Part Two
- Private policies
· EKG policy
· Nursing care policy for angina patients
· Nursing care policy for heart attack patients
· Nursing care policy for patients with heart failure
· Nursing care policy for trauma patients
· Nursing care policy for patients with pulmonary infiltrates
· Policy for nursing care of an unconscious patient
· Nursing care policy for diabetic coma patients
· Electroshock device policy
· Central cannulation care policy
· Policy for receiving a patient for the first time
· Policy for receiving a regular patient in the unit
· A policy that assesses the dry weight of a patient with kidney failure
· Central venous catheter installation policy (MAHOCER)
· Policy for inserting a femoral venous catheter
· Policy for conducting serological examinations for patients
· Policy for starting a hemodialysis session
· Policy for completing the hemodialysis session
· Machine care policy
· Peritoneal dialysis policy
· Monthly analysis policy
· Monthly treatment disbursement policy
· Laundry unit accounts policy
· Employee health policy
Electrocardiogram policy
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Politics:
Teaching nurses how to perform electrocardiograms for hospital patients in a quality manner and to protect the electrocardiogram device from damage as a result of misuse.
Tools and supplies:
The EKG device and its accessories, and ensuring that there are connections to the device
- Chart paper for the device - medical gel - cotton or tissue paper.
Steps:
Review the receipt of the patient’s application in terms of completing his data or not.
Hand washing (routine).
Preparing the necessary tools (EKG device and its accessories, ensuring the availability of the device’s connections - graph paper for the device - medical gel - cotton or tissue roll)
Help the patient to relax and lie on his back.
Explaining the procedure to the patient.
Help the patient to take off or lift his clothes from the places where the device’s electrical connections will be placed.
Ensure that there is no jewelry or metal on the patient before installing the extensions.
Placing the medical generation of electrodes.
Tie the electrodes around the wrists and around the legs in the correct manner.
The first connection for the chest (V1) is placed between the fourth and fifth ribs on the right side of the rib cage, (V2) the second connection is placed next to it on the left side of the chest, the third connection (V3) is placed under the nipple of the left breast, and the fourth, fifth and sixth connections are next to it on the left side.
Start operating the device.
Ensure that the feather traces its impact in the center of the device’s graph bar if the device is manual.
Complete the EKG by waiting until the readings are recorded.
Remove all connections from the patient and remove the medical gel using dry medical cotton or a tissue roll.
Help the patient cover himself and get out of bed.
Recording the patient’s data on the EKG (the patient’s name in four - date - hour - the signature of the person performing the work in three) after completing the EKG.
Record this in its own register to know the number of cases that have been completed daily.
Delivering the EKG to the nursing staff responsible for the patient.
Return the tools and arrange them in place until they are used.
Wash hands after finishing.
- Administrator :
Department nursing staff members.*
Department supervisor.
- The Reviewer :
Procedural work guide for the artificial kidney unit (Nursing Guide Line).
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Policy for dealing with angina patients
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Politics:
Dealing with angina patients.
The Definition:
It is chest pain resulting from a lack of blood ischemia of the heart muscle due to narrowing of the coronary arteries.
Steps:
Taking a medical history from the patient to confirm his condition and determine the location of the pain.
It calms the patient and puts him in a semi-sitting position.
Connecting the patient to the monitor to follow up on the situation.
Connecting the patient to oxygen.
Make an electrocardiogram and show it to the doctor.
Giving medications to the patient according to the doctor’s instructions (aspirin, heparin, nitroglycerin...).
Continuously assess pain according to the pain assessment map.
Conduct continuous follow-up of the patient through vital signs and electrocardiogram, and inform the doctor immediately.
The Reviewer :
Nursing Guide Line
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Policy for dealing with heart attack patients
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Politics:
Dealing with angina patients.
The Definition:
It is chest pain resulting from a lack of blood ischemia of the heart muscle due to narrowing of the coronary arteries.
Steps:
Taking a medical history from the patient to confirm his condition and determine the location of the pain.
It calms the patient and puts him in a semi-sitting position.
Connecting the patient to the monitor to follow up on the situation.
Connecting the patient to oxygen.
Make an electrocardiogram and show it to the doctor.
Giving medications to the patient according to the doctor’s instructions (aspirin, heparin, nitroglycerin...).
Continuously assess pain according to the pain assessment map.
Conduct continuous follow-up of the patient through vital signs and electrocardiogram, and inform the doctor immediately.
The Reviewer :
Nursing Guide Line
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Policy for dealing with heart attack patients
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Politics :
Sudden chest pain resulting from the blockage of one of the coronary arteries, most often by a blood clot, which leads to part of the heart muscle being deprived of blood supply and thus dying.
Steps:
Taking a medical history from the patient to confirm his condition and determine the location of the pain.
Work to calm the patient and place him in a semi-sitting position.1
Connecting the patient to the monitor to follow up on the situation - Connecting the patient to oxygen.
Take an electrocardiogram and show it to the doctor.
Installation of 1-2 peripheral cannulae and taking a blood sample to perform complete laboratories including cardiac enzymes (troponin LDH - CPK).
Giving medications to the patient according to the doctor’s instructions (analgesics - tridylnitroglycerin - streptokinase...).
Nursing note when administering streptokinase:
Observe the patient's pressure and pulse, as well as note the patient's complaint of shortness of breath, vomiting, profuse sweating, and scratching. This occurs as a result of an allergy to it. In this case, streptokinase is stopped and a large dose of hydrocortisone is given.
The anti-streptokinase drug is cyclocaprone and is given in case of bleeding.
Performing an electrocardiogram for the patient before, during, and after administration.
Do not give intramuscular or subcutaneous injections to the patient during or immediately after administration.
Noticing bleeding from the nose or mouth.
Important notes: Nursing staff members must:
Continuously assess pain according to the pain assessment map. - Evaluate and record a complete description of the pain.
Complete rest for the patient to reduce oxygen consumption. - Do an EKG during pain.
Giving the patient oxygen if the patient feels short of breath and informing the doctor.
The Reviewer :
Procedural work guide (Nursing Guide Line).
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Policy for dealing with heart attack patients
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Politics :
Sudden chest pain resulting from the blockage of one of the coronary arteries, most often by a blood clot, which leads to part of the heart muscle being deprived of blood supply and thus dying.
Steps:
Taking a medical history from the patient to confirm his condition and determine the location of the pain.
Work to calm the patient and place him in a semi-sitting position.
Connecting the patient to the monitor to follow up on the situation - Connecting the patient to oxygen.
Take an electrocardiogram and show it to the doctor.
Installation of 1-2 peripheral cannulae and taking a blood sample to perform complete laboratories including cardiac enzymes (troponin LDH - CPK).
Giving medications to the patient according to the doctor’s instructions (analgesics - tridylnitroglycerin - streptokinase...).
Nursing note when administering streptokinase:
Observe the patient's pressure and pulse, as well as note the patient's complaint of shortness of breath, vomiting, profuse sweating, and scratching. This occurs as a result of an allergy to it. In this case, streptokinase is stopped and a large dose of hydrocortisone is given.
The anti-streptokinase drug is cyclocaprone and is given in case of bleeding.
Performing an electrocardiogram for the patient before, during, and after administration.
Do not give intramuscular or subcutaneous injections to the patient during or immediately after administration.
Noticing bleeding from the nose or mouth.
Important notes: Nursing staff members must:
Continuously assess pain according to the pain assessment map. - Evaluate and record a complete description of the pain.
Complete rest for the patient to reduce oxygen consumption. - Do an EKG during pain.
Giving the patient oxygen if the patient feels short of breath and informing the doctor.
The Reviewer :
Procedural work guide (Nursing Guide Line).
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Heart failure care policy
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Politics:
Inability to pump an appropriate amount of blood to the rest of the body in order to reduce patient complications.
Tools and devices used:
EKG device.
Earphone .
Pressure device.
Normal range: 5 – 12 cm.
Steps:
Place the patient in a cool, quiet room to help him sleep.
Connect the patient to a monitor to monitor the number of heartbeats and perform an EKG.
Place all things within the patient's reach.
Keep the patient in a comfortable position constantly.
Reassure the patient about his health.
Conducting the necessary tests for the patient.
Educating the patient about the importance of rest when he returns home.
Introducing the patient to the symptoms of poisoning from Digitalis (nausea, vomiting, diarrhea, headache, depression, tension, dizziness, spasms, hallucinations, memory loss, increased or decreased heart rate, urticaria).
- Nursing staff must do the following before giving Digitalis (Lanoxin):
Taking the patient's pulse for a full minute with the stethoscope on the patient's chest.
Carefully observe the heart rate if it is regular or irregular and record it.
Stop the dose and inform the doctor if the patient's pulse is fast or less than 60 beats per minute.
Carefully observe the patient for any symptoms of anoxin poisoning.
Giving the patient meals rich in potassium.
Avoid giving the patient any food that contains sodium salts.
Weigh the patient every day at the same time on the same scale, usually before breakfast.
Taking care of the patient's skin because swollen skin is more susceptible to cracking.
Connecting the patient to oxygen in case of difficulty breathing.
Make a fluid chart for the patient.
The Reviewer :
Nursing Guide Line
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Policy on how to deal with trauma patients
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Politics :
A decrease in the amount of blood that reaches the vital organs in the body, such as (the brain, heart, and kidneys), which leads to the tissues of these organs being deprived of a sufficient amount of oxygen and nutrients carried by the blood.
Steps:
Bringing the patient to the reception area and calming the patient down.
Connecting the patient to a monitor device and measuring vital signs in a regular manner to follow his condition moment by moment while monitoring the patient’s degree of consciousness.
Implementing the doctor’s instructions to treat the patient according to the type of shock and the factor causing it (in cases of bleeding, the patient’s blood is given - in cases of burns, plasma is given - in cases of vomiting and diarrhea, solutions are given to the patient) i.e. compensating the patient for the amount of fluids that were lost, whether through sweat Or bleeding.
Raise the patient's lower part so that the blood reaches the brain and this does not negatively affect the patient.
Put the patient on oxygen according to the doctor’s instructions.
Warm the patient naturally so that sweat secretion and loss of fluids from the body do not increase.
The Reviewer :
Procedural work guide (Nursing Guide Line).
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Policy for dealing with the unconscious patient
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Politics :
It is a condition in which the patient loses his awareness and sense of what is happening around him. This is the result of disorders in the sensory nervous system, and these disorders are accompanied by a decline (decrease) in some brain cell functions.
Steps:
Assess the level of awareness and reporting.
Maintaining the integrity of the airways and breathing (setting an airway - adjusting the patient's position - applying oxygen according to the doctor's instructions)
Observe breathing and report. - Observing vital signs.
Observing the skin (its color - the areas of contact - the presence of dryness...).
Turn the patient over and create a turning pattern to maintain blood flow and skin integrity.
Continuously provide full care for the patient, especially (mouth, eyes, nose, skin folds...)
Maintaining the patient’s provision of appropriate nutrition for his condition via (intravenous or gastric tube (RIL) and recording the quantity on a fluid chart).
Place a urinary catheter and take appropriate care of it.
Maintaining the safety and security of the patient (such as raising bed barriers - taking care not to place sharp machines or supplies on the patient’s bed).
Recording, reporting, and restraining the patient according to the doctor’s orders, and following up on the restraint according to patient safety procedures.
Take notes for the comatose patient on the following points:
Description of level of activity or awareness:
- In full awareness (Alert) in danger - (Confused)
- Restless - Very sleepy - (Drowsy)
- In lethargic (Lethargic) in a complete coma (comatose)
Recording the data on a fluid balance map with the amounts taken in from treatment and fluids and out from urine and feces secretions...etc.
References:
Procedural Action Guide (Nursing Guide Line)
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Policy for dealing with patients with pulmonary edema
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Politics:
It is lung congestion resulting from an increase in the amount of blood in the blood vessels in the respiratory system, which leads to great difficulty in breathing
Steps:
Help the patient to sleep at an angle of 90 or 45 degrees or sit in a chair because this position facilitates the breathing process.
Supply the patient with 8 liters of humidified oxygen or according to instructions.
Giving the patient medications according to instructions, such as:
Giving the patient a diuretic such as Lasix intravenously slowly.
Giving aminophylline to dilate the bronchi.
Suctioning the airways if secretions are present.
Installing a urinary catheter to calculate the amount of incoming and outgoing fluids, especially since these patients are given diuretics in large quantities.
Sometimes a patient needs a respirator to save his life.
The Reviewer :
Procedural work guide (Nursing Guide Line).
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Central cannula care policy
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The Definition :
◾ It is a measurement of blood pressure in the right atrium or vena cava through the installation of a catheter
Section: Nursing staff members before inserting the cannula:
◾ Explaining the steps to the patient and trying to reduce stress
◾ Hand washing (hygienic) – preparing tools
◾ Connect the patient to the monitor device
◾ Prepare the entire emergency vehicle next to the patient
Section: Nursing staff during cannula insertion:
◾ Place the patient in the appropriate position according to the doctor’s orders
◾ Open tools while maintaining sterilization steps
◾ Observe the monitor, discover any disorders, and inform the doctor
◾ Assisting the doctor in the installation steps
◾ Replacement of the cannula
◾ Take x-rays after installation to confirm its location
Section: Nursing staff after cannulation:
◾ Replace the catheter and follow infection control methods
◾ Observe the location of the catheter to detect any signs or infection
◾ Do not bend the catheter
◾ Measuring vital signs
◾ Keep the catheter open by dripping with a solution of saline + heparin, depending on the case
◾ Do not push the solutions forcefully in the event of a blockage of the catheter, but they must be drained by drawing blood
Method for measuring central venous pressure:
◾ Connect the CVP ruler to the patient.
◾ Close all solutions connected to the patient.
◾ Adjust the zero level with the ruler at the middle of the armpit.
◾ Close the valve towards the patient and open it towards the solution and the ruler until it is full, then close it towards the solution and open towards the patient.
◾ If the readings are below zero, they are negative, usually in a state of drought.
◾ The reading is unstable between two numbers if the patient is on a respirator and the second reading is taken.
Implementation Officer:
◾ The nursing team.
The Reviewer :
◾ Procedural work guide
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