LA Pol and Proc

Lower Annex- Policies and Procedures 2018
Scope of Practice
The Internal Medicine Ward is for all patients over the age of 14 years old. Lower Annex
(LA) has a 47- bed capacity and can hold up to 64 beds on the alley if the census is more
than the bed capacity.
Female Ward : 18 beds
 Female Pay – 1 ( Beds 1-6)

 Female Pay II – (Beds 7-12)
 Female Pay III – (Beds 13-18)
May Ward : 15 beds
 Male Pay – 1 (Beds 1-6)

 Male Pay – II (Beds 7-15)
Private Room : 6 rooms
Critical Care Unit : 3 Beds
Intensive Care Unit : 5 beds
Alley : can accommodate up to 16 beds
LA caters to patients with insurance such as PhilHealth and a number of Charity patients.
Care of Patient in the Medicine Ward
Care of Patients admitted at the Lowe Annex is the direct responsibility of the admitting
Physician at the Emergency Room during his/her duty.
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The care of the patient will only be transferred once the admitting Physician will hand over
its services to other equally competent doctor in the medicine ward.
Following admission criteria:
1. Care of admitted patients in the pay ward or charity is the direct responsibility of
the Internal Medicine Head or to the admitting Physician at the ER during her/his
duty time.
a. RN on duty is responsible for tagging the chart of the MDs respective color code.
b. Nurse Aide must put the patient’s name outside the door with the MDs color
code:
i. Yellow - Dr. Bomediano
ii. Blue - Dr. Hitosis
iii. Pink - Dr. Dorado
iv. Violet - Dr. Borromeo
v. Orange - Dr. Gersan
vi. Red - Dr. Solutan
vii. Green - Dr. Saad
viii. White - Dr. Maningo
General Ward: Gastro, GI, Lungs, Neuro, Endo, Nephro, Pulmo, Immunology
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Intensive Care Unit (ICU):
a. Cardiac System
i. High probability of myocardial infarction
ii. Hemodynamically stable myocardial infarction
iii. Any hemodynamically stable dysrhythmias
iv. Mild to severe congestive heart failure
v. Hypertensive Urgency
Critical Care Unit (CCU):
a. Neuro
i. Patient’s with established stroke
b. Septic shock
c. ARDS
d. COPD in failure
e. GBS
f. Dengue Hemorrhagic Shock
g. End Stage Renal
Preadmission Protocol Equipment for:
A. ICU
1. All monitor set- up
 NIBP
 Cardiac Monitor
 Pulse Oximeter
 EKG
 TEMP
2. IV stand
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3. O2 source ( pipe-in)
4. Bedside cabinet with consumables (for patient only if hospital diet allows)
B. CCU
1. Manual Monitor
 TEMP
 Manual BP
 Suction machine
2. IV stand
3. O2 (tank)
4. Bedside cabinet with consumables ( for patient only if hospital diet allows)
Monitoring:
A. ICU
 Non-Invasive
o ECG monitoring
o SPO2
o Temperature
o NIBP
o Pulse Rate/ Respiration rate
B. CCU
 Non-Invasive
o BP monitoring
o Pulse rate/ Respiration rate
o Portable SPO2
o O2 level
Investigation
A. ICU
 12 lead ECG on admission and PRN
 Chest X-Ray on admission and PRN
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Staffing
Lower Annex has a total work force combined by regular and contractual personnel:
MS. Anamay G. Ambos – Head Nurse
Nurse I
Ms. May Stephanie Abubo
Ms. Michelle Dumat-ol
Ms. Gianna Marla Caracena
Casual Nurses
Mr. Teofanes Ansok Jr.
Mr. Jebsen Carl Mongcopa
Mr. Don Adrian Duran
Ms. Shanley Lyn Cabrera
Ms. Lorette Diane Roque
Ms. Rachellyn Llego
Ms. Jazminne Tam
Ms. Adelia Kristie Generoso
Ms. Ivy Rodriguez
Ms. Karen Bangca
Ms. Leah Doon
Ms. Danica Katada
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Mr. Prince Jay Lapinid
Ms. Janice Teves
Ms. Cathleen Dales
Ms. Marilou Mante
Nursing Attendants
Ms. Marites Tanac
Ms. Julie Sulit
Ms. Janet Entac
Ms. Marietta Lugatiman
Volunteer Nurses are directly supervised by the Head Nurse, Nurse I and casual nurses
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Documentation and Charting
Staff Nurses:
1. RN documentation should be done with his/her respective shift.

a. RN is responsible for recording the following:
 IV sheet
 Medication Sheet
 Nurses Notes
 I and O sheet
2. (Refer to the hospital manual for RN’s duties and Responsibilities)
Ward Procedures:
1. All Medications must be ordered by the authorized attending Physician.

a. MDs are responsible for writing legibly all the medication and diagnostic orders
for the patient.
2. All verbal order must be countersigned within 24 hours.
3. Medication Time should follow the Hospital’s Policy:
 Twice daily should be given 8am - 6pm
 Thrice daily 8am – 1pm – 6pm
 Once daily 8am
 During hours of sleep 8pm
 Every 8 hours 8am - 4pm- 12 am
 STAT immediately
 Every 6 hours 9am- 3pm- 9pm- 3am OR 12am- 6am- 12noon-
6pm
 Every 12 hours 8am- 8pm OR 9am- 9pm OR 12am- 12noon OR
3pm-3am OR 4am- 4pm OR 6am- 6pm
 QID 8am- 12noon- 4pm- 8pm
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 PRN As needed
4. Prior giving the medicine, RN must do aseptic hand washing (adopted from the
Philippine Infection Control Society)
5. Proper identification of patient must be done prior administration
a. Ask patient’s name (if patient cannot speak, check arm band and IV label to
assure correctness of patient’s identity.)
b. Check arm band (patient’s ID)
c. Follow the 10 Rights of medication administration:
 Right Patient
 Right Drug
 Right Route
 Right Timing
 Right Evaluation
 Right Documentation
 Right Assessment
 Right Implementation
 Right Education
6. Prior giving antibacterial, an ANST must be done. RN must carry out the order
immediately.
a. There should be two (2) RNs reading the result of the ANST
b. Should there be abnormalities in the result, a second ANST must be done on the
other arm.
c. If it does not show any reactions, RN can give the medication.
7. Never recap or bend needles.
8. Use disposable gloves only.
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Patient’s Safety
1. Upon admission to ward, patients should be given a copy of the patient’s rights and
responsibilities (refer to hospital manual for Patient’s Right and Responsibilities).
Also included in the print out are hospital reminders regarding:
a. Visiting hours
b. Watchers allowed
c. Food/ things to bring
2. Orient patient to the room (side rails, waste disposal, comfort room, side tables and
hospital policy regarding visiting hours. (see Hospital Policy on visiting hours).
a. Patients whose beds are with side rails, family members should be advised to
keep the side rails up at all times.
b. Food stool is available for those beds with no knots for adjustment.
c. Strictly implement waste segregation:
 Black plastic: for food residue, wrappers, tetra packs, plastics
 Yellow: sanitary napkins, diapers, tissue paper
 For breakage: refer to RN station. It should be disposed in a Red plastic
bag.
d. Comfort rooms should be clean, flush every after use.
3. During orientation, patient and family members are advised to pass by the Nursing
Station to hand-in all medicines (PO), IV bottles, and have their injectable medicine
(ampules and vials) received by the RN on duty.
a. RN must record properly all injectable in the logbook and put the IV ticket unto
the IV bottle.
4. Patients and family members are advised to keep safe other unnecessary things, to
avoid over stuffing of personal belongings, preventing cross infection.
a. Patients are allowed to bring 1 piece pillow
b. Family members should have a selected food container such as plastic to avoid
flies and rodents in the vicinity.
c. Utensils used for eating should be washed properly.
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5. Visiting hours is only from 8am-8pm. Per visitor is allowed to stay for one hour.
6. Only two watchers are allowed per patient.
a. Initially, upon admission, patient is allowed to have more two watchers to
accompany him/her and to do the errand.
b. After being settled, accompanying watcher should not be more than two, to
avoid overcrowding.
c. During night time, there should be one (1) watcher only.
 However, for CCU and other Priority patients, 2 watchers are allowed.
7. Advised family members not to sleep in the make-shift bed (under the patient’s
bed).
 RN on duty must see to it that watchers don’t lay mat or any make-shift
boxes placed under the patient’s bed.
8. Family members are discouraged to sleep beside the patient.
 RN or Nurse aide is responsible for informing the family member of the
house rules.
9. Overcrowding of patients in the ward must be avoided to maintain therapeutic
environment.
 MDs and RNs must see to it that watchers should not exceed at least 2.
 Visitors are allowed to stay on the allotted visiting hours.
10. Children below 10 years old are not allowed to visit the ward, to avoid acquired
infection.
11. Patients and family members are advised not to bring valuables. For any losses due
to theft, the hospital is not accountable.
12. Vendors are not allowed to come/loiter in the ward
13. No loud music allowed at all times in the patient’s room
14. Strictly no smoking is allowed (refer to hospital policy on no smoking)
15. RNs are advised to wear gloves during IV reinsertions, IV push and IV
discontinuance.
 Wash hands with soap and water immediately.
 Inform immediate Head nurse of the incident
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 Make a request at the NSO for immediate Hepa-B titer, Hepa C and other
blood work-up
 Refer to Philippine Hospital Infection Control Society for Needle stick injury
policies and procedures.
16. Private room reservation is not allowed.
 Private room reservations are only allowed for In-Patients only. There shall
be no advance reservations by all means.
 All Private room reservations are coursed through the RN station.
 Nurse aide or RN should write at the black board the family name of the
patient and the present ward.
 First come First serve basis should be followed. Unless patient waved his/her
reservation.
17. Patients and family members/visitors are advised not to SPIT anywhere within the
hospital vicinity.
 Any hospital personnel is responsible for informing patients, family members
and visitors about the NO SPIT house rules.
 Janitors and Institutional workers, and nursing aides are held responsible for
informing the patients, family members and visitors in the ward not to spit
anywhere. Instead to use the comfort room.
 A separate signage for the benefit of everyone must be posted near the RN
station.
18. Attending MD should do daily assessment of the patient.
 MDs must see to it that their patients are well informed of the daily progress.
 MDs are open for patient and family meeting, should there be a need, to
discuss prognosis or even death.
 Doctor’s should encourage family members to discuss and join in the care of
the patient.
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Patient’s Rights
The Internal Medicine ward has adopted the following statements for patient’s rights.
(From World Medical Association)
1. Right to Quality Care

 Every patient has the right to be cared for by a physician, either from NOPH
or from other hospitals as co-management.
 The patient shall be treated in accordance with his/her best interests. The
treatment applied shall be in accordance with generally approved medical
principles.
 Physicians and other health care team members should accept responsibility
for being the custodian of the quality of medical services.
 Should there be insufficient or limited supply or equipment in patient’s care,
all such patients are entitled to fair selection of treatment. That choice must
be based on medical criteria and made without discrimination.
2. Right to Freedom of Choice
 The patient has the right to choose freely and change his/her physician or
any member of the health care team, hospital.
 The patient has the right to ask the opinion of another physician at any time.
3. Right to Self Determination
 The patient has the right to self- determination, to make free decisions. The
attending physician will inform the patient of the outcome of his/her
decisions.
 The patient has the right to the information necessary to make his/her
decisions.
4. Unconscious Patient
 If the patient is unconscious or otherwise unable to express his/her will,
informed consent must be obtained from a legally entitled representative.
 Refer to hospital policy on unconscious patient.
5. Right to Information
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 The patient has the right to receive information about his/her treatment.
 The patient has the right to know what is in his/her medical records.
 Exceptionally, information may be withheld from the patient when there is
good reason to believe that such information would create a serious
threat/hazard to his/her life or death.
 The patient has the right to choose who, if anyone should be informed on
his/her behalf.
6. Right to Confidentiality
 All identifiable information about the patient’s health status, medical
condition, diagnosis, prognosis, and treatment and all other information
must be kept confidential, even after death.
 Confidential information can only be disclosed if the patient gives consent.
 Only the members of the healthcare team are allowed to have access of the
chart.
7. The legally incompetent patient
 If the patient is legally incompetent or is a minor, the consent of a legally
permitted representative is required.
 However if the legally incompetent patient can make rational decisions,
his/her decisions must be respected and he/she has the right to forbid the
disclosure of information to his/her legal representative.
 (Refer to the hospital’s manual)
8. Procedures against the patient’s will
 Diagnostic procedures or treatment against the patient’s will be carried out
only in exceptional cases, if specifically permitted by law and conforming to
the principles of medical ethics.
9. Right to Health Education
 Every patient has the right to health education. Members of the health care
team will help him/her in making informed choices about personal health
and other available services due to him/her.
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 The health education should include: prevention and early detection of

illness.
 Discharge health teachings.
 Nearest district hospital where they can seek help.
 It should also include: hygiene, household basic sanitation, and cleanliness.
10. Right to Dignity
 Regardless of socio-economic status, each patient must not be discriminated.
 Other beliefs, whether religious or cultural practice, values must be
respected at all times.
11. Right to Religious Assistance
 The patient has the right to accept or decline spiritual assistance from the
hospital. However, should the patient prefers his/her own pastor pr priest to
come and give him/her spiritual comfort, the hospital should allow and
respect their accepted rites.
 Should patients seek religious assistance from the hospital’s chaplain, family
members should inform the nurse’s station for the RN on duty to coordinate
with the chaplain.
Patient’s Responsibilities
(Refer to the Hospital’s Policy written in Visaya for patient and family members to fully
understand their Responsibilities)
Medical Equipment
1. Lower and Upper Annex has the following medical equipment:

 EKG machine
 Glucometer
 Portable Pulse Oximeter
2. All operating Manual for medical equipment are kept in the RN station
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Emergency Drugs:
1. All emergency drugs are kept in the Emergency Crash cart:

 Adrenalin
 Antamin
 Atropine Sulfate
 Buscopan
 Cordarone
 Depo-Medrol
 Diazepam
 Dobutamine
 Dopamine
 Furosemide
 Hydrocortisone
 Isoket
 Lanoxin
 Magnesium Sulfate
 Metoclopramide
 Nitroglycerin
 Tranexamic Acid
 Vitamin K
 Aminophylline
 D50
 Sodium Chlordie
 Lidocaine
 NahCo3
 Potassium Chloride
 Dilantin
 Regular Insulin (keep at the ref)
 Captopril
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2. All Emergency Drugs should be checked every shift daily for floor stock purposes
and expiration dates.
 RN on duty should check all Emergency drugs and IV bottles in the ward.
 RN should do a thorough checking on the expiration date every two weeks (
2).
o For expired drugs, RN must document the said drug and have it
received by the pharmacist for proper disposal. (refer to the hospital
policy on expired medicine drugs disposal).
a. RN must follow the First In, First Out procedures to avoid spoilage.
DISCHARGE POLICY
1. To provide continuity of care, planning an preparing of discharge begins on the

admission process and continues throughout the treatment of the patient.
2. Patients are discharge when:
 When the patient’s physiologic status has stabilized.
 When the repeat X-ray bares normal result
 When the patient decides to go on Discharge against Medical Advise
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WASTE MANAGEMENT
A. Needles/ sharps
1. All needles and sharps must be disposed in the punctured proof containers.
 Sharps receptacles in ward must be labelled accordingly to avoid
inappropriate disposal.
 Empty mineral water container can serve as punctured proof
containers.
 It should be disposed every shift
 Janitor/Institutional worker must wear PPE upon collection of the
garbage and disposal.
B. Ward garbage must be properly segregated:
 Black plastic trash are for: non-infectious dry waste
 Bottles, cans, papers, cartoons, tetra packs
 Yellow plastic: infectious and pathological waste
 Sanitary napkins
 Diapers, bandages with blood
 IV tubing
 Used tissue paper
 Red: sharps and pressurized containers
 Needles, ampules, vials
 Blades
 Sprays
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INFECTION CONTROL
 HAND WASHING is a must before and after care

 For every IV insertion, RN must wear disposable gloves, to avoid needle stick
injuries.
 Refillable hand sanitizer must be provided in every room, placed near the door.
 Patients with: Measles, Meningococemia, Rabies, Tetanus, PTB, and HIV. Must be
placed in a separate isolation room.
 For PTB with hemoptysis, patients must be provided with a separate kidney
basin for them to spit into and must be flushed immediately.
 A signage for NO SPITTING must be placed in every room.
 All patients/family members/visitors must be informed of such policy.
 All Isol rooms must be kept clean daily.
 Janitor must do the cleaning daily or every after shift as the need arises.
 Upon discharge, patients are advised to monitor their respective temperature. If
after 24 hours, the discharge patient will have an elevated temperature of 38
degrees Celsius, he/she must come back to the hospital, for a check-up and possibly
laboratory works.
Ward Procedure:
 Patient’s with communicable diseases such as PTB are placed in the isolation room
at the Upper Annex
 MDs and RNs attending to the Isol patients must wear N-95 mask, then
dispose
 HANDWASHING must be done before and after care.
 Patients with Hepatitis
 RNs and MDs and other members of the health care team must wear gloves,
mask, and gown.
 HANDWASHING before and after care.
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 RN must discreetly label the chart with HEP PREC.

 All needles/ syringes must be disposed right after use at the “sharps”
container and at the infectious trash.
 Patients with Meningococemia
 RN and MDs and other health care team members must wear gloves, mask,
and gown.
 Any member of the health acre team who are exposed must be given
prophylaxis. Ciprofloxacin 500mg tablet one dose.
 Patients with Rabies
 Members of the health care team must wear gloves, gown, and mask.
 HANDWASHING before and after care
 Any member of the health care who are exposed must be injected with
Verorab zero days, 7 days, 21 days doses at 0.1 cc intradermal route.
 Patients with HIV
 Members of the health care team must wear mask, gloves, gown, and eye
goggles.
 All needles/syringes must be disposed right after use at the sharps container
and at the infectious trash.
 Soiled patient care equipment like stethoscope, blood pressure apparatus
 RN/Nursing aides are responsible for cleaning or wiping it with 70% alcohol.
 It should be cleaned in between patient use.
 For AMBU-Bag and mask
 Nursing aide is responsible for cleaning it with detergent, dry then sterilized.
 Mask should be changed after each patient.
 Bedside Tables
 Janitor or IW should disinfect with 70% alcohol.
 Clean with detergent and water then dry.
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 Environment should always be clean.

 Trolleys
 Disinfect with 70% alcohol
 Clean with detergent and water
 Suction equipment and mask
 Janitor or IW must clean machine with detergent and water then dry
 Discard mask after each use
 Change tubing every 48 hours
 Floor/Walls
 Janitor/IW must do damp mopping with detergent and water.
 Clean every shift if possible
 Commode toilet seats
 Janitor/IW is held responsible for cleaning the seat and arms with detergent
and water
 Wipe with disinfectant.
 Soiled Linens
 If reusable, put it in a plastic and separate
 Soak in clean water with bleaching powder (refer to hospital manual)
 Wash with detergent and water
 Drier or sun dry
 Mattress/Pillows
 Wipe with 70% alcohol
 Pillows- refer to soiled linens
o Must be changed 2-3 days
o If heavily soiled change daily or ASAP
o Must be changed every after patient use
 Spillage- blood, body fluid, secretions, and excretions
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 Wipe with tissue paper or cloth

 Dry the area
 For Medicine Caps and nebulizer mouth piece
 Wash with liquid soap or hospital provided soap
 Boil for at least 5 minutes
 Wipe with clean cloth
 Store in hygienic environment
 Telephone
Quality Improvement (Lower Annex)
1. Patients and family members are encouraged to fill-out the Patient survey form for
feedback purposes.
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ICU/CCU
Admission Policy
1. These are critically ill patients in need of intensive treatment and monitoring
 For ICU- only patients with CHF, MI and other cardiac cases
o Only Trop-T positive patients are admitted at the ICU if the case is MI
o At the ER attending physician must request for immediate Trop-T
determination. If the patient cannot come up with the money yet, they
must be admitted at either Payward or charity ward.
o If the result is positive days after the request, patient should be
transferred to the ICU room
o Should ICU beds are full, initially patient will remain in his/her
respective bed, awaiting the decision of the ICU head.
 Family members/patients must be given a copy of the patient’s rights and
responsibilities, together with the hospital’s reminders. (see pamphlets)
General Policies and Procedures:
1. Care of ICU/CCU admitted patients is the direct responsibility of the Internal

Medicine Head or to the admitting Physician at the ER during her/his duty time.
 RN on duty is responsible for tagging the chart of the MDs respective color-
code.
 Nurse aide must put the patient’s name outside the door with the MDs color
code.
Yellow - Dr. Bomediano
Blue - Dr. Hitosis
Pink - Dr. Dorado
Violet - Dr. Borromeo
Orange - Dr. Gersan
Red - Dr. Solutan
Green - Dr. Saad
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White - Dr. Maningo

2. Family members and visitors must adhere to the Unit’s policy on visiting hours
 Visiting hours is from 8am- 8pm
 Visitors are allowed 30 minutes only
3. Eating and drinking are not permitted inside the ICU/CCU room
 Only patient’s food and snack items are allowed inside the room.
 Watcher’s food and snack item is not allowed. They can put their food/snack
items in the waiting lounge.
4. Only one watcher is allowed per patient
 RN on duty must see to it that only one watcher is in the room
5. Should visitors be granted by the attending physician
 Only 2 watchers maximum per visit are only allowed to stay for 30 minutes
only to prevent potential infections
6. Visitors shall abide by the hospital to visit outside visiting hours
 No visitors are allowed to visit outside visiting hours
7. Traffic should be monitored and kept to a minimum
 Visitors with colds or other obvious signs of infection should be restricted
from entering patient care areas
8. Bringing food is not allowed inside the ICU
 Should anyone including the members of the health team bring food inside,
RN on duty is held responsible for informing them of the said house rules.
9. Family members and visitors should eat outside ICU.
 RN or any member of the health care team is responsible for informing the
family members or visitors to eat at the canteen or at the waiting lounge.
10. There are four (4) designated for PhilHealth members only
 Upon admission, admitting clerk should ask patients if they are member of
PhilHealth
 If the patient is member, admitting clerk should inform the ICU regarding the
admission
11. One room (1) is designated for charity patients
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 Non PhilHealth member who requires ICU admission is placed at the Charity
bed usually Room #5
 On cases where patient/s can work on his/her PhilHealth membership, while
currently confined at ICU 5, he/she can stay at room 5. This is to avoid any
hospital related accident.
12. In cases where ICU beds are all occupied, incoming ICU admission is placed in the
alley near the RN station
 Patient will be placed in the alley near the RN station
 Patient will be the first priority, once an ICU bed becomes available.
13. If in the event that all the PhilHealth ICU beds are occupied and the Charity room is
empty, admission for any PhilHealth members will be placed in the alley near the RN
station.
 Patient with PhilHealth for ICU admission will be situated first in the alley,
near the RN station
 Patient will only be admitted at the ICU once, there is an available bed
 Attending MD having made the thorough assessment, must be informed of
the admission
14. Attending MD should do daily assessment of the patient. (Family Conference)
 MDs must see to it that their patients are well informed of the daily progress
 MDs are open for patient and family meeting, should there be a need to
discuss prognosis or even death
 Doctors should encourage family members to discuss and join in the care of
the patient
 During family conference, relatives and or family member must sign at the
doctor’s side notes for documentation purposes
15. (other relevant procedure, please refer to ward guidelines)
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Medical Equipment:
 EKG machine
 Cardiac Monitor
 Cardiac Monitor with Defib
 Infusion pumps
 Motor bed
 Endotracheal Intubation set
 Nebulizer
 Pipe-in O2
 IV stand
 Suction machine
 NIBP
 Pulse Oximeter
Emergency Drugs
1. All emergency drugs are kept in the Emergency Crash cart:

 Adrenalin
 Antamin
 Atropine Sulfate
 Buscopan
 Cordarone
 Depo-Medrol
 Diazepam
 Dobutamine
 Dopamine
 Furosemide
 Hydrocortisone
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 Isoket
 Lanoxin
 Magnesium Sulfate
 Metoclopramide
 Nitroglycerin
 Tranexamic Acid
 Vitamin K
 Aminophylline
 D50
 Sodium Chlordie
 Lidocaine
 NahCo3
 Potassium Chloride
 Dilantin
 Regular Insulin (keep at the ref)
 Captopril
2. All emergency drugs should be checked every shift daily for floor stock purposes
and expiration dates
 RN on duty should check all Emergency drugs and IV bottles in the ward
 RN should do a thorough checking on the expiration date every two weeks
o For expired drugs, RN must document the said drug and have it
received by the Pharamcist for proper disposal ( refer to the hospital
policy on expired medicine drugs disposal)
 RN must follow the First –In, First Out procedure to avoid spoilage
Documentation
1. All components of the patient care process, plan of care, evaluation, and outcomes
will be documented in the patient’s medical record
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 RN documentation should be done with his/her respective shift

 RN is responsible for recording the following
o IV sheet
o Medication sheet
o Nurses notes
o I and O sheet
2. (Refer to the hospital manual for RN’s duties and responsibilities)
27 | P a g e
WASTE MANAGEMENT
A. Needles/ sharps
 All needles and sharps must be disposed in the punctured proof
containers.
 Sharps receptacles in ward must be labelled accordingly to avoid
inappropriate disposal.
 Empty mineral water container can serve as punctured proof
containers.
 It should be disposed every shift
 Janitor/Institutional worker must wear PPE upon collection of the
garbage and disposal.
B. Ward garbage must be properly segregated:
 Black plastic for: non-infectious dry waste
 Bottles, cans, papers, cartoons, tetra packs
 Yellow plastic: infectious and pathological waste
 Sanitary napkins
 Diapers, bandages with blood
 IV tubing
 Used tissue paper
 Red: sharps and pressurized containers
 Needles, ampules, vials
 Blades
 Sprays
28 | P a g e
INFECTION CONTROL
 HAND WASHING is a must before and after care

 For every IV insertion, RN must wear disposable gloves, to avoid needle stick
injuries.
 Refillable hand sanitizer must be provided in every room, placed near the door.
 Patients with: Measles, Meningococemia, Rabies, Tetanus, PTB, and HIV. Must be
placed in a separate isolation room.
 For PTB with hemoptysis, patients must be provided with a separate kidney
basin for them to spit into and must be flushed immediately.
 A signage for NO SPITTING must be placed in every room.
 All patients/family members/visitors must be informed of such policy.
 All Isol rooms must be kept clean daily.
 Janitor must do the cleaning daily or every after shift as the need arises.
 Upon discharge, patients are advised to monitor their respective temperature. If
after 24 hours, the discharge patient will have an elevated temperature of 38
degrees Celsius, he/she must come back to the hospital, for a check-up and possibly
laboratory works.
Ward Procedure:
 Patient’s with communicable diseases such as PTB are placed in the isolation room
at the Upper Annex
 MDs and RNs attending to the Isol patients must wear N-95 mask, then
dispose
 HANDWASHING must be done before and after care.
 Patients with Hepatitis
 RNs and MDs and other members of the health care team must wear gloves,
mask, and gown.
29 | P a g e

 RN must discreetly label the chart with HEP PREC.
 All needles/ syringes must be disposed right after use at the “sharps”
container and at the infectious trash.
 Patients with Meningococemia
 RN and MDs and other health care team members must wear gloves, mask,
and gown.
 Any member of the health acre team who are exposed must be given
prophylaxis. Rifampicin capsule 600mg one dose.
 Patients with Rabies
 Members of the health care team must wear gloves, gown, and mask.
 Any member of the health care who are exposed must be injected with
Verorab zero days, 7 days, 21 days doses at 0.1 cc intradermal route.
 Patients with HIV
 Members of the health care team must wear mask, gloves, gown, and eye
goggles.
 All needles/syringes must be disposed right after use at the sharps container
and at the infectious trash.
 Soiled patient care equipment like stethoscope, blood pressure apparatus
 RN/Nursing aides are responsible for cleaning or wiping it with 70% alcohol.
 It should be cleaned in between patient use.
 For AMBU-Bag and mask
 Nursing aide is responsible for cleaning it with detergent, dry then sterilized.
 Mask should be changed after each patient.
 Bedside Tables
 Janitor or IW should disinfect with 70% alcohol.
30 | P a g e
 Clean with detergent and water then dry.

 Environment should always be clean.
 Trolleys
 Suction equipment and mask
 Janitor or IW must clean machine with detergent and water then dry
 Discard mask after each use
 Change tubing every 48 hours
 Floor/Walls
 Janitor/IW must do damp mopping with detergent and water.
 Clean every shift if possible
 Commode toilet seats
 Janitor/IW is held responsible for cleaning the seat and arms with detergent
and water
 Wipe with disinfectant.
 Soiled Linens
 If reusable, put it in a plastic and separate
 Soak in clean water with bleaching powder (refer to hospital manual)
 Wash with detergent and water
 Drier or sun dry
 Mattress/Pillows
 Wipe with 70% alcohol
 Pillows- refer to soiled linens
o Must be changed 2-3 days
o If heavily soiled change daily or ASAP
o Must be changed every after patient use
31 | P a g e
 Spillage- blood, body fluid, secretions, and excretions

 Wipe with tissue paper or cloth
 Dry the area
 For Medicine Caps and nebulizer mouth piece
 Wash with liquid soap or hospital provided soap
 Boil for at least 5 minutes
 Wipe with clean cloth
 Store in hygienic environment
 Telephone
Transfer to ward policy
1. ICU patients can be transferred to the general ward provided:

 After repeat Trop-T and the result is negative
 If patient no longer requires intensive monitoring
Discharge policy
1. Discharge of patient from the ICU shall take place

 When the patient’s physiologic status has stabilized and the need for
intensive patient monitoring is no longer necessary and the patient can be
cared for on the general ward.
 When the repeat Trop-T and CK-MB result brae negative result
 When the repeat X-ray bares normal result
 When the patient decides to go on Discharging against Medical Advise
32 | P a g e
IV INSERTION
Equipment
 Rubber tourniquet
 Disposable gloves
 Antiseptic swab (alcohol, povidone-iodine)
 Transparent IV dressing
 Arm splint (if necessary)
 Desired IV cannula
 Trash receptacle
 Scissor
Procedure:
Preparatory Phase:
1. Hand washing is required before and after handling sterile supplies and initiating
venipunture.
2. Explain the procedure to the patient. Have him/her lie on bed. Ascertain whether
patient is left or right handed.
3. Clear all IV tubing of air (prime it first)
4. Don gloves
5. Sterile site for insertion
6. Apply tourniquet 5-15 cm (2-6 inches) above the desired insertion site and
ascertain satisfactory distension of the vein. Distal pulses should remain palpable.
7. Have the client open and close first several times.
8. Cleanse the site
 Clean the skin with an alcohol swab
 Prepare skin with povidone-iodine swab for 1 minute, working from the center of
proposed site to the periphery until a circle of 5-10 cm (2-4 inches) has been
disinfected.
33 | P a g e
9. Allow area to air dry

10. Clip hair if site is too obscured.
Performance Phase:
1. Remove needle guard

2. Grasp patient’s arm so that the nurse’s thumb is positioned approximately 5 cm (2
inches) from the site. Exert traction on skin in direction of hand.
3. Insert the needle bevel up, through the skin at a 45 degree angle. Use a slow,
continuous motion
4. If the Bessel rolls, it may be necessary to penetrate the skin first at a 20 degrees
angle and then apply a second thrust parallel to the skin
5. When the vein is entered, lower the catheter to skin level
6. When inserting, always hold the catheter by the clear plastic flashback chamber and
not by the colored hub
7. Advance the catheter approximately 0.635- 1.3 cm (1/4 to ½ inch) into the vein
8. Pull back on needle to separate needle from catheter 0.635 cm (about ¼ inch) and
advance catheter into vein
9. If resistance is met while attempting to thread catheter,s top, release tourniquet,
and carefully remove both needle and catheter. Attempt another venepuncture with
a new catheter
10. Apply pressure on vein beyond catheter tip with the small or ring finger. Release
tourniquet and slowly remove needle while holding catheter hub in place
11. If an IV, attach the cleared administration set to the hub of the catheter and adjust
the infusion flow at the prescribed rate
12. Place one 1.3cm (1/2 inch) strip of tape under hub of catheter (sticky side away
from skin), criss-cross tape up over the catheter hub, and secure to skin at an angle
away from the direction of insertion site
13. Label strip on tape with an arrow indicating the path of the catheter, size of catheter,
date, time of insertion and inserter’s initials. Affix to dressing. Prepare similar label
with each dressing change
34 | P a g e
14. Regulate
15. Document
Follow-up Phase:
1. Inspect site for infiltration or infection. Ask patient if he/she is experiencing

discomfort
2. Record date of insertion, size,a nd type of catheter
3. Change gauze dressing every 24-48 hours
4. Change IV cannula every 48-72 hours
5. Change IV tubing every 23-48 hours. Label using the date and initials whenever
hung
Discontinuance of IV infusion:
1. If an infusion is discontinued due to complications at the site, the tubing is to be

capped with a sterile needle and may be reused (if less than 24 hours old) following
reinsertion of a new IV needle or catheter.
2. To remove the cannula
 Turn off infusion
 Olace alcohol swab 2x2 inch gauze sponge over insertion site and carefully remove
the IV cannula
 Apply pressure on the insertion site until bleeding stops, generally less than 1
minute, unless patient has a bleeding disorder
 Apply small gauze pas to site and tape
3. Document time of discontinuance and statue of insertion site on appropriate chart
records
35 | P a g e
GIVING MEDICATIONS
1. Review the medication administration record (MAR) to determine the medication to

be administered.
2. Examine the MAR for accuracy and completeness. Check patient’s name, room/bed
number, drug, dosage, and time the drug is to be given
3. Review information about the medications to be given
4. Assess patient’s abilities
5. Assess patient’s need for prn medications
6. Determine equipment needed
7. Wash hands
8. Gather equipment needed
9. Read name of medication from the record
10. Check the label on the medication before picking it up
11. Pick up medication, and compare the label again
12. Remove the correct amount of medication for the individual dose
13. Check the medication label with the MAR a third time
14. Place medication in its unit-dose in a container or on a tray
15. Place medication label on the prepared medication
16. Approach and identify the patient
17. Explain what you are going to do
18. Administer medication as appropriate for the rout
19. Leave the patient in a comfortable position
20. Discard disposable medication container or clean as appropriate
21. Wash hands
22. Evaluate using the following criteria
 Right patient right medication, right dosage, right route, tight time, right
documentation
 Effectiveness of drug for desired purpose
 Side effects
36 | P a g e
23. Document that the medication was given including the name of medication, dosage,
route, time, and signature
24. If medication error occurs, it must be reported as soon as it is discovered so that
necessary actions can be taken immediately. The physician is notified of the error,
and plans are instituted for assessing the patient for adverse effects.
INTRAVENOUS MEDICATION
1. Validate orders
2. Examine the medication administration record (MAR) for accuracy and
completeness
3. Assemble information on the drug including effects, dilution, rate of administration
and potential for incompatibility with other fluids or medications being given
4. Assess patient’s abilities
5. Assess patient’s need for prn medications
7. Wash hands
8. Gather equipment needed
11. Pick up medication, ad compare the label again
12. Determine whether medication has been given or is to be held
14. Prepare the medication using sterile technique
15. Place medication label on the prepared medication
16. Approach and identify patient
18. Administer the medication appropriately
37 | P a g e
20. Dispose of equipment correctly

21. Wash hands
 10 rights followed
 Medication given for correct time
 Criteria established for determining medication’s effectiveness used
 Side effects promptly identified
23. Indicate on the medication administration record that the medication was given,
including the name of medication, dosage, IV route used, time and your initials
24. If 50 or 100 ml fluid was given, add amount to intake record
ADDING OF A NEW FLUID CONTAINER
1. Review medication record to determine if any medications, vitamins, or electrolytes

are to be added.
2. Examine MAR of IV record for accuracy and completeness
3. Review information about the medication, vitamin or electrolytes to be added
4. Assess patient’ abilities
5. Assess patient to see what type of IV access is present and to identify need for prn
medications ordered
7. Wash hands
8. Select appropriate equipment
 Large volume fluid container with ordered IV fluid
 Syringe, needle, and alcohol swab
11. Pick up medication, and compare the label again
12. Remove the correct amount of medication for the individual dose
38 | P a g e
14. Place drug in its unit-dose in a container or on a tray
15. Place drug label on prepared medication
16. Approach and identify patient
18. Inject the additive into new fluid container
 Open top of new container and identify injection port
 Clean port with alcohol swab
 Inject medication
 Tilt the container back and forth to mix additive
 Hang new infusion container
 Regulate the flow
 Label new fluid container with name, amount of additive, date, time, your initials
20. Dispose of equipment appropriately
21. Wash hands
22. Evaluate using the following criteria: 10 rights
23. Indicate on the medication administration record that the drug was given, including
the name of medication, dosage, IV route used, time and your initials
24. If 50 or 100 ml fluid was given, add amount to intake record
PROCEDURE FOR CATHETERIZATION
1. Assess patient and check the order

2. Determine if the procedure is to be straight or indwelling catheterization
3. Assess need for collection of a specimen
4. Wash hands
5. Select specific type and size of catheter
39 | P a g e
6. Collect appropriate equipment including catherization set, light source, bath blanket
or sheet for draping and extra equipment as individually determined
7. Identify patient
8. Explain procedure. Answer any questions
9. Draw bed curtains and position and drape the patient
 Pediatric patient or confused- seek assistance
 Female patient in dorsal recumbent position with knees flexed or in sim’s
position
 Male patient in supine position
10. Set up the equipment
 Arrange the lamp
 Open catheterization set and arrange sterile field
 Set up receptacle for soiled cleansing swabs
 If drainage bag is in separate package, open it and attach to bed
 If sterile drape is on top of the set, grasp drape by side that is to be non-sterile and
place under patient. Then put on sterile gloves
 If sterile gloves (not drape) are on top of set, put them on. Then grasp drape by side
that is to be sterile and place under patient, protecting your gloves
 Place second drape to enlarge sterile field
 Open cleansing solution and pour over swabs
 Open lubricant and place it on end of catheter
 For the indwelling catheter, attach syringe and test balloon by instilling all the
sterile water and then deflating balloon by withdrawing water. Leave syringe
attached
 Set the specimen container and its cap upside down
 If drainage bag is in set, connect end of catheter to drainage tubing
11. Catheterize the patient
 Use non-dominant hand to expose the meatus
40 | P a g e
 After meatus is identified, cleanse the area surrounding the meatus, suing swabs
held in forceps. Use circular motion on males. Swab from anterior to posterior on
females. Discard swabs away from sterile field.
 Use sterile hand to move tray containing catheter close to patient, and to pick up
catheter
 Insert catheter 2-3 inches into female and 6-9 inches into male, holding the penis at
a 45 degree angel until urine returns.
12. If using straight catheter, obtain a specimen and drain the bladder
13. If using an indwelling catheter, fill the balloon
14. Connect the bag to the container
15. Tape on catheter to the patient- for a male, to the lower abdomen, for female, to the
thigh or loosely over the leg without taping
16. Assist patient to comfortable position
17. Gather and discard disposable equipment. Clean non-dominant equipment
18. Wash hands
 Indwelling catheter draining properly or straight catheter inserted and removed
without discomfort
 Patient comfortable
20. Document the following
 Date and time
 Type and size of catheter
 Whether a specimen was obtained
 Amount of urine
 Description of urine
 Patient’s response to procedure
41 | P a g e
CARING FOR A PATIENT WITH AN INDWELLING CATHETER
1. Place patient on intake and output

2. Encourage increased fluid intake
3. Maintain closed system
4. Maintain external cleanliness around catheter
5. Keep catheter drainage bag below level of bladder
6. Keep tubing coiled by patient’s side
7. Keep drainage bag off the floor
8. Tape catheter to prevent pulling
9. Observe for irritation at meatus
10. Empty bag at regular intervals
PROCEDURE FOR REMOVING AN INDWELLING CATHETER
1. Verify the order

2. Determine whether a urine specimen is needed
3. Wash hands
4. Obtain necessary equipment
 Paper towels
 A syringe to remove the fluid from balloon
 A small container to catch urine
 Clean gloves
5. Identify patient
6. Explain that catheter is to be removed and what to expect
7. Prepare patient by proper draping. Put on clean gloves
8. Withdraw the catheter
 Place paper towels under catheter
 Use syringe to remove fluid balloon
 Punch catheter and pull it out smoothly
42 | P a g e
 Wrap catheter in paper towel

 Hold end of catheter up to allow urine to drain from tubing
9. Assist patient for comfortable position
10. Measure urine output
11. Dispose of the equipment to the infections trash bin
12. Remove gloves (infectious trash bin) and wash hands
 Catheter removed without difficulty
 Patient voiding adequate amounts (at least 30 ml/hr)
 Patient is continuing to increase fluid intake
14. Document time of catheter removal, urine, output, and patient’s response
PROCEDURE FOR ORAL AND NASOPHARYNGEAL SUCTIONING
1. Check order
2. Assess patient’s need for suctioning before proceeding
3. Be familiar with equipment available and details of procedure as performed
4. Wash hands
5. Plan for any needed assistance
6. Choose appropriate equipment for route of suctioning planned
7. Identify patient
8. Explain
9. If room lighting is inadequate, secure additional lighting
10. Position patient
 OROPHARYNGEAL- semi- fowler’s with head toward you
 NASOPHARYNGEAL- semi- fowler’s with neck hyperextended
 Unconscious- lateral position facing you
11. Place drape or clean towel across patient’s chest and hyperoxygenate the patient if
needed
43 | P a g e
12. Provide a sterile field

13. Set up a sterile container and pour solution
14. Connect tubing to suctioning and equipment
15. Turn on suction machine and test by placing thumb over end of tube
16. Put on sterile gloves
17. Pick up catheter with dominant hand and using non-dominant hand, attach
connector end of suction tubing
18. Test equipment by suctioning water through tubing and catheter
19. Insert catheter using either the oral or the nasopharyngeal route and describe
procedure
20. Apply suction by closing the system
21. Withdraw the catheter
22. Flush catheter with sterile water to remove secretions
23. Turn off suction and listen to patient’s breath sounds. Repeat suctioning if needed
24. Detach catheter from tubing and discard to infectious trash bin
25. Pull glove downward over used catheter, enclosing it for disposal
26. Reposition patient for discomfort
27. Provide oral hygiene
28. Wash hands
 Breath sounds
 Vital signs stable
 Patient comfortable and calm
30. Document procedure and pertinent observations
44 | P a g e

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Lower Annex- Policies and Procedures 2018

Female Ward : 18 beds

 Female Pay – 1 ( Beds 1-6)

May Ward : 15 beds

 Male Pay – 1 (Beds 1-6)

Private Room : 6 rooms

Critical Care Unit : 3 Beds

Intensive Care Unit : 5 beds

Alley : can accommodate up to 16 beds

Care of Patient in the Medicine Ward

Following admission criteria:

Intensive Care Unit (ICU):

Critical Care Unit (CCU):

Preadmission Protocol Equipment for:

MS. Anamay G. Ambos – Head Nurse

Ms. May Stephanie Abubo

Ms. Michelle Dumat-ol

Ms. Gianna Marla Caracena

Mr. Teofanes Ansok Jr.

Mr. Jebsen Carl Mongcopa

Mr. Don Adrian Duran

Ms. Shanley Lyn Cabrera

Ms. Lorette Diane Roque

Ms. Rachellyn Llego

Ms. Jazminne Tam

Ms. Adelia Kristie Generoso

Ms. Ivy Rodriguez

Ms. Karen Bangca

Ms. Leah Doon

Ms. Danica Katada

Mr. Prince Jay Lapinid

Ms. Janice Teves

Ms. Cathleen Dales

Ms. Marilou Mante

Ms. Marites Tanac

Ms. Julie Sulit

Ms. Janet Entac

Ms. Marietta Lugatiman

Documentation and Charting

1. RN documentation should be done with his/her respective shift.

1. All Medications must be ordered by the authorized attending Physician.

1. Right to Quality Care

 The health education should include: prevention and early detection of

1. Lower and Upper Annex has the following medical equipment:

1. All emergency drugs are kept in the Emergency Crash cart:

1. To provide continuity of care, planning an preparing of discharge begins on the

 HAND WASHING is a must before and after care

 RN must discreetly label the chart with HEP PREC.

 Environment should always be clean.

 Wipe with tissue paper or cloth

Quality Improvement (Lower Annex)

General Policies and Procedures:

1. Care of ICU/CCU admitted patients is the direct responsibility of the Internal

White - Dr. Maningo

1. All emergency drugs are kept in the Emergency Crash cart:

 RN documentation should be done with his/her respective shift

 HAND WASHING is a must before and after care

 HANDWASHING before and after care.

 Clean with detergent and water then dry.

 Spillage- blood, body fluid, secretions, and excretions

Transfer to ward policy

1. ICU patients can be transferred to the general ward provided:

1. Discharge of patient from the ICU shall take place

9. Allow area to air dry