Welcome to all

Nursing Staff
By :- Sheetal Jain
Nursing
Induction
By :- Sheetal Jain
 Nursing Organogram
Nursing Superintendent

Deputy Nursing
Superintendent

SUPERVISORS EDUCATOR INCHARGES

Shift Incharge

Staff Nurse
Nursing Quality Indicators
INITIAL NURSING ASSESSMENT

MEDICATION ERROR

FALL

PRESSURE ULCER

NURSE-PATIENT RATIO

NURSING CARE PLAN

 Bench Mark Against Each Indicator
 1. INITIAL NURSING ASSESSMENT = Need to be completed within 30 minutes on arrival to the unit/ward.

 2. MEDICATION ERROR, FALL, PRESSURE ULCER = Need to be zero percentage.

 3. NURSING CARE PLAN = Each IP patient should have Nursing care plan documented against each shift and
maintain the continuity of care.

 4. NURSE- PATIENT RATIO (AS PER ACCREDITED HOSPITAL) =

Ward = 1:6
Double sharing room = 1:4
ICU (Venti) = 1:1
ICU (Non Venti) = 1:2
NICU/PICU = 1:1
LR = 1:1 (As per no. of LR table)
OT = 2:1 (2 staff for 1 table)
ICN = 1 :100
 Initial Nursing Assessment

Page - 1 Page - 2 Page - 3 Page - 4

VIP Score
Detection and Advice Scale for
Peripheral Phlebitis
Types of Phlebitis
Veins : Upper Extremity
Blood Vessel Walls
 Good Practice Points’
 Observe cannula site at least daily.
 Secure cannula with a proven intravenous dressing.
 Replace loose, contaminated dressings.
 Cannula must be inserted away from the joints whenever possible.
 Aseptic technique must be followed.
 Consider your police position on resisting of the cannula.
 Use the smallest gauge cannula most suitable for the patient’s needs.
 Replace the cannula at the first indication of infusion phlebitis (Stage 2 on the VIP score).
 Apply tourniquet to the upper arm ensuring it does not obstruct arterial flow
 Plan and document continuing care.
 10 cm above site (3 finger breadths)
 2 fingered gap
 10ml syringes used for flushing
What are the Sings of a Good Vein ?

 Bouncy
 Soft
 Visible
 Above previous sites
 Refills when depressed
 Has a large lumen
 Well supported
 Straight
 Easily palpable
 What Veins should you avoid ?

 Thrombosed / Sclerosed / Fibrosed

 Inflarned / bruised
 Thin / Fragile
 Mobile
 Near bony prominences
 Areas or sites of infection, oedema or phlebitis
 Have undergone multiple previous punctures
 Do not use if patient has IV fluid in situ
 Avoid in joints
 MRM pt.
 Ready Reckoner
Considering the drip Fluid Ordered Rate per min

Factor = 20drops 50 ml/hr 17 drops Tablet Calculation

Formula: What we want
60 ml/hr 20 drops
What we have
70 ml/hr 23.3= 23 drops Ex: 250mcg=2 tablets
80 ml/hr 26.6= 27 drops 125mcg

90 ml/hr 30 drops
Fluid Calculation
100 ml/hr 33.3= 33 drops Formula: Total fluid x 15 (drop factor)

110 ml/hr 36.6= 37 drops Total time x 60

120 ml/hr 40 drops Multiply

with 60, if
converting
to min.
Nursing Care Plan
 Nursing Process

 Organized framework to guide practice

 Problem solving method – client focused

 Systematic – sequential steps

 Goal oriented – outcome criteria

 Dynamic –always changing, flexible

 Utilizes critical thinking processes

 Nsg Dx vs MD Dx

 Within the scope of Nursing Practise  Within the scope of Medical practise

 Identify responses to health and illness  Focuses on curing pathology

 Can change from day to day  Stays the same as long as the disease is present
Nursing Care Plan or Process
 Planning-begin by Prioritizing Client
Problem
• Prioritize list of client’s nursing diagnoses using

Maslow

• Rank as high, intermediate or low

• Priorities can change

• Client specific
Pressure Ulcer: What are the Risk
Factors??
 EXTRINSIC  INTRINSIC
 Pressure  Nutritional status
 Friction  Body build of Patient
 Restricted mobility  Age
 Moisture  Sensory impairment
 Surgery  Infection
 Poor handling of Patient  Reduced mobility
 Inappropriate positioning  Circulatory disorder
 Tissue tolerance  Neurological disease
 Poor hygiene  Incontinence
Stages of Pressure Sores
Unstageable
Deep Tissue Injury
Identify the stages......
Management
 Provide appropriate support surface

 Reposition every two (2) hours in bed

 Off-load heels, use pillows or positioning boot

 Reposition every hour when in chair

 Use pillow between legs for side lying

 Protein rich diet

 Manage Incontinence

 Reduce friction and shear

 Maintain skin hygiene

Interpretation of the score
 Very High Risk : Total Score 9 or Less

 High Risk: Total Score 10-12

 Moderate Risk: Total Score 13-14

 Mild Risk : Total Score 15-18

 No Risk: Total Score 19-23

 Ryle’s Tube Feeding
Determine length of tube Nasogastric tube anchoring
to be inserted. technique
 Feeding Technique
 Flush feeding tube with water prior to medication administration.

 Do not administer sublingual and Buccal medications via feeding tube.

 Flushing the feeding tube prior to drug administration removes any enteral feeds that
remain in the tube to prevent drug nutrient interaction.

 Sublingual and Buccal medications are designed to be absorbed into the systemic
circulation by placement under the patient’s tongue or in the cheek pouch. Thus, these
should not be administered via the feeding tube.
Blood Transfusion
 Preparation for Blood Administration
 Physicians order
 Look at labs
 Consent by Doctor
 Take consent from patient first, if conscious & oriented. If not then only relative.
 Obtain IV access, large bore catheter (18-20 gauge), 2 lines if possible.
 Check the patency of the existing IV line
 *Get patient ready for transfusion prior to getting blood from the lab
 Gather supplies
 *Staff signs for and obtains blood (only one patient & 1 unit a time!)
 Routine compatibility testing takes about 1 hour to identify recipient ABO and Rh type; in emergency O-negative RBC’s can be safely
given to most without serologic testing.
 Why can O-neg blood be safely given to most people?
 *Universal RBC donor is O negative; universal recipient is AB positive
 2 checks (dr & nurse) at bedside with patient chart
 Blood administration must complete within 3-4 hours after receipt from blood bank!
 Blood Product Administration
 Compare all labels second time.

 Check vital signs and record.

- Initial vitals before admin blood product.

- Vitals 15 minutes after admin blood product.(stay with pt 1st 15 min.

- Vitals q30min after that until transfusion complete.

- Vitals post admin blood product and then in 1 hr.

 Document the vitals in nurses note with name, time and date.
 Post Administration
 Flush IV site With NS
 Post administration vitals
 Dispose of tubing and blood Bag in biohazard bag
 If a 2nd unit is ordered
 Prime new tubing
 Retrieve 2nd unit
 Repeat double/2 checks
 Document
 When started & ended
 Volume infused
 Premeds given
 How the pt tolerated procedure
 Fall Prevention
Fall Risk Assessment for Inpatients

 On admission

 On any transfer from one unit to another unit within the facility.

 Following any change of status

 Following a fall, on shift change.

 Fall Prevention Interventions
 Daily fall assessment
 Identification of high risk patients
 Near vicinity
 Signages while mopping the floor
 Anti ski dding slipper
 Appropriate hospital attire/gown
 Lower the height of the bed
 Adequate lighting & clutter free
 Nurse call bell
 Hourly rounding for 4 Ps.
 Effective communication to staff while handing over
 Lock the wheels
 Ensure safety belt in put while transportation
Example: Morse Fall Scale
 Effective Communication
I–S–B–A-R
 Introduction – of Staff, Patient

 Situation – the current problem

 Background – Past problem, co-morbidities, treatment given so far

 Assessment – Vitals, pains, drains etc.

 Recommendation – Investigations to be done, Iedication to be given, consults to be taken, pending

things, planning for discharge/transfer
 Right Formula
A nurse will administer the medicine after cross checking
1. Right Patient
2. Right Medication
3. Right Dosage
4. Right Route
5. Right Time
6. Right Documentation
7. Right Client Education
8. Right to Refuse
9. Right Assessment
10. Right Evaluation
Right Medication
Flow Rights
of Medication
 When Patient is No More
 Straighten body.
 Close mouth immediately.
 Remove all equipment's & lines.
 Give sponging.
 Change clothes.
 Plug nose, ears & other orifices with cotton plug.
 Cover the patient with white bed sheet.
 Attach an ID card having name & IP no.
 Nurses check bill paid.
 Release the body or transfer to mortuary.
Hand Washing is very Important

WHEN !
 Barrier Precautions
 These are designed to protect you from exposure to infectious material and reduce the risk of
transmission of microorganisms to patients. They are also known as Personal Protective
Equipment's (PPE):
 Cap
 Gloves
 Gowns
 Protective eye wear
 Masks
 Respiratory masks
 Gum boots
 Administrative Policies
 Improve communication skills.  Do not have a casual attitude.
 Keep up the discipline and organizational values.  Put the learning into practice.
 Admit mistake.  Do not hide the mistakes.
 Respect the senior.  Take a proactive actions.
 Take part in all in service programmes.  If doubt ,clarify the things.
 Do not use regional language while on duty.  Go the next level for help in patient needs.
 Do not misuse PC. Don’t share the password.  Take a patient complaints for betterment of
organization.
Be alert – For Disciplinary Action
 Willful absenteeism.

 Neglect basic patient care.

 Found guilty /theft.

 Proven to be drunk while on duty.

 Not improve inspite of verbal or written warnings.

 Grooming
 Maintain the personal hygiene.  Hair should be tie into simple bun.
 Use the deodorants.  Ensure light make up.
 Keep the nails cut & short.  Avoid powder sindur.
 Do the oral hygiene.  Do not use bangles. Use wrist watch
 Do not wear heavy jewellery.  Can wear wedding ring.
 Look confident with smile.
 Wear neat shoes with proper Note : Do not use ring and bangle while doing procedure
polishing and proper lace.
 Uniform Policy

 Wear the uniform as per policy.

 ICU & OT Nurse should wear scrub suits.
 Do not use lab coats when on unit.
 Uniform will be provided by hospital.
Telephone Etiquettes
 Pick up the phone as early as possible.

 Greet the caller.

 Identify area and introduce yourself.

 Listen carefully.

 Put the caller on hold appropriately.

 Learn to transfer the call.

 Make sure that caller understood you.

Admission Formalities
 Arrival of Patient
 Day care.
Ambulance.
Emergency room.
Direct admission.
OPD
 At the Nursing Station
 You will :

 Receive call from admission desk.

 Ensure room is prepared.

 Check the patient file (Face sheet)

 General consent.

 Surgical clearance.

 ID Band.

 Ht and Wt. recording.

Steps at the time of Admission

 Identification of patient and ID band application.

 Orientation of unit.

 Filling of admission assessment form.

 Caring of valuables.

 Vital checking.

 Information to other department.

 Care of Sedated Patient
Nurses Responsibility

 Check for the written order for conscious sedation.

 Check for informed consent taken.

 Keep the resustative equipment at the bed side

 Check the baseline vital signs before administering medication.

 Do not leave the patient unattended during the procedure

 Monitor the patient throughout the procedure.

 Document all the relevant details in conscious sedation monitoring chart

 Medication Management & Usage

 CRASH CART POLICY

 It is to be open in crash situation.

 To be replenish immediately.

 DEFIBRILLATOR should be checked daily and always on charging mode.

 When crash cart is not opened for the month then should be checked for the expiry on 1st week of the month.
 Abbreviation
 BD – 1-1 – Twice in Day.  IV – Intra Venous.
 TDS – 1-1-1 – Thrice in days (oo – oo)  IM – Intramuscular.
 OD – 1 – Once in day.  SC – Subcutaneously.
 STAT – Immediately to be given.  ID – Intradermal.
 PRN / SOS – When required.  Orally.
 STOP.  Nebulization.
 CST – Continue same treatment.  O2 - Oxygen Therapy
 Sublingually .  Intranasally.
 End of Life Care Policy
 Assess & Manage pain.

 Fulfill the spiritual & cultural needs.

 Give psychological support.

 Give the care with respect and dignity.

 Family Education .

 Documentation in end of life care form

Escalation Policy
MEDICAL SUPERINTENDENT

 DEPUTY MEDICAL SUPERINTENDENT

NURSING SUPERINTENDENT

DEPUTY NURSING SUPERINTEDENT

NURSING SUPERVISOR

INCHARGE
FLACC TOOL (0-3years)
Wong Baker (3 -12 Years & Cognitive
Impair Patient)
Monitoring of Vital Signs
 Respiratory rate.

 BP.

 Pulse.

 Temp.

 SPo2
 Falls in the Hospital:
Client Risk Factors Institutional Risk Factors
Postural hypo-tension. Recent admission.
Lowest weight percentile. Furniture placement.
Medications: 4+ or sedatives. Slick and/or hard floors.
Previous fall. Unsupervised activities.
Impaired arm strength or range Reduced # of nurses.
of motion. Meal times.
Uneven gait. Absent handrails.
Unable to move from bed to bath without Poor lighting.
assistance.
 Tool used for fall Assessment MORSE
FALL SCALE
Variables Scores
History of fall Yes 25 No 0

Secondary diagnosis Yes 15 No 0

IV or IV access, medicine for potential fall risk Yes 10 No 0

Ambulatory aid -cane/ crutches/walker Yes 15 No 0

Gait – Weak /impaired Yes 20 Normal / bed rest/wheel chair

Mental status Yes 15 Oriented to own ability

 Risk level
Low Risk 0- 24 score.
Medium Risk 24 – 44 score.
High Risk 45 and higher.
 Reassessment Frequency
In low risk when required.

Medium risk once in day.

High risk once in every shift.

 Discharge Intervention
 Health education to patient and family.
 Keep the side rails up.
 Call for assistance.
 Returning of medicines.
 Collection and Xeroxing of all reports.( If in system
 Discharge summary
 Handover all reports, fridge medicine, chest binder, insulin
 Billing process and financial clearance
 Completion of discharge checklist.
 Education and explain the discharge summary.
 Dress change, remove all lines like IV cannula ,Dressing change if present and ID band
 IF patient is going if Drain , Catheter , IV cannula or some other lines ,consent have to take (As per infection control
policy)
 Feedback form
 Documentation in discharge registers
 MLC and TPA Discharge

Inform expected time of discharge

Originals should not give in MLC

 Key Points
 Don’t be panic

 Be clear

 Make to do list

 Documentation

 Be proactive

 Final greeting
 Thank you for
Nursing Induction

MP Birla Hospital & Research Center Chittorgarh – Raj.