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GULFDIAGNOSTIC CENTER
HOSPITAL
NURSING POLICY Policy No:MED-NUR-P0033/12
TITLE: Nursing Standards of CareIssue Date : July 2012
Revision No.: Original
Department : Nursing Revision Date :
Section : Nursing Care Next Revision : July 2014
Distribution : Hospital Wide Page 1 of15
Nursing Standards of Care
APPROVAL SHEET
Prepared by:
Name Signature Date
Ms. Gela Mocanu
Head of Nursing Department
Reviewed by:
Name Signature Date
Prof. Dr. Emad Al Rahmani
Medical Director
Mr. Zuher ArawiIT, QA Manager
Approved by:
Name Signature Date
Mrs. Jamal KaddouraCo-founder & Hospital Director
__________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ] No [ ]
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GULFDIAGNOSTIC CENTER
HOSPITAL
NURSING POLICY Policy No:MED-NUR-P0033/12
TITLE: Nursing Standards of CareIssue Date : July 2012
Revision No.: Original
Department : Nursing Revision Date :
Section : Nursing Care Next Revision : July 2014
Distribution : Hospital Wide Page 2 of15
DOCUMENT AMENDMENT RECORD SHEET
Date Description of Change Page EffectedRevision
Number
__________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ] No [ ]
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GULFDIAGNOSTIC CENTER
HOSPITAL
NURSING POLICY Policy No:MED-NUR-P0033/12
TITLE: Nursing Standards of CareIssue Date : July 2012
Revision No.: Original
Department : Nursing Revision Date :
Section : Nursing Care Next Revision : July 2014
Distribution : Hospital Wide Page 3 of15
TABLE OF CONTENTS:
SUBJECTS PAGE NO.
1. DEFINITION 4
2. POLICY 4
3. SCOPE 4
4. RESPONSIBILITY 4
5. PROCEDURE 4-15
6. REFERENCE 15
__________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ] No [ ]
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GULFDIAGNOSTIC CENTER
HOSPITAL
NURSING POLICY Policy No:MED-NUR-P0033/12
TITLE: Nursing Standards of CareIssue Date : July 2012
Revision No.: Original
Department : Nursing Revision Date :
Section : Nursing Care Next Revision : July 2014
Distribution : Hospital Wide Page 4 of15
1. PURPOSE
1.1. The purpose of these standards is to ensure that all patients will receive quality nursing
care according to established standards, which are evidenced based and supported by amulti-disciplinary team.
1.2. Nursing policies are given where necessary to assist the nurse to find more information
if required.
2. POLICY
2.1. To ensure adequate Nursing Standards of Care for all patients.
3. RESPONSIBILITY
3.1. All Medical Staffs
4. PROCEDURE
4.1. PATIENT ASSESSMENT
4.1.1. Complete physical assessment will be performed on all new admissions and
transfers to the ward within 1 hour of admission and the first 2 hours of eachshift and prn.
4.1.2. All sections of the nursing assessment form including psychosocial, cultural,
spiritual assessment and initial discharge planning will be completed within
24 hours following admission.4.1.3. All entries in the nursing assessment form will be completed, dated and
timed,along with name, signature and staff number of the nurse who
completed the section. Information or sections not completed require reasonof no completion.
4.1.4. Risk assessment form, patient and family education form, and oral assessment
form will be completed within 24 hours of admission and updated as specifiedon the forms.
4.1.5. The nurse will obtain and interpret an ECG rhythm strip on all patients
requiring cardiac monitoring at the beginning of each shift and during anyepisodes of dysrhythmias or hemodynamic instability.
4.1.6. Nurses will report any clinically significant or symptomatic deviations in vital
signs to the attending physician as per the MEWS score.
4.1.7. Vital signs will be recorded every four hours, as per MEWS score, or as perphysician's order.
4.1.8. Temperatures will be documented with vital signs, every 4 hours on pyretic
patients, within 1 hour post administration of anti-pyretic therapy and as perMEWS score. Documentation of temperature readings will include the site
used.
4.1.9. An apical pulse will be checked for one minute and documented prior to theadministration of digitalis
4.1.10. Intake and output will be recorded on the Intake and Output Record for__________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ] No [ ]
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GULFDIAGNOSTIC CENTER
HOSPITAL
NURSING POLICY Policy No:MED-NUR-P0033/12
TITLE: Nursing Standards of CareIssue Date : July 2012
Revision No.: Original
Department : Nursing Revision Date :
Section : Nursing Care Next Revision : July 2014
Distribution : Hospital Wide Page 5 of15
patients who are nil by mouth, on diuretics (if recent or increased dosage),
receiving IVF; with urinary catheter, Intercostal drains, Renal/Cardiac
admitting diagnosis.4.1.11. The necessity of all lines and drains will be addressed on each shift. This
includes all IV lines, Foley catheters, and surgical drains.
4.2. The patient can expect that his/her health data will be analyzed and used to guide theplanning of care.
4.2.1. Patient problems will be identified within 1 hour of admission anddocumented with the assessment and plan of care.
4.2.2. A plan of care will be formulated, reviewed and revised as necessary at aminimum of once per shift, and when the patient's condition changes.
4.3. The patients physiological, behavioral and self-reporting indicators of pain will be
assessed, documented and treated according to their individual needs. This will be done:4.3.1. Immediately upon admission to the ward/unit
4.3.2. With vital sign assessment and upon discharge from the unit
4.3.3. When patient complains of pain or as per Non verbal Pain Scale4.3.4. Before analgesia administration
4.3.5. Following analgesia administration within:
4.3.5.1 60 minutes post oral / rectal analgesia.
4.3.5.2 30 minutes post intramuscular / subcutaneous transdermal administration.4.3.5.3 30 minutes post intravenous administration
4.3.6. The appropriate pain assessment tool will be used and reassessed for
effectiveness of analgesia as per policy4.4. Planning of Patient Care
4.4.1. The patient can expect that a written plan of care is documented, implemented
and evaluated in a systematic way.4.4.1.1 Nursing care will be planned according to the individual patients
holistic care requirements.
4.4.1.2 Implementation of the plan of care will be reflected in the nursingDocumentation.
4.4.1.3 The plan of care will be evaluated for achieving desired outcomes on
current /potential problems and revised as needed. This will be done by
the nurse as per Policy every shift and updated as necessary in the patientschart according to changes in the patients health status.
4.4.2. The patient can expect that the nursing plan of care is coordinated, developed
and implemented in collaboration with the multi-disciplinary team.4.4.2.1 The plan of care will be implemented in collaboration with the
multidisciplinary team on an ongoing basis through team conferences, clinical
rounds and/or multi-disciplinary referrals as appropriate.4.4.3. The patient can expect that the plan of care promotes continuity of care by:
__________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ] No [ ]
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GULFDIAGNOSTIC CENTER
HOSPITAL
NURSING POLICY Policy No:MED-NUR-P0033/12
TITLE: Nursing Standards of CareIssue Date : July 2012
Revision No.: Original
Department : Nursing Revision Date :
Section : Nursing Care Next Revision : July 2014
Distribution : Hospital Wide Page 6 of15
4.4.3.1 Encouraging the same nurse to have the same patient assignment as
much as possible, staffing permitting (taking into account the competency,
emotional and intellectual needs of the nursing staff).4.4.3.2 Including the patient / family in the care planning process.
4.4.3.3 Keeping the plan of care updated and reflective of current patient
problems.4.4.3.4 Including specific information related to the patient / family
educational needs as appropriate (documented as Patient and FamilyEducation (PFE) form).
4.4.3.5When leaving the unit during the shift, the nurse will give a completehandover of his/her assigned patient to another nurse competent to manage all
aspects of their assigned patients care.
4.4.4 Planning for care includes a succinct change-of-shift report which iscommunicated from nurse to nurse. At the change-of-shift report, pertinent patient
information is provided to ensure a smooth shift transition. Change-of-shift reports
include:4.4.4.1 Patient diagnosis, past medical history, current events, length of stay
and surgery or intervention date, if applicable
4.4.4.2 Review of focus charting, plan of care, outstanding procedures and
referrals.4.4.4.3 A review of the patients medication administration record including
IV infusions and calculation of doses and rates.
4.4.4.4 An update regarding family members, to include: who visited, theinformation that was shared and their level of coping.
4.4.4.5 Update regarding process of discharge planning.
4.4.4.6 Charge Nurse / Shift in charge is to receive the change of shift reportsat the end of each shift.
4.4.5 Psychosocial/Cultural/Religious Needs of The Patient
4.4.5.1 The patient/family can expect support of theirpsychosocial/cultural/religious wellbeing using
the following interventions:
4.4.5.1.1 Utilizing translation services when necessary to enhance
communication.4.4.5.1.2 Maintaining privacy during the delivery of care.
4.4.5.1.3 Explaining tests and procedures before performing them.
4.4.5.1.4 Providing an environment that allows the patient/family topractice their
Religious/cultural beliefs.
4.4.5.1.5 Encouraging family participation in the care of the patient, asappropriate.
__________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ] No [ ]
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GULFDIAGNOSTIC CENTER
HOSPITAL
NURSING POLICY Policy No:MED-NUR-P0033/12
TITLE: Nursing Standards of CareIssue Date : July 2012
Revision No.: Original
Department : Nursing Revision Date :
Section : Nursing Care Next Revision : July 2014
Distribution : Hospital Wide Page 7 of15
4.4.5.1.6 Allowing the patient the use of personal items, such as head
coverings for women, which do not interfere with medical or nursing
procedures or hospital valuable policy.4.4.6 Physical Needs of the Patient
4.4.6.1 The patient can expect assessment and supportive treatment and care of
physiological function for the following body systems: neurological,cardiovascular, respiratory, integumentary/musculoskeletal, gastro-intestinal, and
genitor urinary/reproductive.4.4.6.1.1 Neurological
4.4.6.1.1.1 A GCS will be completed on patients with an acuteneurological pathology, those who have undergone neurosurgery
or neurological interventional procedures as per physician orders
or:4.4.6.1.1.1.1 Every 1 hour for a minimum of 6 hours post
admission or procedure
4.4.6.1.1.1.2 Then, if stable, it is completed every 2 hoursfor 12 hours then every 4 hours for 12 hours, then every 8
hours and prn.
4.4.6.1.1.1.3 If not stable, the timings of the GCS will not
change and the Physician will be notified.4.4.6.1.1.2 The nurse will immediately notify the Physician if:
4.4.6.1.1.2.1 There is a new development of agitation or
abnormal behavior4.4.6.1.1.2.2 Any drop of more that two points in the GCS
4.4.6.1.1.2.3 Development of severe or increasing headache
or persistent vomiting4.4.6.1.1.2.4 New or evolving neurological symptoms or
signs.
4.4.6.1.1.3 Suspected spinal injuries will be immobilized andspinal precautions will be implemented until clear authorization
to mobilize is documentedin the medical records by the physician.
Verbal orders are not acceptable for spinal clearance and C-spine
precautions are to continue until a written order is received fromthe physician.
4.4.6.1.1.4 Any patient with a C-collar (hard collar) will have
collar released every 2 hours for care of the neck and pressure areaassessment. C-spine alignment will be maintained during release of
collar and this procedure requires a minimum of two competent
persons.4.4.6.1.1.5 For acute patients who have or are at risk of raised
intra-cranial pressure, care will be provided that prevents__________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ] No [ ]
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GULFDIAGNOSTIC CENTER
HOSPITAL
NURSING POLICY Policy No:MED-NUR-P0033/12
TITLE: Nursing Standards of CareIssue Date : July 2012
Revision No.: Original
Department : Nursing Revision Date :
Section : Nursing Care Next Revision : July 2014
Distribution : Hospital Wide Page 8 of15
elevations in Intra-Cranial Pressure (ICP) and/or promotes ICP
reduction including:
4.4.6.1.1.5.1 Maintain head and neck alignment.4.4.6.1.1.5.2 Maintain head of bed elevation at 30 degrees
4.4.6.1.1.5.3 Avoid hip flexion greater then 30 degrees
(consider reverse trendelenburg).4.4.6.1.1.5.4 Avoid positions that may increase intra-
abdominal or intrathoracic pressures such as prone or semi-prone.
4.4.6.1.1.5.5 Minimize stimulation and lighting; avoidprolonged periods of stimulation.
4.4.6.1.1.6Beds containing air mattresses will not be used for
patients with suspected or diagnosed spinal trauma.4.4.6.1.1.7The nurse will attempt to minimize injury to the seizing
patient by such measures as padding the side rails, placing a pillow
under head, and clearing the area of potentially harmful materials.The nurse will never attempt to place anything into the patient's
mouth.
4.4.6.1.1.8 Oxygen therapy may be required if the seizure is
prolonged e.g. longer than 5 minutes. All witnessed seizures willbe reported to the Physician.
4.4.6.1.1.9 Patients at risk for neurovascular compromise will have
a neurovascular assessment completed with the vital signs anddocumented in the patient chart. Documentation will include color,
warmth, movement, sensation & the presence of pulses distal to the
injury.4.4.6.1.2 Cardiovascular
4.4.6.1.2.1 A 12 Lead ECG will be carried out on all patients who
require cardiac investigations as deemed necessary by the treatingphysician or as part of the nurses assessment when deemed
necessary.
4.4.6.1.2.2 All monitored alarm limits will be assessed and
documented at the beginning of each shift and as patient conditionchanges.
4.4.6.1.2.3 High/low alarm limits will be set to a maximum of 20%
above and below the patients current reading.4.4.6.1.2.4 All monitor alarms will be on and audible at all times.
4.4.6.1.2.5 Alarms will be addressed immediately by the nurse and
corrective action taken accordingly.4.4.6.1.2.6 ECG electrodes will be changed every 24 hours and
prn.__________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ] No [ ]
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GULFDIAGNOSTIC CENTER
HOSPITAL
NURSING POLICY Policy No:MED-NUR-P0033/12
TITLE: Nursing Standards of CareIssue Date : July 2012
Revision No.: Original
Department : Nursing Revision Date :
Section : Nursing Care Next Revision : July 2014
Distribution : Hospital Wide Page 9 of15
4.4.6.1.2.7 A physicians written order and signed patient consent
must be obtained prior to the transfusion of blood / blood products
as per policy4.4.6.1.3 Respiratory
4.4.6.1.3 .1 Lung sounds will be auscultated on all patients at the
beginning of the morning and afternoon shifts. On night shift, lungsounds will be auscultated only if the patient is awake, or unstable.
4.4.6.1.3.2 The nurse will closely monitor the patient receivingoxygen by pulse oximetry and clinical assessment such as
respiratory rate and depth, presence of cyanosis, and mental status.4.4.6.1.3.3 Oxygen flow rate via face mask will be greater than six
(6) liters per minute. These patients may use nasal cannula to
permit mouth care and/or eating/drinking.4.4.6.1.3.4Oxygen flow rate by nasal cannula will not exceed six
(6) liters / min.
4.4.6.1.3.5 At least once per shift the nurse will assess the patientfor possible skin breakdown where tubing may cause pressure and
apply protective measures such as padding. (e.g. over ears and
bridge of nose)
4.4.6.1.3.6 Oxygen is to be started if SpO2 is less than 95% atroom air and Physician needs to be notified.
4.4.6.1.4 Integumentary/Musculoskeletal
4.4.6.1.4.1 A head to toe skin assessment will be carried out on all patientsevery shift and will be documented in the Nurses Notes. Particular
attention will be paid to vulnerable areas, such as bony prominences.
4.4.6.1.4.2 Immobile patients will be turned or repositioned at least every2 hours, including night shift. If this is not done, reasons will be
documented.
4.4.6.1.4.3 A 30 turn to either side is required to avoid positioning
directly on the trochanter, unless medically contraindicated.4.4.6.1.4.4 Reddened areas and bony prominences will not be massaged.
4.4.6.1.4.5 Pillows or foam wedges will be used to avoid contact between
bony prominences.4.4.6.1.4.6 Devices, such as pillows or foam wedges will be used to
relieve pressure on the heels and bony prominences of the feet. Heels
should be floating in air.
4.4.6.1.4.7 Shearing forces will be reduced by maintaining the head of thebed at no more than 30.
4.4.6.1.4.8 Friction will be reduced by the use of transfer sheets to move
patients.
__________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ] No [ ]
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GULFDIAGNOSTIC CENTER
HOSPITAL
NURSING POLICY Policy No:MED-NUR-P0033/12
TITLE: Nursing Standards of CareIssue Date : July 2012
Revision No.: Original
Department : Nursing Revision Date :
Section : Nursing Care Next Revision : July 2014
Distribution : Hospital Wide Page 10 of15
4.4.6.1.4.9 Rehabilitation or physiotherapy services will be consulted
when devices are required to reduce pressure, friction and shear.
4.4.6.1.4.10The nurse will protect and promote skin integrity by:4.4.6.1.4.10.1 Ensuring hydration through adequate fluid intake.
4.4.6.1.4.10.2 Showering when possible.
4.4.6.1.4.10.3Avoiding hot water and use a pH balanced, non-sensitizing skin cleanser.
4.4.6.1.4.10.4Minimizing friction and shear4.4.6.1.4.10.5The application of a non-sensitizing, pH balanced,
lubricating moisturizers and creams with minimal alcohol content.4.4.6.1.4.10.6Using protective barriers (e.g. Extra-thin
hydrocolloid, or transparent film) or protective padding to reduce
friction injuries.4.4.6.1.4.11 Minimize skin exposure to excess moisture. (e.g. urine,
faeces, perspiration, wound exudate, saliva etc).
4.4.6.1.4.12 When moisture cannot be controlled use absorbent pads,dressings or briefs that draw moisture away from the skin. Replace pads
and linen when damp.
4.4.6.1.4.13 forWound Care
4.4.6.1.4.13.1 Open wounds will be irrigated with the abovesolutions ONLY using a 30cc syringe and a 19g angiocath/cannula.
4.4.6.1.4.13.2 Physician or wound management team orders will
be followed for the type and frequency of dressing as per policy4.4.6.1.5 Gastro-Intestinal
4.4.6.1.5.1 Naso/Oro Gastric Tube [N/OGT] placement will be checked
following initial insertion, at the beginning of each shift and prior to use.4.4.6.1.5.2 If there is any doubt that tube is not in the stomach or the
patient becomes acutely breathless or develops difficulty in breathing
during administration of feed /medications, stop administration and notifyphysician.
4.4.6.1.5.3 Confirmation of tube placement will be made by:
4.4.6.1.5.3.1 Auscultation over the epigastric region whilst rapidly
injecting 10-20ml of air AND4.4.6.1.5.3.2 Aspirating 20 mLs of stomach contents AND testing
with pH indicator strip. A pH measurement of less than 5.0
requires an X-ray ordered and read by the physician in order toconfirm the placement of the tube.
4.4.6.1.5.4 The patients head of bed will be elevated to 30 degrees for all
feeds via N/OGT or PEG whether the feed is intermittent of continuous
__________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ] No [ ]
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GULFDIAGNOSTIC CENTER
HOSPITAL
NURSING POLICY Policy No:MED-NUR-P0033/12
TITLE: Nursing Standards of CareIssue Date : July 2012
Revision No.: Original
Department : Nursing Revision Date :
Section : Nursing Care Next Revision : July 2014
Distribution : Hospital Wide Page 11 of15
4.4.6.1.5.5 Bowel function will be monitored and documented on each
shift and a bowel protocol will be implemented as required according to
physicians order.4.4.6.1.5.6 For Percutaneous Drains:
4.4.6.1.5.6.1 Percutaneous drains will be secured firmly.
4.4.6.1.5.6.2 Accurately measure and record drainage output onintake and output record at the end of every shift or when emptied
or removed.4.4.6.1.5.6.3 The nurse will report any significant changes in the
character or volume of fluid, leaking of fluid or bleeding at site ofdrain to the nurse in charge.
4.4.6.1.5.6.4 The nurse will notify the Physician if total drainage is
greater than 300mls over 6 hours.4.4.6.1.5.7 Urinary/Fecal Ostomy
4.4.6.1.5.7.1 The nurse will report excessive bleeding from stoma
(a small amount of bleeding during cleaning is normal),discoloration, signs of necrosis, retraction below skin level or
herniation of 2.5 cms (or greater) more than usual to the nurse in
charge.
4.4.6.1.6 Genito-Urinary/Reproductive4.4.6.1.6.1 Urinary catheter and perineal care are performed with
soap and water during the daily bed bath and every 8 hours and
prn.4.4.6.1.6.2 Urinary drainage bags will be emptied using an aseptic
technique at the end of each shift [and prn] and recorded on intake
and output sheet.4.4.6.1.6.2 Silastic and Foleys urinary catheters will only be
changed if there is evidence of obstruction by encrustation or
mucus, symptomatic infection, or leakage around the catheter.Changes are documented in the multidisciplinary notes.
4.4.6.1.6.3 Urinary catheter tubing will be secured to the leg with
an elastic cuff.
4.4.6.1.7 Pre & Post-Operative Care4.4.6.1.7.1 Pre-op checklist will be completed prior to transfer to OT.
4.4.6.1.7.2 The nurse will initiate incentive spirometry to prevent
postoperative pneumonia in patients with underlying respiratory disease.This will be initiated pre-operatively if possible. Post-operatively, the
patient will be assisted to undertake the exercise every hour while patient
is awake for 24 48 hours post operatively or longer if required. Patienteducation will be documented in the Patient and Family Education form
(PFE).__________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ] No [ ]
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GULFDIAGNOSTIC CENTER
HOSPITAL
NURSING POLICY Policy No:MED-NUR-P0033/12
TITLE: Nursing Standards of CareIssue Date : July 2012
Revision No.: Original
Department : Nursing Revision Date :
Section : Nursing Care Next Revision : July 2014
Distribution : Hospital Wide Page 12 of15
4.4.6.1.7.3 A concise and appropriate handover will be given to the OT by
the nurse transporting the patient and will include ongoing infusions,
abnormal vital signs, allergies and latest capillary blood glucose level ifapplicable
4.4.6.1.7.4 The ward nurse will go to the Recovery Room to collect the
patient and receive handover from the staff.4.4.6.1.7.5 The ward Nurse will check and assess the following in the
Recovery Room prior to transport back to the ward: Operation performed,type of anaesthesia given, any medication or blood given, post operative
wound dressing and drainage,presence and/or quality of pain, presence ofanalgesia, level of consciousness and post operative orders.
4.4.6.1.7.6 Provide safe transportation for return to ward as per escort
policy4.4.6.1.7.7 Assess for pain and give analgesic as required as per Patient
Pain Assessment Policy.
4.4.6.1.7.8 Contacts the Physician if analgesia does not relieve pain in theallotted times.
4.4.6.1.7.9 Observations/vital signs will be completed and documented as
follows: 15 minute interval x 2 (started on arrival to the ward), every 30
minutes x 2, every 1 hour x 2, every 2 hours x 2 and every 4 hours.4.4.6.1.7.10 Deep breathing and coughing will be taught and encouraged
and analgesia provided, if required. Patient education to be documented in
the Patient and Family Education form (PFE).4.4.6.1.7.11 Fluid intake and urine output will be monitored and
documented every 2 hours for the first 8 hours.
4.4.6.1.7.12 The physician will be notified if the patient has not urinated 8hours post-op.
4.4.6.1.7.13 Patients will be supported and encouraged to mobilize as soon
as possible or as per physicians orders4.4.6.1.7.14 Patients will be kept NPO until there is a Physicians order to
feed the patient.
4.4.6.1.7.15 Oral care will be given to patients at least every 4 hours while
NPO.
5. INFECTION CONTROL
5.1. The patient can expect that infection control and prevention measures are implemented5.1.1 Suction liners and tubing will be changed every 24 hours and when required.
5.1.2 Irrigation bottles will be changed every 24 hours and dated and timed.
5.1.3 All disposable products used directly for the patient will be either discarded
or transferred with the patient.
__________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ] No [ ]
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GULFDIAGNOSTIC CENTER
HOSPITAL
NURSING POLICY Policy No:MED-NUR-P0033/12
TITLE: Nursing Standards of CareIssue Date : July 2012
Revision No.: Original
Department : Nursing Revision Date :
Section : Nursing Care Next Revision : July 2014
Distribution : Hospital Wide Page 13 of15
5.1.4 All medication vials and infusion solutions will be dated, initialed, and
utilized for no more than 24 hours and then discarded (exception: Insulin and
Heparin vials which are good for one month).5.1.5 Non-disposable equipment is cleaned between patient use and PRN.
5.1.6 Hand washing and/or hand disinfection with alcohol based gel will be
performed before and after patient procedures, between patients and uponentering and leaving the ward.
5.1.7Isolation barriers will be initiated according to policies5.1.8 Standard precautions will be applied to all patients.
5.1.9 Patients/visitors will be instructed regarding infection control measures.5.1.10 Peripheral vascular access device (PVAD) will be checked for phlebitis
and infiltration within 30 minutes of insertion and then every 2 hours if solutions
are being infused and every 4 hours if no solutions are being infused.5.1.11 IV tubing and burettes that are continuously used are changed every 96
hours and dated, timed and initialed.
5.1.12IV tubing and burettes that are NOT continuously used are changed every24 hours and dated, timed and initialed.
5.1.13 At any time IV tubing, secondary sets and add-on devices are disconnected
from the cannula they must be immediately discarded.
5.1.14 Peripheral IVs will be re-sited every 96 hours and prn. If it is difficult tostart an IV on the patient, the IV may be kept longer with a Physician's order
provided the site is free of complications, with documentation in the
multidisciplinary notes.5.1.15Blood and blood product IV tubing will be changed every 24 hours and
dated, timed and initialed.
5.1.16 TPN IV tubing will be changed every 24 hours and dated, timed andinitialed.
5.1.17 A transparent, occlusive dressing will be used for all invasive line insertion
sites. The catheter hub and tubing connection will be left exposed. Transparentdressings will be changed when damp, loosened, or soiled.
5.1.18Gauze dressings will be used for invasive lines which are leaking from the
site
5.1.19 All unused lines will be Normal Saline locked and will be capped withextension tubing with positive pressure valve. Closure cap will be changed
each time the line is accessed.
5.1.20 All CVC dressings will be assessed at least every 4 hours.5.1.21 CVC's will be checked for phlebitis and infiltration within 30 minutes of
insertion and then every 2 hours.
6. SAFETY
6.1 The patient can expect that their safety needs are addressed__________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ] No [ ]
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GULFDIAGNOSTIC CENTER
HOSPITAL
NURSING POLICY Policy No:MED-NUR-P0033/12
TITLE: Nursing Standards of CareIssue Date : July 2012
Revision No.: Original
Department : Nursing Revision Date :
Section : Nursing Care Next Revision : July 2014
Distribution : Hospital Wide Page 14 of15
6.1.1An identification bracelet will be placed on the patient upon arrival to the
unit with accuracy verified and then checked per shift for placement. The
identification bracelet may need to be replaced and/or re-sited due to edema, orprocedures prn.
6.1.2A falls prevention/ risk assessment will be performed daily. It will be placed
on the patient that is identified as high risk of fall. Appropriate interventions arefollowed as specified on the risk assessment form.
6.1.3 All bedside emergency equipment will be checked at the beginning of eachshift. This check will ensure all equipment is present and functioning.
61.4 Medications, hazardous supplies and cleaning materials will be kept underlock and key.
6.1.5Call bells will be within patient reach at all times.
6.1.6 Crash carts are maintained on each unit and checked as per policy6.1.7All equipment that is donated or brought into the hospital will be cleared by
Biomedical as per policy.
6.1.8Blood products will be double checked by two registered nurses beforeadministration. Vital signs will be documented before initiating infusion,
during and after the transfusion as per blood and blood product infusion
procedure.
6.1.9Patients will be observed at least once per hour by a member of the nursingstaff.
6.1.10 Patients requiring physical restraints will be assessed and evaluated as per
policy6.1.11 All patients being transported will be assessed against set criteria to
determine the type of escort required.
6.1.12The escorting nurse will ensure that the appropriate documentation hasbeen completed, and will accompany the patient.
6.1.13Transfers within the UAE will be according to policy
7. COMFORT
7.1 The patient can expect that comfort, rest and pain alleviation needs are supported
7.1.1 A bath and linen change will be done at least once per day unless
contraindicated by patient's clinical condition.
7.1.2 Lip and mouth care will be given as per oral assessment tool.7.1.3Male patients will be offered a shave each morning or as per patient/family
request; documentation will reflect if the patient or family has refused a shave.
Cultural norms and values will be adhered to.
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Appendix: Yes [ ] No [ ]
7/27/2019 Ppg Gdch Nur 33 Nursing Care
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GULFDIAGNOSTIC CENTER
HOSPITAL
NURSING POLICY Policy No:MED-NUR-P0033/12
TITLE: Nursing Standards of CareIssue Date : July 2012
Revision No.: Original
Department : Nursing Revision Date :
Section : Nursing Care Next Revision : July 2014
Distribution : Hospital Wide Page 15 of15
8. PATIENT EDUCATION / DISCHARGE PLANNING
8.1 The patient/family can expect education that supports their transition towards self-
care, and adaptation to their health/illness condition8.1.1 The nurse will collaborate with other services as appropriate.
8.1.2 The nurse will assess barriers to learning and level of learning achieved by
the patient.8.1.3 The nurse will document all teaching performed.
8.1.4 Appropriate patient and family education materials will be provided.8.2 The patient/family can expect that an individualized discharge plan of care is
assessed, established and implemented8.2.1 A Nursing Discharge Summary will be completed on all patients prior to
transfer or discharge.
8.2.2 Discharge planning will be initiated within 24 hours of admission anddocumented on the Initial Assessment Form.
8.2.3 Discharge planning will demonstrate a multidisciplinary collaboration with
necessary referrals8.2.4 All patient and family education will be documented on the Patient and
Family
Education Form.
8.2.5 Patients may be transferred to transit area prior to discharge8.2.6 If the patient is leaving against medical advice, the registered nurse inquires
why the patient requests to leave the hospital, notifies the MRP and document
this in the patients record as per policy.
9. REFERENCES
9.1 5 Million Lives Campaign. Getting Started Kit: Prevent Central Line Infections How
to Guide. Cambridge, MA: Institute for Healthcare Improvement; 2008. www.ihi.org Accessed 19 February, 2009
9.2Brain Trauma Foundation, (2007) "Guidelines for the management of TBI: American,
Association of Neurological Surgeons (AANS), Congress of Neurological Surgeons,
(CNS), AANS/CNS Joint Section on Neurotrauma and Critical Care". Journal of
Neurotrauma; Volume 24, Supplement 1, 2007.
9.3Buchanan S, Coltart L, Cowie K, Davidson R, Don C, Elder F, Gravill P, Guild C,
Manson L, McGibbon G, Nardi A, Rait C, Wood A. (2007). Caring for the patientwith a tracheostomy - Best Practice Statement. NHS Quality Improvement Scotland.
March http://www.nhshealthquality.org/nhsqis/files/TRACHEOREV_BPS_MAR07.pdf
-Accessed 09 February, 20099.4Centre for Disease Control (CDC), [2003]. Guidelines for Preventing Health Care
Associated Pneumonia. CDC: U.S.A.
9.5 Centre for Disease Control (CDC), [2011]. Guidelines for Preventing of IntravascularCatheter Related Infections. CDC: U.S.A.
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Appendix: Yes [ ] No [ ]
http://www.nhshealthquality.org/nhsqis/files/TRACHEOREV_BPS_MAR07.pdfhttp://www.nhshealthquality.org/nhsqis/files/TRACHEOREV_BPS_MAR07.pdfTop Related