver to prevent an extension of

the episiotomy.

If there is any delay before the head emerges pressure should be applied to the site to

minimize bleeding.

REPAIR OF AN EPISIOTOMY

Carefully examine the episiotomy for any extensions and other tears.

Apply an antiseptic solution around the site of the incision.

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

other time.

Choose an appropriate suture material. Although 2-0 chromic catgut is commonly used

for patient with history of catgut allergies vycril may be used. For patients with catgut

allergy inform a gynaecologist before suturing the episiotomy.

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

homeostasis.

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

the vaginal opening.

Close the perineal muscle using interrupted 2-0 sutures. Good approximation of tissues is

important as the strength of pelvic floor will depend on the adequate repair of this layer.

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

Sutured area should be inspected in order to confirm haemostasis.

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

narrowed.

Rectal examination is made in order to ensure that no sutures have penetrated the rectal

mucosa. Any such sutures to be removed to prevent fistula formation.

If the episiotomy is extended through the anal sphincter or rectal mucosa call a

gynecologist.

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CARE OF NEW BORN

Make sure that all equipments and drugs for resuscitation are ready and in good working

order, before delivery. (Refer to newborn resuscitation guideline for list of drugs and

equipments.)

At birth an initial assessment should be performed for all the babies and the following

conditions should be observed.

Clear of meconium

Breathing or crying

Good muscle tone

Colour pink

Term gestation

If the baby has no apparent problems and if all of the above criteria are met provide routine

care. Routine care includes drying the baby, clearing the airway, providing warmth.

If the baby is born with a problem/condition that requires urgent intervention care should

provided as follows.

When born with meconium stained liquor suctioning of the mouth and nose as soon as

the head is born. While doing suction care should be given not to suction deep in the

throat as it may cause bradycardia or the baby may stop breathing.

If the baby is not breathing or crying dry and remove wet cloth, keep baby under

radiant warmer, clear the air way and provide tactile stimulation. Tactile stimulation

should be given by flicking the soles of the foot twice and gentle rubbing of the back.

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If the baby does not start breathing initiate newborn resuscitation (refer to guidelines

for newborn resuscitation)

If the baby has cyanosis oxygen can be administered.

Assess baby’s condition, at 1minute, 5 minutes and 10 minutes after birth using apgar

scoring.

The cord should be clamped with cord clamp and cord care should be given with spirit.

Provide eye care for the baby with sterile swabs and saline

For all babies with term gestation vitamin K 1mg should be administered intramuscularly to

the thigh muscle. For preterm babies and babies with low birth weight dosage of vitamin K

would depend on the doctor’s order.

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

Oesophageal patency should be checked using a nasogastric tube.

Clean and dress baby.

An identification label should be attached to baby’s leg as soon as possible. The label should

be legibly written with the following details:

- Mothers name and address

- Date and time of birth

- Sex

- weight of baby

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

Breast feeding should be initiated within the first half an hour of birth and necessary

assistance should be provided for the mother while feeding.

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Inform the relatives of the baby’s condition and show the baby to the relatives.

The newborn sheet should be completely filled and a nurses note should attached to the

newborn sheet before the baby is transferred to postnatal ward.

NEONATAL RESUSCITATION

Preparation for delivery1. Anticipate need for resuscitation;

Ante partum and intra partum history may help to identify the possibility of a

depressed or asphyxiated newborn.

2. Personnel;

When neonatal asphyxia is expected’ two staff should be present in the delivery room

and be prepared to work as a team to perform a complete resuscitation. The person

conducting the delivery should not be considered as one of the resuscitators.

Initiating resuscitation should not be delayed.

3. Equipments;

Equipments and medications should be checked daily and before each delivery.

Used items should be cleaned as soon as possible after resuscitation.

The delivery room should be kept warm and the radiant heater should be preheated, to

prevent excessive heat loss.

Pre warming of towels and blankets is helpful.

(Refer to appendix C for equipments and medications needed for resuscitation)

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Post resuscitation:

Baby’s condition should be explained to parents as soon as possible.

If condition of the baby allows, show the baby to mother and relatives.

Initiate breast feeding as soon as possible if condition allows.

Keep a close observation on the baby.

Accurate documentation is very important.TRANSFERRING NEWBORN

BABIES TO NURSERYExplain to the mother why the baby is being transferred

to nursery

Inform the nursery before shifting the baby.

Ensure that the baby is wrapped in a blanket to prevent heat loss.

If the baby requires oxygen transfer the baby in the incubator.

Show the baby to the mother and the relatives before shifting to nursery.

Ensure the newborn sheet and the nurses notes are completed and handed over to the nursery

staff. If the baby has received any medications document it in the treatment sheet.

NURSING CARE OF PATIENTS WITH ANTE PARTUM HEMORRHAGE

Assess the general condition of the woman record the vital signs including foetal heart rate.

Call for a gynecologist.

If foetal distress is evident, manage as for foetal distress and prepare the patient provisionally

for LSCS.

Send for all routine investigations including cross match (send minimum 2crossmatches)

Start an IV line. Assess the amount of bleeding and restore the blood volume as advised by

the doctor.

Do not do a vaginal examination: Check the scan reports and rule out placenta previa.


Monitor the foetal heart rate every 15 minutes.

Accurately document the interventions carried out

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MANAGEMENT OF PATIENTS WITH PIH IN LABOUR

On admission:

Collect the history and check whether the patient is on any medications.

Do a general examination and asses the woman for edma.

Send for all routine investigation including a crossmatch. Get advice from a

gynecologist or medical officer for any special investigation.

Record the vital signs including foetal heart rate.

If the diastolic blood pressure is more than 100 inform a gynaecologist or a medical officer.

Monitor the blood pressure every hourly or as indicated

Monitor foetal heart rate and uterine contractions every half hourly.

If the diastolic BP is more than 100 donot allow the women to walk to the toilet alone. Offer a

bedpan and monitor urine output.

Maintain strict intake and out put.

Start an IV line to keep the vein open.

Watch for signs of impending eclampsia:

Headache

Blurred vision

Do not leave the woman alone and keep the bed rail as a safety precaution.

Keep the equipments ready for the management of a convulsion

Air way

Suction machine

Suction tubes

Oxygen

Ambu bag and mask with tubing

Drugs (inj Diazepam, inj Epsolin, inj magnesium sulphate)

In case of convulsion:

Clear airway

Adminster oxygen at 4-6 liters/ minute

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Inform a gynaecologist or medical officer

Protect the women from injury

Position the woman on her side to reduce the risk of

aspiration

If any narcotic is administered carefully monitor the foetal heart sounds and inform a

pediatrician at the time of delivery. Keep injection Naloxone ready to resuscitate the baby.

USE OF MAGNESIUM SULPHATE FOR PRE- ECLAMPSIA AND ECLAMPSIA

Minimum requirements for the administration of magnesium sulphate

PR greater than 16/min

Urine out put atleast 30ml/hour

Knee jerk should be present

Preparation of 50% magnesium sulphate for use:

1. IV loading dose: 4gm magnesium sulphate over 10 minutes

Magnesium sulphate is supplied in 2ml ampules and 4 ampules (8ml) would provide 4 gms.

Dilute this amount to a volume of 20 ml by adding 12 ml of normal saline. Give this slowly over

10 minutes.

2. IM maintenance: 5gm of 50% magnesium sulphate solution in each buttock initially and then

on alternate buttock four hourly. 5 ampules (10ml) of the solution for each 5gm to be mixed with

1ml of 2 % lignocaine syringe to be mixed in the same syringe. .

Assessment & Drug Effects

When magnesium sulphate is given IV, patient requires constant observation. Check BP

and pulse 10-15 min or more often if indicated/ as ordered by the gynecologist.

Monitor patients with high levels of magnesium very closely as cardiac arrest may occur

in such cases. Plasma levels in excess of 4 mEq/L are reflected in depressed deep tendon

reflexes and other symptoms of magnesium intoxication. Cardiac arrest occurs at levels in

excess of 25 mEq/L.

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Early indicators of magnesium toxicity (hypermagnesemia) include cathartic effect,

profound thirst, feeling of warmth, sedation, confusion, and depressed deep tendon

reflexes.

For women receiving magnesium sulphate, monitor urine out put every hourly and if it

falls below 30ml/ hour inform a gynecologist

Before each repeated parenteral dose, patellar reflex should be tested. Depression or

absence of reflexes is a useful index of early magnesium intoxication. Also check

respiratory rate and character and urinary output. Therapy is generally not continued if

urinary output is less than 100ml during the 4 h preceding each dose.

Newborns of mothers who received parenteral magnesium sulfate within a few hours of

delivery should be observed for signs of toxicity, including respiratory and neuromuscular

depression.

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CARE OF PATIENTS WITH MALPRESENTATIONS

Common mal presentations include:

Breech

Face

Brow

Trasverse lie/ oblique lie.

A breech or a face presentation may be allowed for a vaginal delivery. But inform a

gynecologist.

General management of fist stage of labour for face presentation and breech presentation is

the same as that of a vertex presentation.

In a breech presentation when the membranes are ruptured perform a vaginal examination to

exclude cord prolapse.

Meconium stained liquor is common in a breech presentation and it is not a sign of foetal

distress.

In a brow presentation, trasverse lie or in an oblique lie the woman is likely to have cesarean

section. Inform a gynecologist immediately when these presentations are suspected. If the

woman is in labour keep her provisionally prepared for cesarean section until a gynecologist

decides for the management.

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MANAGEMENT OF CORD PROLAPSE

Following spontaneous rupture of membranes perform a vaginal examination to exclude cord

prolapse.

An abnormal foetal heart rate, especially bradycardia may also indicate cord prolapse. A

vaginal examination should be performed to rule out cord prolapse.

Immediate action:

Call for urgent help. Inform a gynecologist immediately.

Explain to the woman what has happened

Get an assistant to explain to the relatives what has happened and the emergency

measures that may be needed.

Relieve the pressure on the cord by holding the presenting part off the cord, especially

during contractions.

Monitor foetal heart rate carefully.

Adminster oxygen at 4-6 liters /minute.

Start an IV line.

Position the woman with her buttocks elevated to allow the fetus to gravitate towards

the diaphragm. (this position can be by keeping a pillow underneath the patients

buttocks or by raising the foot end of the bed). These measures must be continued

until foetus id delivered or until the patient is shifted to theater.

Keep the woman prepared provisionally for cesarean section until a gynaecologist

decides the management plan.

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ADMINISTRATION OF OXYTOCIN FOR INDUCTION AND AUGMENTATION OF LABOUR

Oxytocin should only be administered with the advice from a gynaecologist. For routine

inductions ensure the necessary investigations including crossmatch is ready. If not, inform

the gynaecologist before starting the oxytocin infusion.

Oxytocin should be used with caution as fetal distress can occur with hyperstimulation and

rarely uterine rupture can occur.

Administer Oxytocin in an IV fluid (dextrose or ringer lactate) and gradually increase the

drop rate according to the doctor’s order until good contractions are established. Contractions

are considered as good when the woman gets about 3 contractions in 10 minutes each lasting

for atleast 40 seconds. When good contractions are established maintain the infusion rate.

Do not leave a woman receiving oxytocin alone and check the arm position inbetween as it

can alter the flow rate.

Carefully monitor the women receiving oxytocin for the following:

Blood pressure and pulse rate

Foetal heart rate every half hourly. Always check the foetal heart immediately after a

contraction. If there is foetal distress stop the oxytocin drip and inform a

gynaecologist. Manage foetal distress according to the protocols provided.

Uterine contractions every half hourly. If hyper stimulation occurs stop the infusion

and inform a gynaecologist.

Rate of infusion. Increase the infusion rate according to the doctor’s advice.

Properly document the findings.

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CERVIPRIME INSTILLATION FOR INDUCTION OF LABOUR

Ensure that the necessary investigations including crossmatch are ready. If not, inform the

gynaecologist.

Prior to the instillation of cerviprime monitor the woman’s vital signs and foetal heart rate.

Ask the woman to empty her bladder prior to the instillation.

Prepare the articles needed (refer to appendix C)

Immediately after instillation check the foetal heart rate.

Ask the woman to take bed rest as per the doctor’s advice.

Keep the woman in the labour room under observation and monitor the uterine contractions

and record the foetal heart rate every 30 minutes.

If there are no contraction the woman may be transferred to ward. Advice the woman to

report with contractions or leaking.

The woman may be allowed to take soft diet if there are no contractions

Before transferring the patient to ward ensure that all the documentation is complete.

EXTRA AMNIOTIC SALINE INSTILLATION Receive the patient and take proper hand over from the ward nurse.

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Check the doctor’s order.

Check whether routine investigations and cross match is done.

Check whether patient and the relatives have been explained about the procedure. If not

already done, explain the procedure to the patient and a close relative and get their consent. If

language is a barrier, call for help.

Check and record patient’s vital signs.

Change the patients dress to a hospital gown.

Ask the patient to empty her bladder.

Prepare the articles needed for the procedure (refer to appendix C)

Keep the patient on lithotomy position. When positioning both legs

should be put on the stirrups at the same time. Ask if the patient is comfortable and level the

stirrups accordingly.

Ensure that adequate privacy is provided for the patient.

Assist the doctor with the procedure. While assisting the procedure

ensure that strict aseptic technique is followed.

After the procedure make the patient comfortable and watch for

uterine contractions, leaking or bleeding PV.

Disinfect the articles used, as per infection control guidelines.

Properly document the procedure. While documenting follow the

guidelines for nursing documentation.

Monitor and record vital signs.

Maintain bed rest as per doctor’s order and carry out any further

orders.


Before transferring the patient to ward provide information to the

patient regarding the conditions that she should report to the nursing staffs. These include

Leaking

Bleeding

If the catheter bulb comes out /If pains increase.

If the patient does not have contractions, transfer the patient to

ward as per doctors advice.

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CARE OF PATIENTS WITH INFECTIOUS DISEASE IN LABOUR

Patients with infectious disease in labour may either need isolation or additional precautions

to prevent the spread of infection. Those with communicable diseases need to be isolated. But

those with infections such as hepatitis B/ HIV and other blood bourn disease does not need

isolation.

Patients who need isolation in labour should be given the same nursing care given to other

patients in 1st, 2nd, 3rd, and 4th stage of labour. The patient should get the same respectful

treatment that is given to any other patient.

Patients with communicable diseases need to be nursed in a separate room with separate

equipments. All the unnecessary furniture and equipments should be removed from the room.

While caring for the patient the nurse must follow the practice of medical and surgical

asepsis. Wear all personal protective equipments to prevent the spread of infection. Do not let

soiled linen and other articles touch the uniform.

Hand washing is the most important method of controlling the spread of infection. Wash

hands thoroughly using an antibacterial solution:

Before and after the procedures.

After contact with blood and body fluids.

Things used for the patients with infectious diseases need to washed separately. Keep

separate equipments for the patients where necessary. (eg bedpans). Before washing the

instruments soak them in 0.5% sodium hypochlorite for 10 minutes.

Put contaminated things in a separate plastic bag and label it as “BIO HAZARD”.

Dispose of urine, feces and vomits at once. Mop up any spilled fluids immediately using the

standard precautions. (Make sure that the attendants understand the restrictions and supervise

them while cleaning the spillage).

Mental support for isolated patients:

Carefully explain the patient and the relatives why the restriction is necessary.

Make sure that the patient does not feel emotionally isolated.

Communicate with patient.

Support the patient to go through labour as others.

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Airborne transmission precaution:

Patient placement: place the patient in an individual room if available.

Respiratory protection: wear a mask when giving care for the patient.

Patient transport: Limit patient transport to essential purpose only. If movement is

necessary minimize the risk of infection to others by placing a mask on the patient.

Environmental control: ensure appropriate environmental and equipment cleaning,

disinfection and sterilization. All surface areas should be disinfected with 0.5% sodium

hypochlorite solution

Contact transmission precaution:

Use personal protective clothing and practice hand washing:

When equipments are shared decontamination of the equipments are necessary before

using on another patient.

All surface areas should be disinfected with 0.5% sodium hypochlorite solution.

Droplet transmission precaution:

Patient placement: place the patient in an individual room if available

Respiratory protection: wear a mask when giving care for the patient.

Environmental control: All surface areas should be disinfected with 0.5% sodium

hypochlorite solution.

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INFECTION CONTROL PRACTICES IN LABOUR ROOM

Recommended infection control practice are based on the following principles

Every person (patient or staff ) must be considered potentially infectious;

Hand washing is the most practical procedure for preventing cross contamination.

Wear gloves before touching anything wet – broken skin, mucous membranes,

blood or other body fluids (secretions or excretions).

Use barriers (protective goggles, face masks and aprons) if splashes and spills of

any body fluids (secretions or excretions) are anticipated.

Use safe work practices, such as not recapping or bending needles, proper

instrument processing and proper disposal of waste. Soak used instruments in

0.5% sodium hypochlorite for 10 minutes before washing them

Handling of sharps

Use each needle and syringe only once.

Do not disassemble needle and syringes after use.

To prevent needle stick injuries, put used disposable syringes and needles, scalpel

blades and other sharp items in puncture-resistant containers for disposal immediately

after use. Keep these containers as close as possible to where sharp objects will be used.

Do not recap-if disposable needles are not available and if recapping need to be

practiced, use the “One handed” recap method:

General house keeping:

o The floor should be cleaned at least three times in 24 hours using 0.5% sodium

hypochlorite

o Thorough cleaning of delivery room should be done at least once a month.

o High dusting should be done at least weekly.

o All surfaces should be disinfected with 0.5% hypochlorite solution once a day and when

the patient is transferred.

o Toilets should be cleaned three times a day using detergent

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o Wash basins should be cleaned at least twice a day.

Additional precautions

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

If Positive: Linen which is used should be sent to laundry marked as “BIO HAZARD”

Post delivery:

All babies born to hepatitis B surface anti body positive mothers are immunized against

hepatitis B as soon as possible. If the mother is known to be HBe antigen positive inform

a pediatrician.

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CARE OF THE PATIENT AFTER ABORTION

Death or expulsion of fetus before 28th weeks of gestation either spontaneously or by induction is

termed as abortion.

Rights of women:

All women presenting with abortion has a right for immediate and quality care regardless

of of their marital status, religion, age, socioeconomic status, sexual behaviors, political

beliefs and whether tried for unsafe abortion

All women have a right for INFORMATION regarding their clinical condition and the

treatment planned for her

They have a right to discuss their concerns and express their own views regarding their

condition in a confidential environment. The information provided by the patient should

be treated CONFIDENTIALY unless it is required in a life threatening situation

They have a right for PRIVACY when ever undergoing any examination as it helps to

protect her confidentiality and promotes a sense of security and dignity

Immediate care

If a woman is admitted with vaginal bleeding perform a rapid assessment of her clinical

condition

Check for signs of shock (assess all vital signs)

Check the amount and duration of bleeding (passage of any clots)

Signs of any infection or injury

Get a detail medical and obstetric history of the patient using effective communication

techniques

History should include the last menstrual date

History of abdominal pain

History of fever

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History passage of clots

Past medical history

Secure an intravenous line keeping shock in mind

Send all routine investigations and a cross match

In suspected unsafe abortions observe for signs of infection and any injury

Inform the consultant on call

In case of the need for D&C proper explanation of the procedure and its risks should be

explained both to the woman and her family/husband

Women should be prepared for D&C

An informed consent should be taken from the woman/husband before the procedure

Woman should be made as comfortable as possible during the procedure and her stay in

hospital

Provide as much privacy as possible for the woman during the procedure

Provide pain medication/sedation as ordered by the consultant

After care

Respect the religious and cultural beliefs of the couple

Show the products of conception to the husband as well as to the woman

If a fetus is there allow the mother to touch if she wants to

All the D&C has to be entered in the D&C register

It is essential to provide adequate counseling to the couple after the complication is dealt

with.

In case of unsafe abortion provide counseling regarding the availability of family planning

methods which can be started immediately

Hand over a delivery/death form depending on the products of conception

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ROUTINE INVESTIGATION CHECKLIST

Investigation for labour patients

Hb

PCV

Bloog grouping and Rh typing

G6PD

Random blood sugar

HIV screening

HbsAg screening

VDRL

Investigations for PIH

All routine investigation

Blood urea

Serum creatinine

Uric acid

BT/CT

Investigation for babies born to Rh negative mothers

Hb

PCV

Blood grouping and Rh typing

Reticulocyte count

Serum bilirubin-total

Serum bilirubin- direct.

Direct coomb’s test.

Investigations for septic screening (Babies)

TC/DC

ESR

Blood culture.

CRP

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Investigations for birth asphyxia

Blood gas anal

Admission checklist

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Emergency Pre- operative checklist

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Documentation checklist

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Appendix

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APPENDIX A: PATIENT UNIT PREPARATION

For first stage of labour: Bed ready with curtains around the bed

Oxygen with tubing

Doppler /BP apparatus / thermometer /Stethoscope

P/C bowl,Gloves, Dettol cream (for P/V examination)

IV fluids and medication (listed in the daily inventory)

IV tray/ injection tray/ IV stand

Water

Feeding cup / medicine cup

Kidney tray

Dustbin

Relevant papers for documentation.

For second stage of labour:

Delivery bed with stirupps

Doppler

Suction machine with tubing

Suction tubes no: 8 (if liquor is clear ) no: 10 (if liquor is meconium stained)

Oxygen with tubing

Light

IV fluids and medication (listed in the daily inventory)

BP apparatus / Stethoscope

IV tray/ injection tray/ IV stand

Water

Feeding cup / medicine cup

Kidney tray

Delivery set (refer to appendix C)

Newborn resuscitation equipments and medication (refer to appendix C)

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For Severe PIH / eclampsia:

Keep the unit ready as for patients with first stage of labour. In addition keep the following things

ready.

Bed rails

Adult Suction machine with suction tubes

Air ways

Splints

Tongue depressor

For the administration of magnesium sulphate keep the following things ready:

o 50% magnesium sulpphate

o 10 ml of 10% calcium gluconate.

o Injection normal saline

o Injection 2% lignocaine

o Clinical hammer

o 20 ml syringe

o 10 ml syringe

o Foley’s catheter with syringe

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APPENDIX B / ORIENTATION TO LABOUR ROOM

On admission orient the patient and the relatives to the labour room with emphasis on the

following points.

Relatives are not allowed inside labour room.

Patients are not allowed to bring in their mobile phones or any valuables to labour

room.

Once patient is in active labour she will stay in the labour room till delivery.

All the patients will be attended by the doctor on duty/call (even if she has done her

antenatal checkups by a different doctor).

Relatives should stay in the place allocated for them and if they need to get any

information regarding the patient’s condition contact a nurse or a doctor on duty.

Relatives can talk to the patient over phone at any time they want (i.e if the condition

of the patient allows).

To keep the patients belongings a cupboard will be given. The key should be handed

over to labour room when the patient gets transferred to another ward. Relatives

should be advised not to keep any valuable item in this cupboard.

After delivery all patients will be kept in labour room for at least 2 hours.

Once patient is admitted the relatives can book for a room if they wish to. But when

the patient is due for transfer from labour room she will be shifted to a general ward if

the room is not due.

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

Normal delivery:

Sterile delivery set containing

1 gown with long sleeves,

1 lithotomy sheet

2 leggings

1 baby sheet

2 drapes

2 artery forceps

1 cord cutting scissor

1 episiotomy scissor (if needed)

Pad, gauze

Small bowl with an antiseptic solution

In addition,

Local anesthetics

Dettol cream

Personal protective equipments (plastic apron, mask, shoe cover, sterile gloves)

Oxygen

Doppler

Bed side suction machine if meconium is present.

For Vacuum extraction keep an appropriate size of vaccum cup with tubing and vaccum

apparatus ready

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Equipments needed for resuscitation in delivery room:

Radiant heater.

Baby stethoscope.

Oxygen with flow meter and tubing.

Neonatal resuscitation bag.

Face masks of different sizes.

Oral airways

Suction machine with tubing.

Suction catheters: 5F or 6F, 8F & 10F.

Endotracheal tubes; 2.5, 3.0, 3.5& 4.0mm.

Laryngoscope with straight blade no: 0 & 1.

Needles and syringes.

Feeding tube 8F and syringes.

Umbilical vessel catheterization tray.

Umbilical catheters 3.5 & 5F.

Medications needed for new born resuscitation:

Epinephrine (1:10,000).

Naloxone

Volume expander(normal saline).

Sodium bicarbonate.

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Urinary Catheterization:

A sterile tray containing

A sponge holding forceps

Gauze

Cotton

In addition,

Urinary catheter (appropriate size)

Urine bag

Distilled water and syringe

Antiseptic solution

Xylocaine jel

Cerviprime instillation:


2 sponge holding forceps

1 speculum (sim’s / cusco’s)

Small bowl for antiseptic solution

Gauze

Lithotomy sheet

Personal protective equipments

Culdocentesis:

P/ C bowl with cotton

Sterile lithotomy sheet

Speculum (cusco’s)

Sponge holding forceps

Long needles 18G, 20G, 21G (L/P needles)

10 ml syringe

Antiseptic solution

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Antiseptic cream


Extra amniotic saline instillation:


1 Speculum

1 Sponge holding forceps

1 vulsellum

1 artery forceps

1 Lithotomy sheet

Small bowl with betadine solution

Gauze pieces

In addition,

22 FR foley’s catheter

14 FR or 16 FR catheter and urine bag and 5cc of distilled water, if urinary

catheterization is needed

Syringes (20cc, for inflating intra cervical catheter and 5cc for inflating urinary catheter).

Clamp (a cord clamp may be used)

1 pint of normal saline and IV set

Johnson’s Plaster (to fix the catheter)

Xylocaine gel

Dettol cream


Episiotomy suturing:


Needle holder

Artery forceps

Dissecting forceps (toothed and non toothed)

Scissors

Gauze / tampoon

In addition,

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Injection Xylocain 1 %

5ml Syringe with needles

Antiseptic solution


Dilatation and curettage (D & C):


1 set of Hega’s dilators

3 Sponge holding forceps

1 Vulsellum

1 Uterine sound

1 Sims’ speculum

Curettes (blunt & sharp)

Small bowl for antiseptic solution

Lithotomy sheet

In addition,

Pesonal protective equipments

Antiseptic cream

Antiseptic solution

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APPENDIX D: CHECK LIST FOR WARD SISTER / WARD INCHARGE

(LABOUR ROOM)

DAILY

1. Check whether – daily inventory taken

– Missing/borrowed items replaced

2. Check whether – census(transfer in/transfer out/discharge)

3. Check whether – Narcotics inventory taken

– Narcotics register maintained regularly

– Narcotics cupboard key with senior staff nurse

4. Check whether – Emergency trolley (drug/equipments/instruments in both adult and

neonatal resuscitation

5. Check whether – store room locked at all times

6. Check whether – temperature/intake& output chart/files filled/updated ( during ward

rounds and report giving)

7. Check whether – all medication sheets filled accurately

8. Check whether – all special investigations (USG, CT scan, ECG, appointments, reports

etc)

9. Check whether – PAC’s done, consent taken (by the appropriate person)

10. Check whether – welfare letters are given

11. Check whether – linen checked, sent & returned

12. Check whether – infection control practices

– waste disposal/sharp disposal

– cleanliness /disinfection of equipments & instruments

– thorough disinfection of delivery bed and trolley after each delivery

– disinfection of patient unit

– used instruments/ bundles sent for autoclaving

13. Check whether – delivery forms handed over

14. Check whether – patient care components according to the care plan

– patient allocation

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– allocated nurses go on round with doctor

– all doctor’s orders are carried out properly

– daily care given

– all records completed

– all register completed

– malignance of intake/output chart for whom all required (even if no

doctor’s order

15. Check whether – all ward equipments in working order

16. Check whether – overall cleanliness/tidiness of ward

17. Check whether – communication between shifts

18. Check whether – follow up when things go wrong/broken items/missing items in ward

19. Check whether – attendants handover to next shift attendants(mops dry, buckets emptied,

dustbins emptied, kidney tray washed, dirty utility in clean state

– nurses and attendants report before going off duty (other shifts to the

senior staff on duty)

20. Check whether – update the changes in the duty register in the nursing department

21. Reporting – incidents that need immediate reporting

WEEKLY

WARD STOCK

- Identifying consumables required for the next week

- Write & send indent book to Nsg Dept. on the previous day before 12.00nn

DUTY ROTA

- Send duty rota on Wednesday before 12.00nn to Nsg Dept.

- To be made by ward sister only

CLEANLINESS

- treatment room

- patient unit

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- clean utility room

- dirty utility room etc

- fans, windows, racks etc

EQUIPMENT

- serving of all equipments – oiling of trolley wheels etc

- order/replace broken items

CASE SHEETS-DISPATCH

- Charts arranged in order

- Death case sheets stamped and documents filed in order/death summary filled

- Dispatch weekly or biweekly

CHECK AUTOCLAVED ITEMS

- Re-autoclaving after 2 weeks

- (Please allocate to senior nurses/junior nurses accordingly and do over all check)

REPORTING

- Necessary information (patient care/staff progress/ additional requirements etc. to the

nursing department )

MONTHLY

REVIEW CLASS: identifying weakest area – (present in the ward)

- reviewing a nursing procedure of a case presentation

INFECTION CONTROL: washing and C/S of delivery room

CHECK INVENTORY - (3-6monthly) of ward stock, Equipments / machinery

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- ward linen – check total linen count

- maintenance of paint, lights, curtains

- ward meetings – special events of the month

DISPATCH equipments/instruments which cannot be repaired

EXPIRY DATE of drugs and emergency medications

RECORDS & REPORTS: maintenance of ward registers, files

- Birth census

- Narcotic report

MONITORING: staff progress/patients care (appraisal review after 6 months)

REPORTING: necessary information (patient care/staff progress/additional requirements

etc. to the nursing department)

ANNUALLY

FULL INVENTORY OF WARD

ANNUAL BIRTH CENSUS

NEW IMPROVEMENTS TO THE WARD – suggestions and ideas etc.

BUDGET- items required for the following year budget.

LEAVE SCHEDULE OF THE STAFF

STAFF APPRAISAL

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

Ensure that the inventory has been checked by the responsible person (according to the duty

schedule). If the staff allocated for checking inventory has changed duty or has taken sick

leave allocate another staff to check it. DONOT LEAVE THE INVENTORIES

WITHOUT BEING CKECKED.

Verify whether all items necessary for the shift is available. If not, take from the store (If it is

not available in the store inform the ward in-charge).

Ensure that the store room is locked at all times.

Make sure that the narcotic cupboard is locked at all times and if a narcotic is used it should

be entered in the register.

Take hand over of all patients and make sure that the staff responsible for each patient reports

the progress of their patients to you.

Attend the doctors round along with the staff responsible for each patient (when appropriate).

Visit all the patients as often as possible and make sure that they are not left alone.

If there is any problem with any patient make ensure that the responsible doctor is informed

(if the medical officer cannot be contacted for any reason, inform the duty gynecologist

directly).

Make sure that the condition of patients are explained to the relatives at the given times.

Any problem in the ward should be informed to the coordinator and ward in-charge without

delay.

Meet the shift coordinator / supervisor when she comes for rounds and inform the condition

of patients.

Supervise the work of attendants and other staffs and delegate their work equally.

At the end or beginning of each shift check the necessary registers and make sure that the

registers are completed.

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APPENDIX F: DAILY TASKS OF NURSES WORKING IN LABOUR ROOM

Morning Shift


Check ward inventory (check whether all the equipments are in working condition and if

there are any thing missing get it replaced by the previous shift nurses).

Check narcotics inventory. (Check whether any narcotics have been used in the previous

shift and see that it is entered in the narcotics register).

Check the emergency trolley and neonatal resuscitation tray (check whether all

equipments are in working condition).

Check the general cleanliness of labour room

Send instruments for autoclave.

Take report from the previous shift.

Get introduced to the allocated patients and check their condition (check vital signs, FHS,

FM, uterine contraction).

Check IV fluids and if syntocinon drip is on flow check the drop rate and uterine

contraction.


Receive and prepare patients for induction of labour.

Check for investigation reports and get them from laboratory (If cord blood has been sent

make sure that the reports are collected without delay and handed over properly).

Collect reports from the laboratory and hand over to the relevant wards with out delay.

Give any due medications.

Do rounds with doctors.

Explain the patients’ condition to relatives.

If any patient is kept in labour room for a long time, take her out and let the relatives meet

her.

Carry out orders.


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Make the patients comfortable (mobilize the patient if possible).

Monitor the patients condition (check FHS, Vital signs and uterine contraction as needed).

Do not leave the patients alone when they are in pain.

Inform the progress of patients to duty doctors and carry out any emergency orders.

Explain the condition of patients to relatives and inform the relatives if there is any

change in the line of treatment.

Send the attendants to collect clean linen from laundry.

Collect bed sheets and gowns from the OT/ wards.


Hand over delivery forms of LSCS mothers.

Pack used instruments, gloves etc.

Check the cleanliness of labour room before handover to the next shift.



Hand over to the next shift.

Report to the ward incharge or shift incharge before leaving the ward or before going off

duty.

Afternoon Shift








Check the cleanliness and tidiness of labour room.




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contraction.

Complete documentation of the findings.

Give any due medications




Do rounds with doctors and carry out orders


If any patient is kept in labour room for a long time, take her out and let the relatives meet

her.

Check if any delivery forms need to be handed over and remind the relatives to collect the

forms.






Check whether instruments need to be autoclaved and send to CSSD.

Receive autoclaved items from the CSSD.


Check the cleanliness of labour room before handover to the next shift

Report any unusual incidence to the shift coordinator and ward incharge.



Report to the shift incharge before leaving the ward or before going off duty.

Evening Shift




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Check the cleanliness and tidiness of labour room.





contraction.

Complete documentation of the findings.






Make the patients comfortable.

If patient is kept in labour room for a long time, take her out & let the relatives meet her.

Check if any delivery forms need to be handed over and remind the relatives to collect the

forms.











Report to the shift incharge before leaving the ward or before going off duty.

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Night Shift









Get introduced to the allocated patients and check their condition (check vital signs,FHS,



contraction.

Complete documentation of the findings





Complete the census and write newborn census.


trays).







Make the patients comfortable.

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If patients are kept in labour room for observation switch off lights and help them to take

rest.

Give morning care.

Prepare patients for induction of labour.

Receive patients from wards for induction of labour.

Pack used instruments; gloves etc and prepare it to send for autoclave.





Report to shift incharge/ward incharge before leaving the ward or before going off duty.

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APPENDIX G: DAILY TASKS OF ATTENDANTS WORKING IN LABOUR ROOM

Morning Shift


Take over from the night shift attendant.

Check the general cleanliness of labour room.

Take instruments to CSSD and collect it when autoclaved.

Collect clean linen from the laundry.


Take specimens to laboratory. DO NOT WAIT TO FINISH OTHER WORK.

Clean wheel chairs and stretchers.

Accompany patients to wards /OT along with a nursing staff.

Collect reports from laboratory.

Take investigation reports to wards and get signature of the staff who receives the

report.

Assist patients to toilets if required. (ONLY WHEN ASKED BY A NURSE)

When asked by nurses stay with the patients.


give any information to relatives.

Make gauze, swabs and pads.

Check patients’ toilet frequently and clean as needed.

Wash kidney trays and disinfect them if a patient vomits. (Keep in sodium hypochlorite

solution for 10 minutes. DONOT LEAVE THEM FOR MORE THAN THE

SPECIFIED TIME ).

Clean doors, windows and other furniture.

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Wash suction bottles and suction tubing after each delivery.

Clean and disinfect patients unit thoroughly when patients are transferred. (wash used

oxygen tubing and change water in the humidifier)


THING CLEAN

Take things to CSSD.


Wash the slippers.


Report to the shift incharge/ward incharge before leaving the ward or before going off

duty.

Evening Shift


Take over from the morning shift attendant.


Take instruments to CSSD and collect it when autoclaved.

Collect clean linen from the laundry.


Take specimens to laboratory. DO NOT WAIT TO FINISH OTHER WORK .

Clean wheel chairs and stretchers.



Take investigation reports to wards and get signature of the staff who receives the report.


When asked by the nurses stay with patients.


give any information to relatives


Check the patients’ toilet frequently and clean as needed.

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Wash kidney trays and disinfect them if a patient vomits. (Keep in sodium hypochlorite

solution for 10 minutes. DONOT LEAVE THEM FOR MORE THAN THE

SPECIFIED TIME) .



Oxygen tubing and change water in the humidifier)

Take dirty linen to laundry. DO NOT TAKE DIRTY LINEN ALONG WITH ANY

THING CLEAN

Wash the slippers.




duty.

Night Shift


Take over from the evening shift attendant.


Take specimens to laboratory. DO NOT WAIT TO FINISH OTHER WORK.



Take investigation reports to wards and get the signature of the staff who receives the

report.


When asked by the nurses stay with patients.


give any information to relatives


Check the patients’ toilet frequently and clean as needed.

Wash all the kidney trays and disinfect them. (Keep in sodium hypochlorite solution for

10 minutes. DONOT LEAVE THEM FOR MORE THAN THE SPECIFIED TIME) .

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Oxygen tubing and change water in the humidifier)

Assist the nurses in cleaning and disinfecting the delivery room.

Take dirty linen to laundry. DO NOT TAKE DIRTY LINEN ALONG WITH ANY

THING CLEAN

Wash the slippers.




duty.

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REPRODUCTIVE HEALTH CENTRE

RHC-ROUTINES

QUALITY OF MAINTENANCE OF WORK & WORKING ENVIRONEMNT

INFECTION CONTROL GUIDELINE

DAILY TASKS OF NURSES

DAILY TASKS OF SHIFT SUPERVISOR

SHIFT ROUTINES FOR CLINICAL ASSISTANTS

SHIFT ROUTINES FOR RECEPTIONINTS

SHIFT ROUTINES FOR ATTENTANDS

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RHC-ROUTINES

ChargingAll the investigation will be charged

Consultations and other services such as injections are given free

AppointmentsInstruct all antennal clients to confirm appointments 2 days prior to the consultation date. Notify

the confirmation. Appointment with no confirmation will be cancelled & those appointments can

be given to the requested clients. Extra appointments cannot be given without asking the

consultant on duty.

Patients who come with leaking PV, Bleeding PV, and pain abdomenInform to the nurse and the doctor on duty.

Quickly take history

If required direct them to casualty.

Inform to casualty staff before sending them

If needed accompany them to casualty, provide wheel chair or stretcher

Or provide an appointment depending upon the situation.

ANC registration for new clientsPregnancy confirmation result must be there before 4 months of pregnancy.

If they have confirmed with home kit ask them to do urine gravindex (give investigation slip)

If they have not confirmed ask them to do beta HCG (at least one month aminorrhoea)

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Registration MemoFor all new patients Registration memo must be made and the hospital number must be entered in

their concerned clinic registers.

Investigation reportsAll investigation reports (including reports from islands, private clinics) which are done during

the present pregnancy should be entered on the ANC card & write the date of the investigation

done

Investigations (G6 PD DIFICIENT, NEGATIVE BLOOD GROUP, ALLERGIC MEDICINES)

should be written in RED INK.

High Risk PregnanciesHigh risk patients will be consulted only on Sundays and Wednesdays of the week.

A high risk list is maintained in the RHC. Due visit of all clients should be marked in the high

risk list. This list will be evaluated by weekly to identify the due visits and delay visits will be

reminded.

Family Planning Items.Condoms, Oral Pills & inj, Depo must issued throughout the day from 7.30am till 10.00pm.

All clients should be counseled before introducing any family planning method.

Family planning drugs and devices are issued only for family planning purposes.

NSTNST can be done for the RHC patients and Inpatients only. History and condition of the patient

should be assessed before receiving patients from Wards. Clarify the indication for NST. Do not

receive patients on stretcher, cases such patients in active labour, with premature contraction on

duvadilon drip, eclampsia, APH e.t.c. Make memo & maintain records.

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If you are unable to contact the consultant who advised NST, then please call the Gynae MO on

duty to show the report.

Foetal distressIf you identify foetal distress while doing NST or checking FHS, please start Oxygen

immediately & inform the doctor immediately. Also double check with another staff. Document

correctly & accurately

Serum BillirubimSerum Billirubin is done according to the Doctor’s advice after postnatal consultation. Make

memo & maintain records

Urine Albumin,For anyone urine albumin will be done if high blood pressure is being noticed during the

registration. For PIH cases urine albumin will be done for all their visits.

Writing nurses notesNurses’ notes should be written to all clients after NST, newborns admitting after Serum bilirubin

results, antenatal clients admitting after urine albumin/high /low BP, high/low blood sugar

identified at RHC.

Clients with fainting episodes /weakness /leaking PV/ bleeding PV, active labour, diagnosed by

the consultant.

Note: the above mentioned patients should be accompanied by RHC nurse & proper handover

should be given to the nurse of the other ward. Transfer them by wheel chair or stretcher

depending upon the condition of the patient. Make necessary arrangements to transfer them as

soon as possible.

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VaccinesInj. T.T is provided in accordance with the DPH protocols for antenatal mothers and adolescents.

All vaccines other than inj. T.T should be bought by clients

Ward VisitsWard Visits should be done daily to assess the conditions of antenatal and postnatal mothers.

Health education is provided according to their needs.

All the postnatal mothers will be explained about exclusive breast feeding, care of episiotomy or

LSCS wound, cord care & family planning.

Staff should attend to calls made by the ward staff to assist difficult cases of breast feeding.

Health EducationHealth education is given to all clients according to their needs.

Monthly forums are conducted according to a schedule prepared for each month.

The topics for forums are breast feeding, Labour & Labour Room Orientation, Baby bath &

newborn care, and to different high risk groups.

Points to be highlighted during registration for family planning Explain about physiological changes after delivery

involution of uterus

pelvic floor muscle changes

hemoglobin level

o Time is required for the body to adjust the above mentioned processes. It is also

important not to get pregnant again until the body is ready for that. So it is

advisable to follow one of the family planning methods until the decision to have

another baby.

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Inform about the family planning clinic during the postnatal visit

Explain about the procedure/appointments of the family planning clinic

Family planning counseling

Family planning devices – free of charge

Available time

Maintenance of Records All clients’ data are entered to RHC computer soft wear program.

Pap smear reports are entered to computer program and each Pap smear report is filed

with the examination form.

List of high risk patients are maintained. The due visit for each patient will be marked to

monitor their follow-up visits and outcome after delivery will be noted.

Antenatal exercise For all clients ANC EXERCISE fitness form must be explained & filled at 5 months after

anomaly scan.

If a client requests to join the AN exercise classes, proper instructions must be given about the

date, timings, payment & about the necessary items required

Clients details should be entered into the registers & a copy of the completed fitness form should

be given to the physiotherapy department

Pelvic assessmentPelvic assessment form should be given to all clients at 32 weeks during the registration.

Gynecologists will be fixing a date for pelvic assessment after explanation

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QUALITY & MAINTENANCE OF WORK & WORKING ENVIRONMENTEach individual staff is allocated special work in order to maintain the quality work done at

RH centre as well as to maintain a convenient working environment

ANTENATAL CLINICMaintenance of Antenatal registers & ANC cards

Check if registers are properly labeled & neatly maintained

Check if serial no. is followed correctly.

Check if all information (personal identification, medical /obs. /surgical history) is complete.

Check if Bp & weight are entered in each visit.

Check if results (blood, urine, & scan etc) are entered on each visit.

Identify & report incomplete records. The report should include the specific date, type of

record date, & the name of the responsible staff.

Maintenance of ANC statistics

Complete statistics from January – November 2006 at the end of November.

Check if daily statistics are entered to the daily sheet & computer

Prepare a format for statistics report during the 2nd week of October & confirm.

Report the progress of statistics report once every week.

Breastfeeding forum Make monthly schedule for breastfeeding forums.

Ensure all mothers at 6 months of pregnancy are noted down& called for breastfeeding

forums.

Check the no. of clients called for forums.

Check the no. clients attended for sessions.

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Check the no of husbands attending forums.

Check the total no. of clients who attended to ANC at & after 6 months.

Maintain statistics

Labour & Labour room orientation forum

Make monthly schedule for labor /labor room orientation forums.

Ensure all mothers at 7 months of pregnancy are noted down& called for forums.



Check the no. of husbands attending forums


Maintain statistics

New born care forum Make monthly schedule for new born care forums.

Ensure all mothers at 8 months of pregnancy are noted down& called for forums.



Check the no. of husbands attending forums


Maintain statistics

Maintenance of Inj. Tetanus stock & record Check condition & temperature of the fridge daily

Check stock balance weekly & write requisition to DPH whenever necessary

Write the total no. of doses available & total no. of doses issued at the end of each week

Check if all records are entered properly

Maintain cleanliness of the fridge

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ANTENATAL HIGH RISK CLINIC

Maintenance ANC High Risk statistics


Check if daily High Risk cases are entered to the daily sheet & computer

Conduct high risk forums

Maintain record of high risk outcome after delivery

Report the progress of statistics report once a month

High risk clients follow up visit Maintain record of high risk visits with follow up date

Call & confirm if follow up visits are not done

Arrange appointment to those who got delayed due to appointment overbooking

Arrange forum or provide health education on the high risk factor

Antenatal exercise Check antenatal exercise request book daily

Always keep the AN exercise register updated

Ensure if fitness forms are filled for all mothers at 5 months after anomaly scan

Ensure if all forms (fitness forms, item list, and appointment slip) are in the file

Ensure if all copies fitness forms are filed & a copy is sent to the physiotherapy dept.

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POSTNATAL CLINIC

Quality of maintenance of registers




Check if details of mother & newborn are entered in each visit.



Maintenance of PNC statistics


Check if daily statistics are entered to the daily sheet & computer

Prepare a format for statistics report during the 2nd week of October & confirm.

Report the progress of statistics report once every week.

Conducting forums

Conduct forums on complimentary feeding after delivery between 4 & 6 months

Conduct forum monthly once or twice

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FAMILY PLANNING CLINIC

Quality of maintenance of Family Planning registers & cards




Check if Bp, weight & other information are entered in each visit.

Check if investigation results are entered if any.



Maintenance of Family Planning Stock

Check if daily statistics are entered

Check if all the issued items are entered in the registers

Check if stock balance tally with the issued item numbers.

Maintain monthly stock balance /no. of users report form

Sending Family Planning reports to DPH

Send Family planning reports to DPH once in every 3 months

Send Family planning stock request to DPH once in 6 months

Conduct Family Planning Forums

Start conducting family planning forums from November onwards once in a month

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WELL WOMEN CLINIC

Quality of maintenance of Well Women registers & forms

Check if registers & forms are properly labeled & neatly maintained


Check if all information (personal identification/ history & other relevant information) is

complete.

Check if results (Pap smear, blood, urine, & scan etc) are entered on each visit.

Check if all the forms (pap smear & well women forms) are filed in order



Pap smear forms

Collect Pap smear forms daily from the OPD & file them in a separately.

Get reports from the Laboratory weekly once, attach with Pap smear forms and file them.

Enter the data to the computer program on weekly basis.

Keep all files properly labeled with dates.

ADOLSCENT HEALTH CLINIC

Quality of maintenance of registers, files & forms



Check if all information (personal identification & other relevant history) is complete.

Check if all the forms are complete & filed in order

Check if the vaccine register is maintained properly

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MAINTENACE OF ANTENATAL LEAFLETS Arrange leaflet packs & keep ready for distributing patients

Remind to request for leaflets before getting them over

Keep leaflets neatly arranged

MAINTENACE OF POSTNATAL LEAFLETS Arrange leaflets in the cupboard & in other places

Remind to request for leaflets before getting them over

Keep leaflets neatly arranged

MAINTENANCE OF MODELS Check models register weekly once

Maintain lending /receiving items properly

MAINTENANCE OF WARD VISIT RECORDS Check & report if ward visits are not done daily

Check if all the columns of the ward visits are filled accurately

SUPERVISION OF INVENTORY Check if the inventory is checked daily

Check & report missing items

Check & maintain lending& borrowing book

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SUPERVISION OF RECEPTION Remind all staff to keep the reception neatly &tidily

Check if reception inventory is maintained

Check if all appointment registers are labeled & maintained properly

Ensure & report if all posted staff for the reception stay in the reception

Remind about the rules of using reception telephone

Report problems of reception

MAINTENANCE OF LIBRARYBooks & videos

Keep the library books neatly arranged at all times

Check library register once a week

Maintain a record of lending / receiving items

CLEANLINESS & ARRANGEMENT OF COMSULTATION ROOMS Check if all areas of rooms are properly cleaned

Check if all items in the rooms are neatly arranged

Check if all sterile items in the room are not outdated

Make sure thorough cleaning is done once a week

Check if all instruments working condition

Identify & maintain repair & maintenance

Ensure that all documents / forms & files in the room are in place

CLEANLINESS & ARRANGEMENT OF REGISTRATION ROOM Check if all areas of the room are cleaned properly

Check if all items are arranged neatly kept in place

Maintain all fliers in the registration room

Ensure if all instruments are in working condition

Ensure thorough cleaning is done once a week

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CLEANLINESS & ARRANGEMENT OF HEALTH EDUCATION ROOM Check if all areas of the room are cleaned properly

Check if all items are complete arranged neatly


CLEANLINESS & ARRANGEMENT OF HEALTH EDUCATION ROOM Check if all areas /tables in the waiting area is cleaned daily

Check if all items are arranged neatly

Ensure thorough cleaning (chairs / leaflet cupboards , TV) is done once a week

CLEANLINESS & ARRANGEMENT OF VACCINE ROOM Check if all areas of the room are cleaned properly



Ensure that sharps & other waste are handled properly


CLEANLINESS & ARRANGEMENT OF TREATMENT ROOM Check if all areas of the room are cleaned properly



Ensure that sharps & other waste are handled properly


CLEANLINESS & ARRANGEMENT OF COUNSELLING ROOM Check if all areas of the room are cleaned properly


Ensure if FP models & other items are in place


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CLEANLINESS & ARRANGEMENT OF DEMONSTRATION ROOM Check if all areas of the room are cleaned properly


Ensure if all equipments are in working condition

Identify & report maintenance & repair work


CLEANLINESS & ARRANGEMENT OF STORE ROOM Check if all areas of the room are cleaned properly



INFECTION CONTROLL GUIDELINE FOR RHC STAFF

Daily disinfection of all examination couches daily with sodium hypochlorite

Hand washing solution (betadine & chlorhedexine solution) must be available in all

consultation rooms

Clean all rooms thoroughly once a week according to the cleaning schedule

Wash all dustbins once a week

Wash all hand washing solution bottles once a week

Wash / through clean of both treatment rooms once a month.

Clean all fans once in 2 weeks

Wash curtains once a month

Bring sodium hypochlorite daily from CSSD

Wash all trays daily in 3rd shift

Check items required for re autoclaving once a week in the 3rd shift

Send forceps with jar for autoclaving everyday if it has been opened & used

Follow instructions for tray packing for packing used instruments

Disinfect all thermometers /stethoscopes daily in the third shift

Wash & dry the mop after every use

Ensure if mop bucket is washed after every use

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Supervise (shift in charge) attendants during & after cleaning

Supervise attendants - handling of linens, waste, & autoclaved items

All staff should follow universal precaution during procedures

All staff should use sterillium for hand disinfection in-between procedures if hand washing is

not possible e.g before giving inj. T.T

All staff should present self neatly, should maintain short nails & no jewelries

Through cleaning & washing of RH centre once in 3 months

Reception & waiting area

Clean & mop the reception area daily twice.

Clean & arrange all tables daily

Clean the top of the counter with sodium hypochlorite daily at the end of all clinics.

Clean the telephones with spirit at the end of all clinics.

Clean thoroughly the reception area & counter once in a week.

Registration room

Clean & mop daily

Clean the weighing machine, height scale and table tops daily

Clean the stethoscope daily with spirits

Thorough cleaning once a week

Dust & clean inside the cupboard, table drawers

Wash table top with soap & water

Disinfect with sodium hypochlorite

Health Education Room

Clean all areas of the room & mop the room daily

Clean all equipments in the room daily


Dust & clean leaflet cupboard

Dust & clean the TV rack

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Wash table top with soap & water

Treatment room (down stairs)


Carbolize the examination couch with sodium hypochlorite

Clean inside the cupboard

Disinfect NST machine daily / wash cloth belt once a week

Treatment room (up stairs)


Carbolize the examination couch with sodium hypochlorite daily

Change sheets in-between patients

Clean the cupboard & cardiac table top daily with sodium hypochlorite

Keep sterile items separately from non sterile items

Through cleaning once a week

-Dust and clean all areas of the room with sodium hypochlorite including walls & fans

Demonstration Room




Clean inside the cupboard once a week

Clean all chairs once a week

Clean all areas of the room once a week

All consultation rooms

Clean & mop all rooms daily

Clean table tops daily

Wash table tops with soap & water once a week

Ensure the wash basin is cleaned well

Disinfect all examination couches daily with sodium hypochlorite

Keep hand -washing solutions & sterillium solution in all rooms

Disinfect dopplers /Bp apparatus daily

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Disinfect baby mat & measuring tape daily in the 3rd shift

Counseling Room




Clean inside the cupboard once a week

Clean all chairs once a week

Clean all areas of the room once a week

Store Room




Clean inside & top of the cupboards once a week

Office



Wash the table top daily


Clean inside & top of the cupboards once a week

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INSTRUCTIONS FOR TRAY PACKING

Wash instruments / article with diluted soap solution.

Dry immediately with a clean towel

Handle the instruments / article care fully and gently.

Check for proper functioning of instruments / articles.

Keep only sufficient amount of instruments in the tray.

Make sure instruments are enough for a particular procedure.

Keep cotton balls / gauze enough for a particular procedure.

Keep autoclaving indicator before closing the tray

Make sure the wrapper is large enough to cover the tray completely.

Check and label properly.

Fix the autoclaving indicator outside the label (not on the tray cover) and write the date and

name (who packs tray) on the plaster.

Make sure all the trays and articles are accurately written in the book before sending for

autoclaving.

Special instructions

Soak soiled instruments in 0.5% sodium hypochlorite solution for 5 minutes before

washing.

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UNIVERSAL PRECAUTIONProtect health care providers from exposure to disease spread by blood, other body fluids such as

HIV, hepatitis B, MRSA e.t.c

Procedures for universal or standard precaution

1. Hand washing

2. Clothing (uniform/gown)

3. Shoes

4. Caps

5. Mask-patient & staff protection

6. Safe injection practices

Additional precaution

1. Air borne, Contact, Inoculation or Parenteral,

2. Faeco-oral routes, multiple routes.

Transmission- based precautions are special precautions taken in addition to standard precautions

for known infections based on the mode of transmission of the infection.

SHARP DISPOSAL1. Use sharps container for disposing cotaminated needles, blades e.t.c

2. Do not pass sharps to one another

3. Do not recap/if recapping use the correct method

4. Practice safe injection practices

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5. Discard sharps container when 2/3 full

WASTE DISPOSAL1. Double bag/biohazard labeled infectious waste/ attendant must wear rubber gloves for

transferring waste materials

2. Send out of the place as soon as possible

Soiled material after procedure (norlant /copper-T insertion)

Small dressings-episiotomy/surgical wounds.etc

Motion cleaning/nappies

LINEN1. Put soiled linen directly into black bag

2. Count the amount of linen correctly

3. Double bag/biohazard labeled soiled linen

4. Send to laundry as soon as possible

BLOOD/ VOMITUS/ OTHER BODY FLUIDS1. Put sodium hypocrite over the spilled fluid

2. Cover with newspaper and leave for a few minutes

2. Attendant must wear rubber gloves for taking them put them into a plastic bag

3. Mop the area – use the separate mop

4. Wash, clean the mop in bleach & dry

RECEIVING A CLIENT WITH A COMMUNICABLE DISEASE1. If a client is notified with any communicable disease, she should be taken to one of the free

OPD consultation for consultation.

2. Inform the gynaecologist on duty.

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3. Inform to the OPD nurses station & arrange the room

4. All appropriate measures should be taken by the staff

5. Preferably an immuned staff should accompany if possible.

6. If the diagnosis is confirmed after consultation, then used instruments, sheets & examination

couch, chair must be disinfected before next patient

SHIFT ROUTINES FOR RHC NURSES

FIRST SHIFT




Check appointments, staff on duty & doctors duty rota

Check allocated areas of all staff & prepare to start work according to the clinics of the day

Check if rooms are ready for consultations

Check the general cleanliness of the place

Send attendant to collect linen & autoclaved items

Check report & statistics of the previous day

Check the message book

Take delivery list of the previous day & send to the physiotherapy department

Check & record the vaccines & fridge temperature

Prepare for registration & health education

Check & distribute linen & autoclaved items to rooms

Ensure all clients who need health education are given health education.

Report any unusual incidence to the nurse in charge & shift coordinator.

Clean & arrange consultation rooms at the end of the clinics

Wash & pack used intruments

Complete report & statistics


Complete other assigned works / assist in registration of patients if necessary

Check cleanliness & tidiness of all the areas

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SECOND SHIFT









Check if statistics report is correct & complete

Check vaccines & fridge temperature

Prepare for registration & health education

Ensure all clients who need health education are given health education.

Do ward visits

Help family planning clinic





Complete other assigned works



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THIRD SHIFT








Check the total number & type of family planning procedures


Check if statistics report is correct & complete

Check vaccines & fridge temperature

Prepare for counseling, procedure, registration

Prepare for adolescent health clinic



Check & replace all necessary items for the consultation rooms

Count & maintain family planning stock

Wash all trays

Disinfect all articles stethoscope, telephones, baby mat, measuring tape etc.


Complete other assigned works


Write special reports on the message book or on the notice board

Swtich off all lights, air-conditions (except demonstration room & treatment room), close all

doors & recheck before closing the place

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SHIFT SUPERVISOR

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

JOB DESCRIPTION

Check the total number of staff (nurses, clinical assistants, doctors) on duty.

Check the total number of appointments and the number of doctors on duty.

All staff should inform to the SHIFT SUPERVISOR regarding any information (order) given

by a doctor, from other departments, or any other staff.

Receptionists should inform to the SHIF SUPERVISOR regarding any information (order)

given by a doctor or other staff.

SHIFT SUPERVISOR must take action regarding any delay in doctor’s consultation, delay in

attending to duty by staff etc.

All staff must inform their sick leaves to the SHIFT SUPERVISOR.

Ensure that staff posted to all areas, and remain in their posts during clinic hours. And also

ensure all the clinics function properly on time.

Any staff who leaves the posted area for any valid reason (e.g. treatment room) must inform

to the SHIFT SUPERVISOR.

Check the reception for any new Memos, Letters, cards etc.

We all are responsible to minimize the telephone and computer use. However the SHIFT

SUPERVISOR has the authority to observe long telephone calls (>3 minutes) and remind

about the IGMH rules for telephone and internet use.

Monitor and check if the following records are maintained.

Inventory book / Report & statistics file

FP Books

HE books and lists

ANC/PNC

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Computer data etc:

Supervise the cleanliness of all the areas.

Identify repair work and missing items.

SHIFT ROUTINES FOR CLINICAL ASSISTANTS

Check posted consultation room according the particular room check list.

Make the consultation rooms ready according to the type of clinic

Call patients according to their serial numbers after Doctors arrival.

Translate & explain what doctor’s wants to explain patients

Guide the patient for doctor’s examination.

Assist to the doctor to complete investigation forms, prescription for the doctor and explain to

the patient.

Enter each patient’s record for the computer data system.

Maintain cleanliness of the room throughout the consultation.

Completing other allocated tasks (eg: entering records for the data system, assisting to

prepare health education materials) during the off time

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FLOOR STAFF

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

JOB DESCRIPTION

Greet & smile people whoever comes inside the RH centre.

Guide them to the counter.

Explain the procedure for the new comers. (ie: they have to go through the registration, health

education, and then consultation.)

Identify and guide people who need registration, health education, and consultation

(address/call them by their names).

Identify and guide to people who requires breast feeding.

Inform to a nurse about inj. T.T. NST etc. & other procedures

Direct or explain how to go to other departments and their procedures (eg: scan, x-ray)

Check health education check list before they go home.

Maintain health education status file.

RECEPTIONISTS

Greet who ever enters into the Reproductive Health Centre

Enquire the purpose of visit and provide information or make arrangements to fulfill their

needs.

Giving appointments to those who need to attend to the concerned clinics.

Maintaining record of appointments.

Distribute appointments according to the doctor’s duty roster.

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Receive & handover items (eg: letters/cards/circulars) to the concerned staff in time.

Maintain stationeries /books for the reception.

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Nursing Guidelines ( Draft)

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Transcript of Nursing Guidelines ( Draft)