Part Two
- Nursing Plan Policy
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|||||
The purpose :
Understand the patient's needs and meet them.
Providing high-quality nursing care.
Politics :
The Services Department is committed to providing nursing care according to the patient’s needs and documenting it in the nursing care plan for each patient.
Steps:
The nursing team does:
Conduct a nursing assessment of the patient upon admission and determine the patient's problems.
Recording the patient's nursing problems in the nursing plan, which includes: (problems/needs - nursing intervention - evaluation - signature).
Writing the necessary procedures to help solve nursing problems.
Re-evaluation to determine the extent of the patient’s response to nursing interventions.
The department supervisor follows up the plan and implements its procedures.
Administrator :
Department Supervisor - Nursing staff members in the department.
Models:
Nursing care plan template.
The Reviewer :
Comprehensive hospital accreditation guides.
|
|
|
|
|
|
|
|
Nursing registration policy
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|||||
The purpose:
1. Record all patient data.
2. Teaching health team members to register on nursing forms in a correct, accurate and legible manner.
Politics:
The Nursing Services Department is committed to accurate nursing registration 24 hours a day in a correct, accurate and legible manner
Steps:
The nursing team members do:
1. Recording every activity performed by the patient from the moment he enters his form.
2. The team begins by assessing the patient using the prepared form.
3. The patient’s main complaint is identified and needs are determined.
4. Planning the care that will be provided to the patient.
5. Implement the plan carefully to get the desired results.
6. Evaluate the plan each shift to identify the development of the situation.
7. Repeat any of the steps in the plan that did not improve the patient’s condition.
8. Monitor vital signs and notify the doctor when there is any change from normal levels.
9. The necessity of working and submitting a report on any emergency incident during the work period, such as (patient falling - patient escaping - error in administering treatment).
10. The health team members must pay attention to recording the nursing progress, which includes (the patient’s condition - the doctor’s recommendations - all medical procedures, tests, and rumors - and surgical interventions - the nursing intervention - the patient’s evaluation of no new signs and symptoms).
Administrator :
Members of the nursing staff in the department - the department supervisor.
Model:
Nursing notes - nursing assessment - vital signs - nursing care plan - treatment charts
The reviewer:
Operational guide for nursing staff services at the Ministry of Health.
|
|
|
|
|
|
|
|
Minimum medical history and clinical examination policy
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|||||
Policy: The hospital is committed to setting the minimum requirements for a patient’s medical examination upon admission.
Purpose: To determine the minimum medical examination and medical history necessary to evaluate the patient upon admission to the hospital.
Working procedures:-
1. The department doctor takes a medical history and examines the patient upon admission according to the medical history and medical examination form, which includes:
· The patient’s personal history, which explains (full name - gender - age - profession - marital status according to the national ID card - special habits such as smoking and drinking alcohol).
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
2. The doctor conducts a clinical examination of the patient, which includes:
Measuring vital signs (pressure, pulse, temperature).
A comprehensive examination of all parts of the patient’s body.
Local examination of the patient's complaint using various manual examination methods.
The doctor records the examination result and results from the date of admission and the clinical examination in the patient’s file (initial diagnosis).
The doctor records the initial treatment plan
3. The doctor, based on his findings and according to the patient’s need, orders in writing on the doctor’s order form to perform the necessary tests and x-rays for the patient and determines the notes of vital signs that will be taken and the dates for their recording by the department’s nurses.
4. The doctor writes the drug treatment accurately in the treatment description and implementation form.
5. The doctor determines the type of nutrition appropriate for the patient on the doctor’s order form.
6. The nursing staff records the patient’s data on the food form to bring meals to the patient.
7. The treating physician informs the patient and his family of the initial diagnosis, treatment or surgery plan, potential results, expected complications, and nutritional regimen.
Responsible: the specialist doctor
Forms: Medical History and Medical Examination Form - Food Form - Doctor's Orders Form.
References: Egyptian accreditation standards.
|
|
|
|
|
|
|
|
Policy for identifying categories of hospital patients most at risk
|
|
Identifying the categories of hospital patients most at risk |
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|||||
Politics:
Patients in critical condition who are most at risk must be identified and followed up. Then the medical team begins the evaluation process and the plan is coordinated and implemented with the patient and family.
The purpose:
Identifying patients most at risk, such as children, individuals with special needs, the elderly, and psychiatric patients in the hospital, and the special evaluation required for each of them.
Medical cases that require special services regarding hospital care:
Age 75 years or older
Altered state of consciousness or related disorders (mental disorders).
Traumas, multiple fractures, fractures of major joints.
Malnutrition, dehydration, microbial poisoning.
Patients with late cases.
children.
Victims of abuse, neglect or injury.
Dialysis patients.
Intensive care patients.
Chronic disease patients.
Patients at risk of falling.
Patients prone to bed sores.
Patients taking sedative medications and diuretics.
Procedures:
The medical team matches the at-risk cases to each patient within 24 hours of his admission to the hospital, and if the patient’s condition matches one of the following cases, the patient’s expected risk signs are determined.
Doctors and nurses record current and anticipated problems and major and alternative solutions in care plans.
Doctors and nurses follow up the cases and re-evaluate them according to the requirements of each case.
|
|
|
|
|
|
|
|