ORIENTATION / EMERGENCY DEPARTMENT

PATIENT RATIO

Regular Care

General Nursing Services 1:7

High Risk Nursing Services 1:6

Specialized Care

Critical Care Services 1:2

Newborn services 1:4

Government Hospitals 1:12

Manager and staff ratio 1:30-35 maximum is 1:40

INTERNATIONAL PATIENT SAFETY GOALS, (JCI, 2020)

- To promote specific improvements in patient safety
1. Identify patients correctly
a. Patient identifiers at MMC: identify uniqueness of patient
i. Full name (with middle name)
ii. Birthdate
iii. Patient’s hospital number/ Medical record number
b. Different hospital bands
i. White: all patients (inpatient, outpatient)
ii. Red: Allergies (one white band and one red band with allergens)
iii. Yellow: High Risk for Fall (one white band and yellow band)
iv. Green: Legal guardians and parents of pediatric clients below 4 years old (with childs
Identifiers) - to prevent baby abduction
v. Blue: Newborn baby boys
vi. Pink: Newborn baby girls
c. Scenarios where we have to identify patient
i. Administering of Medication
ii. Procedures (bt, surgery)
iii. Received diet or snack in the patient room
iv. Specimen collection: specimen container immediately labeled at the time
v. For reporting of critical test results or taking telephone orders
vi. Prior to any diagnostic or treatment procedure
vii. During the preoperative verification progress and time out that is held

2. Improve effective communication

a. Verbal and telephone orders
i. Verbal: physician is physically present
ii. Telephone: physician is in another location
iii. Must be signed by the physician consultant/ fellow within 24 hours
b. What to remember?
i. Read back and verify
ii. Document directly to medical chart
iii. Pronounce numerical digit separately
iv. Medication order: physician must spell it out
c. Who?
i. Consultants
ii. Fellow can give telephone in urgent cases
iii. Fellow/ resident is allowed ONLY for emergency situation
d. When is telephone order not allowed?
i. Non-formulary drugs
ii. Chemotherapeutic drugs

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iii. Voice mail relay of test results

e. Follow read back and verify policy
f. Handover communication: When does handover of patient care occur?
i. Change of shift or temporary assignment
ii. RN to physician and vice versa
iii. Inpatient to diagnostic/ treatment units
iv. During patient transfer
v. Between different levels of care
g. Can we give and/or receive telephone handovers? YES in specific cases (COVID)
h. Person to person communication is prefered but not possible handover via phone call is
acceptable
i. ISBAR (standardized way of communicating with other health care providers)
i. Introduction
ii. Situation
iii. Background
iv. Assessment
v. Recommendation
j. Minimum data must be communicated during hand off
i. Two patient identifier
ii. Diagnosis and current condition of the patient
iii. Recent changes in condition or treatment
iv. What to watch for in the next interval of care
k. Critical test: urgent test whose results are determined as critical to the patient’s
subsequent treatment decisions
l. Critical test results: Beyond the normal variation and that:
i. Is no what is expected due to the patient’s current medication and/or disease state
ii. May require follow up to ensure stability, resolution, or further evaluation
iii. May change the medical management of the patient
iv. Relay within 15 minutes
v. Med tech → resident on duty →ordering physician
vi. Laboratory print out → nurse → resident on duty → ordering physician

3. Improve the safety of High Alert Medications (HAM)

a. Drug that pose a heightened risk of causing significant patient harm when they are used in
error
b. Double check drug and strength
i. Sticker: Sounds alike (e.g. cefuroxime & cefixime),
ii. Bell: looks the same
c. How are HAMS stored
i. With HAM sticker and stored separately from other medications
ii. Concentrated electrolyte controlled: KCL is removed in regular units
d. High alert sticker must be
e. Narcotics are stored in double lock drawers and are separated from usual medications
f. HAM examples (PINCH Me)
i. Potassium salts, concentrated electrolytes and parenteral nutrition
ii. Insulin and oral hypoglycemic agents
iii. Narcotics, moderate sedation agents, neuromuscular blocking agents, anesthetic
agents
iv. Chemotherapeutic agents, radiocontrast agents, radiopharmaceuticals
v. Heparin and antithrombotic agents
vi. Medication with narrow and therapeutic index

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Medication or Classification Reason designated as HIgh Alert medication: Improper dose,

administration or monitoring can lead to:

Chemotherapeutic agents Serious and fatal results due to the highly toxic nature of
these drugs.

Electrolytes Renal dysfunction or failure, cardiac arrest, coma,

respiratory arrest, seizures, *rhabdomyolysis, and death

Heparin Fatal bleeding (from a dose too high) or thrombotic

events (from a dose too low).
Cardiac changes, electrolyte disturbances, seizures,
Respiratory depression, coma and death.

Warfarin Fatal bleeding (from a dose too high) or thrombotic

events (from a dose too low).

Insulin Cardiac changes, electrolyte disturbances, seizures,

Opioids Respiratory depression, coma and death.

g. How are HAMS administered

i. Validated by most senior (Experienced) RN prior to administration (2 RN checked)
ii. Infusion pumps are use for HAM on intravenous routes
iii. Independent check of infusion pump settings and concentration– before start and
every patient visit
h. Common risk factors in HAM
i. Mix-ups and sound alike and look alike drugs
ii. Incorrect infusion rate
iii. Use of abbreviation
iv. Incorrect concentration of solutions administered

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CATEGORIES OF SAFETY EVENT TAXONOMY OF ERRORS

Hazardous (or “unsafe”) condition A Circumstances or events that have the capacity to
A circumstance (other than a patient’s own cause errors
disease process or condition) that increases the
probability of adverse event

NEAR MISS (or close cal) EVENT: B An error occurred but did not reach the patient
A safety event that did not reach the patient

NO-HARM EVENT: C An error occurred that reached the patient but did
A safety event that reaches the patient but does not cause harm
not cause harm
D An error occurred that required monitoring or
intervention to confirm that it resulted in no harm to
the patient

ADVERSE EVENT: E An error occurred that caused temporary harm to

A safety event that resulted in harm to a patient the patent and required intervention
Preventable Adverse Event: caused by an error
or other type of systems or equipment failure F An error occurred that caused temporary harm to
the patient and required initial or prolonged
hospitalization

G An error occurred that caused permanent patient

harm

H An error occurred that required intervention to

sustain life

I An error occurred that resulted in patient death

Non preventable Adverse Event: not caused by

an error or other type of systems or equipment
failure

SENTINEL EVENT: a patient safety event (not F1 An error occurred that caused severe temporary
primarily related to the natural course of the patient harm and required transfer to a higher level
patient’s illness or underlying condition) that of care/ monitoring for a prolonged period of time
reaches a patient and results in any of the
following: F2 An error occurred that caused severe temporary
a. Death patient harm and required transfer to higher level of
b. Permanent harm care for a life threatening condition, or additional
c. Severe temporary harm: critical, major surgery, procedure, or treatment to resolve
potentially life threatening harm lasting for the condition
a limited time with no permanent residual
but required transfer to a higher level of a G An error occurred that caused permanent patient
harm

H An error occurred that required intervention to

sustain life

I An error occurred that resulted in patient death

4. Ensure safe surgery

a. Repeated check and validation using a surgical safety checklist
i. The document and the process of ensuring that the surgical team consistently follows
a few critical safety steps and thereby minimize the most common and avoidable risks
endangering the lives and well-being of surgical patients
b. When is surgical safety checklist applicable? Prior to any surgical and invasive procedures
performed in:
i. Operating room
ii. Delivery room
iii. Endoscopy Unit
iv. Radiology department

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v. Cardiac Catheterization Laboratory

vi. Other procedural units
c. Bedside procedures:
i. Tracheostomy
ii. Bone marrow aspiration
iii. Paracentesis
iv. Thoracentesis
v. Lumbar Puncture
d. Sign in: before induction of Anesthesia
i. Review of anesthesia needs: Pulse Ox, Blood Loss, Pre-anesthesia Assessment,
Airway Difficulty, Allergy
ii. WHO STANDARD? Anesthesiologist, Nurse (MMC STANDARDS: assisting surgery
resident, Assisting anesthesia resident, Nurse)
iii. Availability and function of anesthesia **ask anesthesiologist*
1. Airways equipment
2. Breathing system
3. Suction
4. Drugs and devices
5. Emergency medications
iv. Verify with patient:
1. Identifiers
2. Procedures & site marking:
a. HOW? Surgeon’s initial with permanent marker
b. WHAT? Site Marking Form is constantly use
c. WHEN? Prior procedure
d. WHY? In case of laterality
e. WHO? Performing surgeon
3. When is surgical Marking not required?
a. Single organ Cases
b. Interventional Cases
c. Premature infants
d. Procedure performed on natural body orifice without laterality
4. Consent
e. Time out: before surgical incisions
i. What is included in the TIME OUT phase?
1. Each surgical team member introduces self by name and role
2. Confirm and ensures: correct patient, correct operation, corect site
3. Surgeon reviews: critical steps, duration of surgery, anticipated blood loss
4. Anesthesia reviews: patient specific concerns
5. Nurse reviews: sterility, equipment and other preparations
6. Essential imaging (ortho, ortho, thoracic surgeries)
7. Prophylactic antibiotic
f. Sign out: during or immediately after the wound closure BUT before removing the patient
from OD/DR theater
i. Teams confirms the procedure performed, procedure may have changed or expanded
during the operation, counting of equipments
ii. Labeling of surgical specimen obtained
iii. Equipment problems
iv. Plans and concerents re post operative management and recovery

5. Reduce the risk of healthcare Associated Infection

a. Hand hygiene: any action of cleaning the hands
b. Types of hand hygiene:
i. Hand washing: water and soap; 20 seconds outside hospital, inside hospital 40-60
seconds, 6 steps of hand hygiene (palm to palm, back of the hand, finger interlaced,
back of fingers, rotational rubbing, fingers on palm)
ii. Hand rubbing: alcohol-based hand sanitizer, 20-30 seconds
c. 5 moments of hand hygiene:
i. Before touching the patient

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ORIENTATION / EMERGENCY DEPARTMENT

ii. Before clean or aseptic procedure

iii. After body fluid exposure risk
iv. After touching a patient
v. After touching the patient’s surroundings
d. Personal protective equipment
i. Donning (paa, katawan, head, kamay)
1. Shoe covers/ booties → gown → Head → hands
ii. Removing (kamay, patas, except mask, katawan, shoes)
e. Hand sanitizers in various locations
f. Types of healthcare associated infection (HAI)
i. Ventilator Associated Pneumonia (VAP)
1. Assess extubation readiness daily,
2. Avoid equipment contamination
3. Keep head elevated at 30-45 degrees
4. Perform oral care regularly
ii. Central Line: Associated bloodstream infection
1. Select optimal catheter site
2. Use maximal barrier precautions
3. Assess need for continuing central line access
4. Replace administration sets regularly
iii. Catheter Associated Urinary Catheter
1. Use a small bore catheter as possible
2. Insert catheter only when indicated: urinary obstruction/retention, urine output
monitoring, peri operative use, assistance in pressure ulcer healing
3. Observe standard precaution
4. Obtain a specimen aseptically
iv. SURGICAL SITE INFECTION
1. Use surgical clipper
2. Maintain postoperative normothermia
3. Control of blood glucose level
4. Give prophylactic antibiotics within 1 hour before surgery

6. Reduce the risk of patient harm resulting from Fall

a. Sudden uncontrolled, unintentional, downward displacement of the body to the ground or
other object, excluding falls resulting from violent blows or other purposeful actions
b. Near fall
i. A sudden loss of balance that does not result in a fall or other injury
c. Unwitnessed fall
i. Occurs when a patient is found on the floor and neither the patient nor anyone else
knows how he or she got there
d. When to do Fall Risk Assessment?
i. On admission
ii. During transfer
iii. After a change in medical status
iv. After a Fall
v. On regular interval depending on fall risk
e. What are ways to prevent and manage fall?
i. Determine fall risk using “Fall Risk Assessment Form”
ii. Communication of Level of risk: physicians → nurses → patient and family → other
members of the healthcare
FALL RISK SCORE FREQUENCY OF FALL
ASSESSMENT

LOW RISK ADULT: 0-6 Every 4 hours

PEDIA: 7-11

High Risk Adult: 7-19 Every 2 hours

Pedia: 12 and above

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f. Risk reduction Strategies

LOW FALL SAFETY RISK MEASURES IMPLEMENT THE UNIVERSAL FALL
PRECAUTION

- Orient to surroundings - Keep call light, telephone, and personal

- Non skid slippers items accessible
- Keep bed in low position - Bedside commode or urinal is available
- Lock wheels on all wheelchairs, beds, at bedside
commodes, and stretchers - Safe use of equipment and cords in
- Wipe up spills immediately safe positions
- Ensure adequate lighting - General medications review by
- Maintain rooms free of excess clutter pharmacy

HIGH FALL SAFETY RISK MEASURES IMPLEMENT THE UNIVERSAL FALL

PRECAUTION PLUS

- Re orient to environment, time, person and - Consider placing patient in a room

place frequently close to nurses’ station
- Post a high risk for fall injury sign outside the - Provide assistive or protective
patient’s room device if needed-such as
- Place a Yellow Wristband wheelchair, special bed, crib for
- Round on patient at least once every 60 pediatric patients
minutes or more often if necessary

g. Consistent rounding and effective education

Fall Tool and Resources

Environmental Fall and Risk Frequent Rounding Form Post Fall Huddle
Assessment Tool

Ensure that every hospital Prevent fall Outline recommendations for

personnel who enter the patient nursing management of
room assesses environment patient who fell
safety at every patient
encounter

h. Post fall management protocol:

i. Assess the patient → Notify the MD → Render care and interventions as ordered →
communicate and educate the patient → post fall huddle
ii. After a fall, post fall protocol assessment is implemented and any immediate measure
to protect the patient
iii. NOTE: for incidence of Head Trauma → RN must monitor Neurologic Vital Sign every
15 minutes for the first hour. If stable, every hour until evaluated by the physician

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CARE OF PATIENT IN THE EMERGENCY DEPARTMENT

Noel Arvin Esteves, RN and Rosline Grajera, RN (Nurse Managers, Emergency Department)
1. Emergency Department Overview
a. Emergency nursing deals with human responses to any trauma or sudden illness that
requires immediate intervention to prevent imminent severe damage or death. Care is
provided in any setting to person of all ages with
actual or perceived alterations in physical or
emotional health
b. Bed capacity MMC: 66
c. ALOS: 4 hours for outpatient- average length of stay
d. Boarding time: (2021)
i. COVID 14 hours
ii. Non COVID 34 hours
iii. ED-ICU 34 hours
e. Emergency Department team members
i. Physicians
ii. Nurses
iii. Allied staff
f. Screening process in attending possible Communicable Disease in triage
i. Cough for more than 2 weeks?
ii. Fever, rashes, skin lesions?
iii. Recent travel abroad? If yes, where?
iv. Cough, SOB, health care facility, close contact with person with symptom
g. Questions for COVID-19 Suspect
i. Travel history in the past 14 days
ii. Live in a community with documented local COVID 19 transmission
iii. Have any of these symptoms in the last 14 days
1. Fever
2. Cough
3. Throat pain
4. DOB
5. Loss of taste/ smell
6. Body Weakness/ body malaise
7. Diarrhea
2. Triage
a. Triage is a process of determining the priority of patient’s treatments by the severity of
their condition or likelihood of recovery with and without treatment
b. The Emergency Department Severity Index (ESI) is a five level emergency department
c. (ED) triage algorithm that provides clinically relevant stratification of patients into five
groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource
needs.
3. Hot Zone vs Cold Zone
a. COVID Protocols
i. HOT Zone: full PPE
ii. COLD Zone: Respirator, face shield, scrub caps
iii. 1 way traffic flow
iv. Tent
v. ARCU (Acute respiratory care unit)
vi. Contact Tracing
b. Donning
i. Hand wash → shoe cover → hand wash → gown/ cover all → respirator (check for
fitness) → goggles → head cover → hand hygiene → first cclean gloves → second
clean gloves → apron
c. DOFFING
i. Hand hygiene → remove apron (away from the body) → remove cover all → remove
shoe cover → hand hygiene → remove first layer of gloves → hand hygiene → remove
goggles → remove inner gloves → hand hygiene

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4. ESI Training System

a. ESI Triage Algorithm
i. Is this patient dying?
ii. Is this a patient who should not wait?
iii. How many resources are needed?
iv. What are the vital signs?
b. Immediate life-saving intervention required: airway,
emergency medications, other hemodynamic interventions
(IV, supplemental 02, monitor, ECG or labs DO NOT count);
NOT count); and/or any of the following clinical conditions:
intubated, apneic, pulseless, severe respiratory distress,
SPO,<90, acute mental status changes, or unresponsive.
Unresponsiveness is defined as a patient that is either:
(1) nonverbal and not following commands (acutely); or
(2) requires noxious stimulus (P or U on AVPU) scale.
c. High risk situation is a patient you would put in your last open bed. Severe
pain/distress is determined by clinical observation and/or patient rating of greater than
or equal to 7 on 0-10 pain scale.
d. Resources: Count the number of different types of resources, not the individual tests
or x-rays (examples: CBC, electrolytes, and coags equals one resource; CBC plus
CXR equals two resources).
RESOURCES NOT RESOURCES

- Labs (blood, urine) - History & physical (including pelvic)

- ECG, X Rays - Point of care testing
- CT, MRI Ultrasound angiography

- IV fluids (hydration) - Saline or heplock

- IV or IM or nebulized medications - PO medications

- Tetanus immunization
- Prescription refills

- Specialty consultation - Phone call to PCP

- Simple procedure=1 (ac repair, foley cath) - Simple wound care (dressing, recheck)
- Complex procedure=2 (conscious sedation) - Crutches, splints, slings

e. Danger Zone vital signs- consider triage to ESI 2 if any VS criterios is exceeded.
Pediatric Fever Considerations
- 1-28 days of age: assign at least ESI 2 if temp >38.0C (1.00.4F)
- 1-3 months of age: consider assigning ESI 2 ifd temp >38.0C (100.4F)
- 3 months to 3 years of age: consider assigning ESI 3 if temp >39.0C (102.2F) or
incomplete immunizations or no obvious source of fever
ESI SCORE 2
Case: 3 week old male.
VS: Temp: 100.8 F (38.2 C)
Heart rate: 48
Respiratory rate: 48
Oxygen saturation: 96%
Narrative: Poor feeding, less active than usual,
sleeping most of the day

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 ORIENTATION / EMERGENCY DEPARTMENT

5. Introduction to BLS/ ACLS

a. BLS: level of medical care which is used for victim of life threatening illnesses or injuries
until they can be given full medical care by advanced life support providers (paramedic,
nurses, physicians)
i. Scene is safe for them and the patient
ii. Is the patient responding? Check for LOC
iii. Check for pulse (carotid pulse for adult, brachial pulse for
pedia)
iv. Every 5 minute, 2 cycles: check for rhythm
v. Once patient has return of spontaneous circulation: transfer
to hospital
b. ACLS: pre eminent resuscitation course for the recognition and
intervention of cardiopulmonary arrest or other cardiovascular
emergencies. This advanced course builds on the foundation of
basic life support skills and takes healthcare provider training to
the next level
i. Closed loops communication
ii. Clear messages
iii. Summarizing and Reevaluation
iv. Mutual respect
v. Knowledge sharing
vi. Constructive Intervention
TEAM MEMBER RESPONSIBILITIES

Team Leader - Assigns role to team members

- Incharge of overall medical management of resuscitation, diagnostic
and therapeutic decision making
- Determines the number of staff needed while other personnel will stay
at the civinity as requested

Compressor - Perform Cardiac compressions

Airway - Obtains and maintains airway with continuous ventilation

- For intubation (as needed)

Defibrillator - Operates AED/ Defibrillator

- Monitor VS

Code Recorder - Records time of interventions and medications

Medication - Assigned for IV/IO access and drug administration

- Prepares all emergency medications

Primary Nurse - Assist physician by providing all the supplies/ materials needed and
confirms drug administration

Crowd Control - Manage crowd and ensures safety and security of patient and health
care workers
c. BLS Dos and Don'ts of Adult high-quality CPR
RESCUERS SHOULD RESCUERS SHOULD NOT

Perform chest compressions at a rate of 100-120/min Compress at a rate slower than 100/ min or faster than
120/min

Compress to a depth of at least 2 inches (5cm) Compress to a depth of less than 2 inches (5cm) or
greater than 2.4 inches (6cm)

Allow full recoil after each compression Lean on the chest between compressions

Minimize pauses in compressions Interrupt compressions for greater than 10 seconds

Ventilate adequately (2 breaths after 30 compressions, each Provide excessive ventilation (ie. too many breaths or
breath delivered over 1 second, each causing chest rise) breathes with excessive force)

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d. During respiratory arrest, the ACLS provider should avoid hyperventilating the patient
i. For patient with a perfusing rhythm, deliver 1 breath every 5 to 6 seconds
e. Use of Bag-Valve Mask
i. The entire lower klips MUST be inside the mask. Not only will you not get a seal if the
lip is outside, you risk injuring the mucosa.
ii. Finger positions are key: thumb and index finger form “C”, and the other three will form
an “E”
f. Emergency drugs
DRUGS INDICATION DOSAGE

Atropine Sulfate DOC or Symptomatic 0.5 mg IV every 3-5 minutes

Bradycardia Maximum dose of 3mg

Epinephrine - Asystole Cardiac Arrest

- Pulseless Ventricular - 1mg IV every 3-5 minutes (AHA guidelines)
Tachycardia
- Ventricular Fibrillation Respiratory Distress/ Anaphylaxis
- Pulseless Electrical Activity - 0.3-0.5 mg (0.3-0.5mL of 1:1000 solution) IM or
SC every 15-20 minutes to 4 hours

Shock
- 2-10 mcg/minute by continuous IV infusion

Dopamine - Cardiogenic and septic shock Renal Perfusion

- Low dose may be useful in - 1-3mcg/kg/min
patients with low CO or renal
impairment
- Higher doses are used for
inotropic support to increase HR
and CO of patients in
cardiogenic shock or severe
cardiac failure

Adenosine Narrow complex tachycardia - Give 6mg rapid IV push over 1-3 seconds (as
close to vein as possible) followed with a rapid
IV NS flush 20ml
- If no response after 1-2 min, give 12 mg rapid
IV push over 1-3 seconds (as close to vein as
possible) followed with a rapid IV NS flush 20ml

Amiodarone - Used to treat atrial and VF/Pulseless VT:

ventricular dysrhythmias - 300mg IVP over 30 sec
- Refractory Ventricular - May repeat once at 150mg in 3-5 min
Tachycardia - Max. cumulative dose: 2.2g IV/24hrs
- Wide Complex Tachycardia V-Tach with pulse
(With Pulse) - 150mg in100cc D,W /over 10 min, may repeat
- Pulseless Ventricular if
Fibrillation necessary
- Pulseless Ventricular Maintenance infusion:
Tachycardia - Initially 1mg/minX 6 hours, then 0.5mg/min x
18
hours
g. DEFIBRILLATION: the process of delivering shock to correct life-threatening dysrhythmia
i. Monophasic: Current delivered in one direction
1. 360 J
ii. Biphasic: Current delivered in two directions
1. Initial: 120J-200J
2. Subsequent: Higher
h. POST-ARREST CARE: therapeutic hypothermia 34-36C, CXR, meds, ECG, NGT, foley
cath

6. Hand Over Process

a. Off to cardiac laboratory

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 CARDIAC CATHETERIZATION LABORATORY

CATH LAB STAFF What do we Cases handled in Stages Leading to a Heart Attack
1. Nurse: Roles look for in our the Cath Lab 1. Coronary Artery Disease: plaque builds
a. Circulate staff? 1. Cardiology up in an artery (atherosclerosis: artery
b. Monitor 1. Educational 2. Neurology constriction)
c. Scrub foundation 3. Peripheral 2. Angina: it is harder for blood to get
2. Radiation 2. Skills Vascular through the artery
Technologist 3. Attitude 4. Radiology 3. Heart attack: plaque cracks and a blood
3. Nursing Aide clot blocks the artery

Radiation Protection How do we ensure WHO Surgical Safety Checklist Coronary Arteries
1. Lead Gown: safe surgery/ 1. Sign in: the period before 1. Aorta
protect body procedure? induction of anesthesia 2. Right coronary artery
against radiation 1. Correct site 2. Time out: period before - C shape (easy to
(1-3kgs) 2. Correct procedure/ surgical incision distinguish)
2. Thyroid Shield surgery 3. Sign out: period before patient 3. Circumflex
3. Lead Cap 3. Correct patient leaves operating room 4. Left anterior
4. Lead Goggles descending artery

Left Heart Catheterization with Coronary Percutaneous Transluminal Coronary Angioplasty

Angiogram 1. A procedure that uses x-ray imaging to treat
1. A procedure that uses x-ray imaging to check for patients with Coronary Artery Disease (CAD)
blocked or narrowed blood vessel in your heart 2. Opens up blocked or narrowed arteries of the heart
2. Use of contrast medium using a balloon and stents
3. 30-60 minutes 3. Use of contrast medium
4. Access points: through the wrist and groin 4. Access points: wrist and groin
5. Local anesthesia 5. Local anesthesia

Nursing Considerations Post Coronary Angiogram/ Angioplasty Procedures

1. Radial Approach
a. Check VS as ordered
b. WOF: bleeding and hematoma. If with bleeding or
hematoma, call cardio fellow or Cath Lab
c. Post PTCA: ACT must be above 250.
d. Deflate TR band every 2-3mL every 15-30 minutes
until fully deflated (done by cardio fellow or MROD)
e. TR Band syringe is not disposable. Please inform the
Nurse’s station.
f. Prepare at bedside: band , BP and apparatus
g. If with pain may give pain meds as ordered
h. Transradial band: post op 4 hours, do not bend wrist

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CARE OF PATIENTS IN ENDOSCOPY UNIT
Margaret May S. Sarmiento, RN Endoscopy Unit

Registration Area/ Admission Area

Donning area
Removal of PPE area
Interview area
- Fasting: 8 hrs prior to the procedure
- Patient will be sedated
Recovery area: motoring of patient post endoscopy
Processing area: cleaning of equipment, materials
Procedural area:

2 red zones area: negative pressure room (even tho

COVID +)

Storage and handling of scopes

Eye Wash Station (green sink): accessible
to all staff, incident of spillage of chemical
in the eyes

Infection Prevention and Control: high

level disinfectant, reprocessing procedure,
handling and storage of endoscope

ENDOSCOPY TEAM
Gastroenterologist
Auxiliary/ GI Fellows
Anesthesiologist
Technicians
Nurse

QUALIFICATIONS for ENDOSCOPY NURSE: renewed annually

1. BLS
2. ACLS
3. PALS
4. Moderate sedation: given narcotics
5. IV Therapy: renewed every 3 years
6. Safe Medical Practice

International Patient Safety Goals (IPSG)

4-Ensure safe surgery (Sign in, time out, sign out)

Pre-procedure Checklist
1. Assessment
a. Pre procedure Assessment: Before, and all throughout the procedure (endorsing)
b. Review of System: focused assessment and physical assessment, question sickness,
special precaution, mastectomy, right arm precaution
c. Level of anxiety: normal for patient to be anxious specially first timer, discuss flow of
procedure → lessen anxiety GOAL: reduce anxiety and encourage cooperation
d. Comorbidities: ask about this, cardio, respi, infectious & communicable disease
e. Previous surgeries: requiring special care, arm precautions(AV fistula), kidney patients,
adverse reactions in previous anesthesia dose
f. IV site and line: observe arm precaution, 5 IV insertions a day
g. LOC: will be the baseline, because the patient will be sedated
h. Relevant Diagnostic Tests: chest x ray, ecg, lab works, clotting time, rt pcr valid for 7 days,
i. VS: bp, temp, pr, hr, oxygen saturation, pain
j. Allergies: food and drugs

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 k. Contraptions: in patient/ admitted; jewelry, contact lenses, and nail polish must be
removed (jewelry, baka makuryente si patient sa cuttery)
l. BMI: Giving of meds (latest weight, and height)
2. Bowel preparation
a. NPO 6-8 hrs prior to procedure
b. Clear diet (milk, fish) low residue diet- 3
days before colonoscopy; clear diet- 1
day before
c. Avoid green leafy veggies, corn (matagal
ma digest)
d. Colonoscopy: oral laxative, ask about
the bowel movement (dumumi na ba?
Kamusta consistency and color, iolang
beses dumumi- light colored and
malambot dapat for better visualization)
e. Suppository
f. Fleet enema
g. Therapeutic cleansing enema- 1 liter of
water (ulit ulit lang unless okay na)
3. Consent / clearances
a. Content of consent:
i. Surgical / invasive procedures
ii. With risk procedure/ treatment
iii. Use of anesthesia
iv. Procedural sedation
v. Clinical photography
b. Elements of informed consent:
i. Nature of treatment: preparations
ii. Risks: imperforation, effect of anes, allergic reaction, inc of BP as an effect of meds
iii. Benefits
iv. Alternatives
v. Opportunity for Questions
c. MD’s should be the one to obtain and explain the procedure/ consent
d. Medical Clearance: 35 years old and above and If with comorbidities
i. Cardiologist, pulmonologist, endocrinologist, nephrologist, infectious disease, others
(ask for clearance from MD)
4. Diet / discharge planning:
a. NPO GUIDELINES: AAGBI^4, ASA^5 & RCN^6 recommended (prevent aspiration)
Ingested Material Minimum fast

Clear Fluids 2 hours

Breast Milk 4 hours

Infant formula 6 hours

Non-human milk 6 hours

Light meal 6 hours

b. Discharge planning
i. Starts admission pa lang
ii. Don’t drive operate heavy machinery (needs companion, effect of anes can last to 24
hrs)
iii. Take meds as prescribed
iv. Avoid lifting or strenuous activity
v. Avoid alcohol
vi. Drink plenty of liquids (especially prune juice)
vii. Eat high-fiber foods or take fiber supplements
viii. Have someone with you to help
5. Emergency department

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 Assorted syringes, Intravenous access Basic airway management
tourniquets, adhesives tape equipment including fluid equipment

- Oxygen supply
- Suction machine and
catheter
- Nasal cannulae and
face masks
- Bag mask ventilation
device
- Oral and nasal
airways (all sizes)

Advanced airway management equipment Cardiac equipment

- Laryngoscope handles and blades* - Pulse oximeter

- Endotracheal tubes and styles* - Cardiac defibrillator
- Laryngeal mask airway (LMA)* - Emergency medications
- Atropine
- Diphenhydramine
- *All appropriate sizes should be - Epinephrine
available - Ephedrine
- Flumazenil
- Glucose 50% hydrocortisone
- Lidocaine
- Naloxone
- Sodium bicarbonate

Intra-procedure Checklist: Ensure safety of patient (SPASM)

1. Surgical safety checklist
2. Position: left side lying
3. Anesthesia medications: propanol, fentanyl, flumazenil
4. Specimen handling
5. Monitoring

Unpacking of Endoscopy Kits

1. Esophagogastroduodenoscopy
2. Colonoscopy Kit
Throat spray: numb the area → mouth guard → anesthesia induction
Indication: Esophagogastroduodenoscopy
Portal of entry: mouth → esophagus → stomach → duodenum/ small intestine

Diagnostics Therapeutic

- Acid reflux - Perform hemostasis

- Evaluate lesions - Polypectomy
- Assess strictures - Removal of foreign object and strictures
- Esophageal varices
- Ingestion of Caustic substances

Indication: Colonoscopy
Portal of entry: anus → sigmoid → descending colon→ transverse → ascending → end: ileum: small intestine

Diagnostics Therapeutic

- CRC Screening - Perform hemostasis

- Evaluate lesion - Polypectomy
- Investigate anemia - Removal of foreign object and strictures
- Hemorrhoidal ligation

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Anesthesia Medication

DRUG REVERSAL AGENT

Benzodiazepine Flumazenil

Opioid Naloxone

Capnography: sensitive to gauge hypoventilation

Specimen Handling Guidelines

- Verify the type of test that will done to the specimen with the physician
- Specimen for routine histopathology processing must fixed immediately with formalin and
not with any other fluid
- Using traditional fixation procedures by immersion, a 1:10 ratio of tissue volume to formalin
volume is recommended
- Confirm patient’s identifiers and label of the specimen sample

Post-procedure checklist
1. Monitoring
a. VS (every 5 or 10 minutes)
b. Observe signs of GI tract perforation: abdominal pain, N/V, pain, chills
c. Monitor for bleeding: expected for 2 days, if increased → report, check for blood thinners
d. Maintain privacy: blanket, curtains “you might pass a lot of air due to natural effect of
colonoscopy, but not smelling”
e. Fall prevention protocol: due to sedation, guide them to the bathroom

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2. Aldrete Scoring (for sedation): should have at least 8 and above score
ITEM ASSESSMENT POINTS

Consciousness Fully awake 2

Arousable 1

Not responding 0

Mobility Able to move four extremities on command 2

Able to move two extremities on command 1

Able to move 0 extremities on command 0

Breathing Able to breathe deeply 2

Dyspnea 1

Apnea 0

Circulation Systemic BP not 20% of the preanesthetic level 2

Systemic BP between 20% and 49% of the preanesthetic level 1

Systemic BP not 50% of the preanesthetic level

Color Normal 2

Pale, jaundiced, blotchy 1

Cyanotic 0

Oxygen Maintaining oxygen saturation >90% on room air 2

saturation
Needs inhalation to maintain oxygen saturation >90% 1

Oxygen saturation <90% despite oxygen supplementation 0

3. Discharge Instructions
a. Diet
b. Medication: MD prescription depending on the result of procedure
c. Activities: needs companion, do not drive
d. Expected symptoms: discomfort in throat
e. Things to report: signs of bleeding, unrelieved pain, sign of infection in IV site, fever
4. Electronic Medical records: accessed by health care workers
5. FAQs
a. How do I prepare for an endoscopy procedure?
b. How long does this procedure take>? Gastroscopy 5-10 mins, colonoscopy 15-20 mins;
30 mins - 1 hr sa recovery area
c. Is EGD/Colonoscopy painful? No, just discomfort (only the IV insertion is painful)
d. What do I expect after the procedure?
e. When are the results available? Right after the procedure (live)
f. Is it safe to undergo endoscopic procedures during Covid 19 pandemic? Yes with special
precautions

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CARE OF PATIENT IN THE INTENSIVE CARE UNIT

Glaize Marie Ballester, MAN RN CLSSYB- Department Manager

Dianne Margarette Mangalili, RN- Nurse Manager
Riena Jean Macaspac, RN- Nurse manager

INTENSIVE CARE UNIT

- Also known as Critical care unit
- A specialty unit that deals with erously or critically ill patient

INTENSIVE CARE MONITORING

- Intensive monitoring ensures rapid detection of changes in the clinical status
- Progression, improvement
- Assessed and monitored every 15 or 30 minutes but not more than 1 hour
- Allows for accurate assessment of progress and response to therapy
- Trends are generally more important than a single reading
- Clinical Alarms are crucial for patient’s health condition and safety

Common Contraptions of Patients in the Critical Care Unit

1. Cardiac Monitor
2. Pulse Oximetry
3. Oxygen Support
4. Peripheral Access/ Central Venous Access
5. Feeding Tube: (e.g. ngt, tpn, enteral feeding, peg)
6. Urinary Catheter

OTHER CONTRAPTIONS OF PATIENTS REQUIRING EXTENSIVE NURSING CARE

1. Swan- Ganz Catheter for Hemodynamic Monitoring
2. IABP Machine (Intra Aortic Balloon Pump)
3. Renal Replacement Therapy
4. ECMO Machine

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 CARE OF PATIENT IN THE INTENSIVE CARE UNIT

Admission Criteria

Priority 1 - Critically ill patient with unstable acute or recent medical or surgical conditions who require
immediate intensive treatment and frequent monitored observation
- Immediate or recent post-surgery or acute respiratory failure patients who require mechanical
ventilatory support
- Shock or hemodynamically unstable patients who require invasive monitor and/or parenteral
vasoactive drugs

Priority 2 - Require urgent intensive monitor and potentially need urgent diagnostic and/or treatment
intervention
- Chronic severe comorbid conditions who develop acute reasonably potentially reversible
several medical or surgical illness or disorder

Priority 3 - Unstable patients who are critically ill with a reduce likelihood of recovery because of
underlying disease or nature of their acute or chronic illness
- Metastatic malignancy complicated by significant serious infection, cardiac tamponade, or
airway obstruction

Priority 4 - Patients who are generally not appropriate for CCU admission. Admission of these
patients is under unusual circumstance and at the discretion of the ICU Officer, admission
of such patient is generally discouraged
- Hemodynamically stable diabetic ketoacidosis, mild congestive heart failure, and
conscious patients with drug overdose

ENTERING PATIENT ROOM

- Assessment cephalocaudal → check contraptions → document

Assessment
1. Identify patient through hospital ID Band,
Patient and/or Companion
2. Cephalocaudal approach
3. Inspection, Palpation, Percussion, Auscultation
4. Abdominal Exam: Inspection, Auscultation,
Percussion, Palpation
5. LOC:
- Consciousness/awake: normal attention
and wakefulness
- Disoriented: confused, slow thinking,
inappropriate responses
- Lethargic: drowsy, can be aroused but cannot sustain wakefulness
- Obtunded: diminished alertness, requires repeated stimulation

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CARE OF PATIENT IN THE INTENSIVE CARE UNIT

- Stuporous: deep sleep, no spontaneous activity, responds to pain by grimacing or

withdrawal
- Coma: no arousal, no response to stimuli
** if pt is intubated, eye opening and motor responses only to be assessed

Pupillary reaction - use of penlight; PERLA

⬇
Assessment of Contraptions

Visual appearance Intactness Brands, sizes, skin Drains

level markers

⬇
Focused assessment - depends on patient’s present health condition

CENTRAL VENOUS PRESSURE

- Reflects right atrial or right ventricular end diastolic pressure (the pressure immediately
preceding the contraction of right ventricle
- It assesses the intravascular volume status, right ventricular function, and patient’s
response to medications and fluid therapy
- Elevated CVP: most common cause is hypervolemia (excessive fluid circulating in the
body) or right sided HF
- Low CVP: indicates reduced right ventricular which is most often hypovolemia.
Dehydration, excessive blood loss, vomiting or diarrhea and over diuresis can result in
hypovolemia and low CVP
- Can be measured through Central Venous Catheter or Pulmonary Artery Catheter

Leveling and Zeroing

1. Leveling
a. Transducer should always be leveled with the Phlebostatic axis
b. 4th intercostal space
c. Level of Aorta
2. Zeroing confirms that when pressure within system is zero, monitor reads zero
3. Performed on initial setup and when is accuracy is questionable before readings

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CARE OF PATIENT IN THE INTENSIVE CARE UNIT

Monitor/Reading can be done in two ways

1. Manual reading using a Manometer
2. Online reading using a transducer cable to be connected to cardiac/hemodynamic
monitor

NURSING CONSIDERATIONS
1. Ensure sterility of ports/ access
2. IV saline changed based on hospital’s recommendation

CENTRAL VENOUS CATHETER

- A large bore catheter inserted to the big veins of the body (femoral vein, intrajugular
vein, subclavian vein, antecubital vein)
- Acts as an IV access to inject medications, infuse fluids or medications or draw blood
specimen

Different Types of Central Venous Catheters

1. Tunneled CVC: passed under the skin and meant to be used for a longer duration of
time
2. Non-Tunneled Central Venous Catheter: designed to be temporary and for emergency
situations
3. Implanted Ports: tunneled under the skin with its port and is only accessed whenever
needed
4. Peripherally-Inserted Central Catheter: inserted in a large peripheral vein (Cephalic or
Basilic Vein) and is advanced until the tip reaches the distal superior vena cava

INDICATIONS
- Long term intravenous access
- To administer drugs that are not recommended for Peripheral Infusion/administration
- Blood extraction for frequent laboratory tests
- CVP monitoring
- Dialysis access

CENTRAL LINE ASSOCIATED BLOODSTREAM INFECTION BUNDLE

- Assess catheter site: visual appearance, condition of catheter
- Determine if line is still necessary
- Catheter and site disinfection
- Practice hand hygiene before and after manipulation: sterile technique
Other nursing considerations
- Dressing changes as advised
- Ensure sterility of the access: sterile technique in dressing change, obtaining blood
sample and opening of catheter ports for IV infusion or injection
- Routine monitoring of site

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CARE OF PATIENT IN THE INTENSIVE CARE UNIT

Foley Catheter
- A catheter that is used to drain the bladder
- May also be used to get urine specimen
- Different types of urinary catheter
- Indwelling urethral catheter: most common
- Condom catheter - male patients; frequent urination
- Straight/ intermittent catheter

INDICATIONS
- Urinary incontinence
- Urinary retention
- Accurate monitoring and management
- Preparation for patients due for surgical procedure

CATHETER ASSOCIATED URINARY TRACT INFECTION BUNDLE

Bundle Care
- Closed system maintained
- Catheter care done
- Gloves used during manipulation
- Unobstructed flow
- No dependent loops
Other Nursing Considerations
- Maintain sterility during insertion
- Monitor and recognize early signs of infetion
- Perineal care
- Proper taping and positioning of catheter tube

Mechanical Ventilation can be:

- Noninvasive, involving various types of face masks
- Invasive, involving endotracheal intubation
- Mechanical ventilation should be considered when there are clinical or laboratory signs
that the patient cannot maintain an airway or adequate oxygenation or ventilation

Indications
- Respiratory rate >30/minute
- Concrete findings
- Inability to maintain arterial oxygen saturation > 90% with fractional inspired oxygen
(FIO2) > 0.60
- pH <7.25
- PaCO2 > 50 mmHg (unless chronic and stable)
- Performed by MD, can be performed by RN at bedside during emergency

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Modes of Mechanical Ventilation

- Volume Cycled: delivering a constant volume with each breath (pressure may vary)
- Pressure cycled: delivering constant pressure during each breath (volume delivered may
vary)
- A combination of volume and pressure cycled

Ventilator Associated Pneumonia Bundle

- Ventilator associated pneumonia (VAP) is a lung infection that develops in a person who
is on a ventilator. A ventilator is a machine that is used to help a patient breathe by
giving oxygen through a tube placed in a patient’s mouth or nose, or through a hole in
the front of the neck. infection may occur if germs enter through the tube and get into the
patient’s lungs
- Head of bed 30 to 45 degrees
- Extensive oral care using chlorhexidine
- Daily sedation assessment/sedation holiday: turn off by an hour and see how the pt
respond
- Use of PPI (-zole): prevents migration of bacteria from stomach to lungs common: H.
pylori
- DVT Prophylaxis - low molecular weight heparin
- Oral care: chlorhexidine 3x a day

BASIC ECG ANALYSIS AND INTERPRETATION

IV. ANALYSIS AND MANAGEMENT
- Sinus Rhythm
- Sinus Dysrhythmia

STEPS TO INTERPRET ECG

1. Identify rate:
a. 1,500 method: count number of small boxes between two Rs divide 1,500 over
number of small boxes (most accurate method)
b. 300 method: count number of big boxes in between the rr interval 1 big box - 5
small boxes, big boxes has more darker lines
c. 6 second strip: count 30 big boxes / count qrs x 10
- One small box: .04
- One big box: 0.20
2. Rhythm: identify whether regular or irregular, use caliper
3. P WAVE: Atrial depolarization
4. PR interval: measure from start of P WAVE up to the end of P WAVE
a. Normal: 0.12-0.20 (3-5 small boxes)
5. QRS duration: Ventricular depolarization
a. Normal .04-0.12
b. Below .04 - narrow QRS complex
6. T Wave: Ventricular repolarization

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CARE OF PATIENT IN THE INTENSIVE CARE UNIT

a. Normal: present

COMMON CAUSES:
- Normal response to exercise and condition in which catecholamine release is
physiologically enhanced: flight, fright, anger or stress
- Hyperthyroidism
- Fever

MANAGEMENT:
TREATMENT: depends on heart rate and patient toleration
A. Treat the underlying cause:
a. Antipyretic, fluids, analgesia, anxiolytics

ECG STRIP INTERPRETATION

Rate: 125
Rhythm: regular
P wave: present and upright
PR interval: normal
QRS: .04 normal
T wave: presen
Interpretation: Sinus Tachycardia

Rate: 37-38
Rhythm: regular
P wave:
Pr interval: .16 within normal
QRS: .06 normal
T wave: present
Interpretation: Sinus Bradycardia

CLINICAL SIGNIFICANCE
a. Common in healthy young adults and the elderly, especially during sleeping hours
b. Well conditioned athletes
c. Common in early stage of myocardial infarction

TWO TYPES OF BRADYCARDIA

- Asymptomatic
- Symptomatic - drug of choice: atropine
Management: *symptomatic
Atropine: first line drug acute symptomatic brady 1mg, max 3mg per day
Transcutaneous Pacing: connect pads to defibrillator
Dopamine:
Epinephrine: if not responsive to treatment, and if bradycardia still persists

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CARE OF PATIENT IN THE INTENSIVE CARE UNIT

Sinus Arrhythmia
- There is a cyclic fluctuation in the rate
- HR increases with inspirations and gradually decrease with expirations - rhythm will be
irregular

Clinical significance
a. Considered a normal physiological progress in children and young adults
b. May occur with digitalis toxicity and increased intracranial pressure

SINUS ARREST/ SA BLOCK/ SINUS PAUSE

TREATMENT:
Depends on length of ventricular asystole and patient tolerance

Atrial Dysrhythmia
1. PACs
a. Impulse originates in an ectopic focus in the atria
b. P-waves: upright and one for each WRS but may merge with preceding T-wave
Clinical Significance
a. Occurs in rheumatic heart disease
b. Isolated PACs may occur in apparently normal persons
c. May be caused by hyperirritability of atrial muscle by
i. Anxiety
ii. Caffeine
iii. Diminished myocardial oxygenation
d. Frequent PACs forewarn of, and possibly initiate, other more serious atrial
dysrhythmias such as
i. Atrial tachycardia
ii. Atrial flutter
iii. Atrial fibrillation

2. SVT

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CARE OF PATIENT IN THE INTENSIVE CARE UNIT

- Can be caused by MI, Congestive cardiac failure, hypoxia, or electrolyte

disturbances
- Usually well tolerated and often paroxysmal in nature
- Can sometimes be easily terminated by a vagal maneuver (carotid massage;:
contraindicated to elderly → poor quality of arteries and veins → emboli going to
brain)
- If rate is very rapid and sustained, cardiac output may become compromised and
symptoms will occur
Management
a. If unstable - give medications
b. If stable - vagal maneuvers
- Adenosine (6mg, 12mg)
- beta/calcium channel blockers
c. Correct electrolytes

Vagal Maneuvers: Used to slow fast heart rates

- gagging
- Holding your breath and bearing down (Valsalva Maneuver
- Immersing your face in ice-cold water (driving reflex)
- Coughing
3. Atrial flutter
General information
a. This is an atrial ectopic rhythm. The irritable focus originates in the atrial tissue and
becomes dominant
b. The atrial electrical activity appears as saw-toothed Flutter waves (“F” waves) on the
oscilloscope
c. The ventricular rhythm is regular or irregular. Usually the ventricular rate is 60-100bpm,
depending on how the atrial activity is conducted through the AV junction to the
ventricles

Clinical significance
a. May be paroxysmal or chronic
b. Common in
- Rheumatic Heart disease
- Coronary artery disease
- Hypertensive heart disease
c. Increased ventricular rates cause decreased cardiac output
- Hypotension
- Palpitations
- Chest pain
d. Congestive heart failure
e. Stasis of blood in the atria increases the potential for clot formation, known as mural
thrombi
Management

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CARE OF PATIENT IN THE INTENSIVE CARE UNIT

a. Drug therapy
- Digoxin
- Ca+2 channel blockers, beta blocker
- Amiodarone
- heparin/warfarin
b. Synchronized cardioversion

Atrial fibrillation
General information
a. This is an atrial ectopic rhythm, and can be classified as a supraventricular rhythm.
b. There is no visible P wave. Atrial activity appears as fibrillatory waves (“f” waves) on the
oscilloscope
Clinical significance
A. May be acute or chronic
B. In uncontrolled atrial fibrillation, the cardiac output may drop, causing:
- Hypotension
- Palpitations
- Chest pain
C. Common in
- congestive heart failure
- Coronary artery disease
- Rheumatic heart disease
D. Stasis of blood in the atria increases the potential for clot formation, known as mural thrombi

Ventricular Dysrhythmias
Premature ventricular contraction
- Impulse may originate anywhere in the ventricular tissue. These are ectopic beats
- PVCs may occur alone (isolated) or occur in patterns:
a. Every other beat = bigeminy
b. Every third beat = trigeminy
c. Every fourth beat = quadrigeminy
- The morphology of the QRS complex may be:
a. Uniformed - there is only one irritable area (or focus) in the ventricle
b. Multiformed - there is more than one irritable area (or foci) in the ventricle. The
complexes have different forms
Classic characteristics
1. Occurs prematurely
2. QRS is greater than 0.12 seconds
3. The deflection of the QRS complex is opposite to the deflection of the ST segment and T
WAVE
Clinical significance
a. Common occurs in

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CARE OF PATIENT IN THE INTENSIVE CARE UNIT

- Myocardial infarction
- congestive heart failure
- Electrolyte imbalance
- Acid base imbalance
- Drug toxicity
- Cardiac contusions
b. Frequent PVCs forewarn of, and possibly initiate, other more serious dysrhythmia such
as ventricular tachycardia and ventricular fibrillation
Ventricular Tachycardia
General information
a. Three or more consecutive PVCs is called ventricular tachycardia
b. The ventricular rate is greater than 100 bpm
c. All irritable foci originate in the ventricles
d. Ventricular tachycardia is a life threatening dysrhythmia that requires immediate attention
e. Usually deteriorates to ventricular fibrillation
Clinical significance
a. Common in
- Acute myocardial infarction
- Electrolyte imbalance
- Acid-base imbalance
- Drug toxicity
b. Mechanical irritations of the heart
- Pulmonary artery catheter
- Intra-aortic balloon pump

Ventricular Fibrillation
- Ventricular rhythm rapid and chaotic
- QRS complex wide and irregular, no visible P waves
- The most serious cardiac rhythm disturbance. The lower chambers quiver and the heart
can’t pump any blood, causing cardiac arrest

First Degree AV Block

- Atrial and ventricular rhythms regular
- PR interval >0.20 second
- P wave precedes QRS complex
- QRS complex normal
- Normal P waves are followed by QRS complexes, but the PR interval is longer than
normal

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CARE OF PATIENTS IN THE ONCOLOGY UNIT
Lecturer: Mariano Nicholas Torres, RN, Nurse Manager

Cancer Center:
a. The cancer center provides services that mirror the rapid and dynamic advances in the
field of oncology
b. Fundamental to good cancer care is the adoption of a multidisciplinary approach where
a patient is cared for by a group of cancer specialists
c. The cancer care center is located on the 1st floor Circular Tower 1
d. Operating Hours: Monday-Friday; 8am-4pm

Reception
- This area comprises the Patient Service Representatives who receive our patients for
the treatment at the center. The central sound system which plays the music inside the
center is controlled in this area (for patient relaxation)

Waiting Area
- The patients are seated comfortably in the waiting area while watching patient education
videos of the services being provided by the unit and the Hospital. Here they are fetched
by our sociable Nursing Auxiliaries as they are led inside our infusion rooms.

Screening area
- Patients are screened for signs and symptoms of covid-9 and assessed for clearance
prior to proceeding with treatment.

Conference Room:
- Fundamental to good cancer care is the adoption of a multidisciplinary approach to
cancer treatment. In the conference room, multidisciplinary meetings are conducted to
consolidate a patient’s pre-treatment journey into one cohesive and concise meeting,
- Our video conference setup enables patients and their families from outside the hospital
to engage in a multidisciplinary meeting with our healthcare team. It also enables the
healthcare team to meet and discuss with experts around the world to be updated on the
recent trend in cancer care in the form of a joint teleconference.
- GOAL OF TREATMENT: Curative, preventive, control or palliative?

Consultation Room
- Our team physicians and nurses assess and examine our patients to provide a
comprehensive plan of care in the management of their disease

Pediatric Infusion Room

- The pediatric infusion room consists of 3 cubicles with a crib/ reclining chair, call light,
wall mounted oxygen and compressed air, visitor’s chair, overbed table, TV set,
medication cart, and an IV pole with infusion pump. It houses the pediatric play area

Play Area
- While the patient is waiting to proceed for treatment or during chemotherapy, they play
inside this area to provide them with entertainment amidst the intricacies of the
procedure that serves as a therapy and diversion from treatment.

Adult infusion Room

- The unit consists of 11 cubicles which consists of a reclining chair/ bed, TV set, visitor’s
chair, wall mounted oxygen and compressed air, call light, overbed table, medication
cart, and an IV pole with infusion pump

Satellite Oncology Pharmacy

- A satellite pharmacy dedicated solely to the Oncology Outpatient unit is housed within
the Cancer Center which allows immediate preparation of medication, board-certified
pharmacists who are highly-trained and specialized with chemotherapy medication are

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 assigned to the Oncology Pharmacy to ensure that medications are handled properly
and safely.
- Negative pressure: air is going outside hospital premises (filtered)

Research Room
- Cancer specialists regularly conduct clinical trials to discover new treatments. The
Cancer Care Center Nurse Clinicians are GCP-certified and trained to conduct clinical
trials, in collaboration with the Clinical Trial Coordinators and Cancer Specialist, to
ensure that all procedures are within the study protocol for accurate data collection;
these data are kept in the Research Room

Ambulatory Infusion
- Patients are pre-scheduled
- Nurse patient ratio 1:5

Services offered
1. Multidisciplinary Consultation
2. Chemotherapy/ Biotherapy
3. Blood Transfusion
4. Injection (SC/IM)
5. Peripheral IV Care
6. Other Therapeutic Infusion
7. Clinical Trials
8. Bone Marrow aspiration and biopsy
9. Blood Extraction
10. Vascular Access Device Care
11. Nutritional Counseling

Chemotherapy
- Use of cytotoxic rugs to destroy cancer cells. It can also be used for non-cancer
treatment of autoimmune disease to reduce

Biotherapy
- Targeted therapy
- Immunotherapy
- Enhances body response

Blood transfusion
- Process of receiving blood or its components through the patient’s intravenous
circulation to replace blood lost
- Patient should have blood type and cross matched prior to actual transfusion day (at
least a day before)
- 2 units of packed RBC per day (max 4 hours transfusion)
- During: monitor every 15 minutes for first 1 hour

Multidisciplinary Consultation
- Multidisciplinary conferences bring together a team of specialist physicians in order to
discuss the goals of care and the treatment with the patient and family. Health Service
Program (HSP) patients can avail of this service free of charge.

Bone Marrow Aspiration and Biopsy

- Procedure done to collect a sample of bone and blood in the bone marrow to diagnose a
certain blood disorders
- Patient can be sedated or local anesthesia

Vascular Access Device Care

- Procedure to maintain patency assessment, and dressing of venous access devices
such as implanted ports, tunneled, and non-tunneled catheters.
- Maintain patency

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 - Peripheral IV catheters:
- PVAD: Peripheral Vascular Access Device
- CVAD: Central Vascular Access Device
- IVAD: Implanted Vascular Access Device
- Tunneled Catheter
- Non- Tunneled Catheters
- PICC: Peripherally Inserted Central Catheter (can stay up to 6 months to 1 year,
ua risk for infection and accidental dislodgement)

Elements of a Chemotherapy Order

1. Patient’s Name and Age
2. Height
3. Weight
4. Body Surface Area
5. Dosing Scheme
6. Dose
7. Dosage Form
8. Route
9. Diluent (if applicable)
10. Pre medications (if applicable)
11. Mainline (if applicable)
12. Frequency
13. Duration

Absolute Neutrophil count: checks if patient is eligible for chemotherapy

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MEDICATION PREPARATION
- Complete PPE, double gloving
- Checked by 2RNs (one holding the bottle, one holding the order)

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Care of Patient in Intermediate Care Unit
Lecturer: Lovely Mabugay, RN
- Also known as a high-dependency unit, step-down unit, or progressive care unit.
- Patients usually do not require invasive monitoring but may require frequent VS
monitoring and/or nursing interventions
- It is considered a possible approach to providing higher levels of care while improving
the efficiency of patient flow

ADMISSION CRITERIA
1. Monitoring- every 2 to 3 hours CBG every hour
2. Cardiovascular: antihypertensive agents IV Bolus Stable STEMI
3. Respiratory: PA02 60mmHG or higher suctioning every 2 hours
4. Gastrointestinal: GI bleeding with orthostasis TIPSS
5. Neurological: high aspiration risk alcohol withdrawal, pca and epidural pumps

ROLE OF CHARGE NURSE

- Informs the IMCU officer of admission/ trans in, provides details of patient’s condition,
contraptions, drips

ROLE OF BEDSIDE NURSE

- Assess physical and neurological status of the patient
- Monitors VS and record. Reports to physicians of any deviation from normal VS.
- Suctions secretions via endotracheal tube
- Feeds via nasogastric tube/ gastrostomy tube with strict aspiration precautions

SUCTIONING
- Procedure of aspirating secretions through a catheter connected to a suction machine or
wall suction outlet
MODE FUNCTION

REG Allows degree of vacuum to be adjusted by use of the regulating knob

OFF Vacuum is no longer on or being supplied to patient

FULL Maximum vacuum is administered to patient

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EQUIPMENT:
Suction regulator
Suction liner
Connecting tube
Twin-o-vac (with rubber tubing)- must be cleaned every after shift
Suction catheter- must be disposed every after use
Sterile gloves:
Sterile water: a new bottle of sterile water is used for each suction treatment and is good for 24
hours
Sterile container: a small amount of sterile water must be laced in a small sterile container. Must
be discarded every after treatment

Nasogastric tubes:
- Inserted through one of the nostrils, down the nasopharynx, and into the gI tract
- Size in “French” scale
- Not advisable for patients without gag (risk for accidental placement to the lungs)
- To prevent nausea, vomiting and gastric distention following surgery
- To remove stomach contents for laboratory analysis
- To lavage (Wash) the stomach in cases for poisoning or overdose of medication

Percutaneous Gastrostomy Tubes

- Used for long-term nutritional support, generally more than 6-8 weeks
- inserted/ placed surgically through the abdominal wall into the stomach
- Care of this opening is done aseptically immediately post-surgery

Nursing Consideration for NGT/PEG

- ALWAYS assess the tube placement: radiologic tests (x-ray. Air injection, pH test)
- Secure NGT following the taping and protocol of MMC: routinely clean and replace the
tape if the patient’s skin is only oily or sweaty
- Ensure the PEG site is properly dressed
- Note the length of the tubes using the “point” markers along its length

Feeding Accessories
- Flush with soap and water
- Indicate patients full name and birthday, and date of expiry
- Completely dry the calibrated glass using paper towel, do not let it air dry
- Whe there are visible scratches and damages, replace the glass
- Ensure the tip does not touch any surfaces
- Before hooking to the nGT/PRG clean the tip using an alcohol swab
- Replace everyday (container)
- Always ensure that the feeding accessories have the patient’s identifiers
- Always ensure that the feeding accessories are clean and dry prior to the storage
- If the patient is on contact precaution, separate the storage of the feeding tray from the
others

Parenteral accessories
Microlave, bifuse, trifuse: Nursing considerations
- Bifuse and trifuse will meet and will form a single lume, vannt be used for drugs with
interactions
- Engage the self-kinking devices whenever the port is not in use

Q Syte, Q Syte with Bi-connector, Q Syte with Tri-connector: Nursing considerations

- Bi- and Tri-connectors will meet and will form a single umen, cannot be used for drugs
with interactions
- Engage the self-kinking devices whenever the port is not in use

Disinfecting cap: Nursing Considerations:

- Covers the luer-lock port of the IV tubing
- Use a new cap every time the previous one has been removed

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 - Eliminates the need to disinfect the IV part

Regular IV Set (Macro or Micro) Volumetric Chamber Set: Nursing Considerations

- Ensure that the tubing have "set due change sticker on them
- Replace every 96 hours (or earlier, if damaged during patient use)
- For the volumetric chamber set, ensure that the chamber has the full patient identifier

General Nursing Considerations for Parenteral Accessories

All accessories are to be replaced at the same time every 96 hours
- Maintain closed system at all te
- Avoid using needleless connectors when infusing blood and blood products
- When disinfecting cap is not in use, clean the luer-lock port using alcohol swab for 15
seconds

Transfer Criteria:
1. Condition has improved
2. Status deterioration
3. Requires isolation transfer

Transferring to Inpatient Floors

Patient Movement
- Transfer is final upon approval of the primary attending physician.
- IMCU Officers and RNs hand off the patient to the resident and CN on duty of the
receiving unit.
- Informs all attending physician/s, Dietary, Laboratory, Inpatient Pharmacy, and
Admissions Office about the patient's transfer.

Accommodation
- Notifies the patient's family and asks about the preferred room accommodation.
- Credit, Billing, and Collections Department will tag patients with potential financial
limitations and difficulties
- Notifies the Admissions Office when a patient may transfer out of the unit.
- Using the Dashboard program, the Nurse administrative assistant tags the room as "
Transferred Out”.

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CARING OF PATIENT UNDERGOING HEMODIALYSIS
Lecturers: Mary Jane O. Rodriquez, RN and Pristine Abbylaine Salvador RN, (Nurse
Managers)

Bed Capacity

Types of Bed Capacity

Regular Bed 32

Private Bed 16

Isolation Bed 1

Schedule

Shift Target start time Target end time Average # of patients

1st 0600H-0700H 1000-1100H 20-25

2nd 1100H-1200H 1500H-1600H 30-35

3rd 1600H-1700H 2000H-2100H 15-20

Services Offered
1. Hemodialysis
2. Peritoneal Dialysis
3. Hemo-dilution
4. Hemo-perfusion
5. Sustained Low-Efficiency Dialysis (SLED)
6. Continuous Renal Replacement therapy (CRRT) - ICU unit

Dialysis: The procedure used to correct fluid and electrolyte imbalances and to remove waste
products in renal failure.
Hemodialysis (HD): Hemo simply means blood. Dialysis means "tO pass through. It removes
nitrogenous waste products, excess fluid and electrolytes from the blood by means of artificial
Kidney.

COVID-19 GUIDELINES:
- No face mask no entry
- One companion only
- Physical distancing
- Temperature check
- Health screening
- No eating

Types of Access: AV, Fistula, AV Graft, Dialysis Catheter

Arteriovenous Fistula
- Permanent access, created surgically by joining an artery to a vein
- It takes 4-6 weeks to mature before it is ready for use
- Patient is encourage to perform exercise to increase the sxe of the vessels
- Arterial segment for arterial flow
- Venous segment for reinfusion of the dialyzed blood

ARTERIOVENOUS GRAFT: can be created by subcutaneously inserting a biologic, semi

biologic, or synthetic graft material between an artery and vein.
- Indicated for patients with very small vein
HEMODIALYSIS CATHETER

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 1. INTRA-JUGULAR CATHETER: emergency or stat, lower risk of complication, easier
ture
2. FEMORAL CATHETER: greater risk of infection

CONDUCTION OF ACCESS
1. Hematoma
2. Redness
3. Swelling
4. Pus
5. Aneurysm

PRINCIPLES OF DIALYSIS
1. Diffusion: Movement of solutes from an area of great concentration to lower
concentration
2. Osmosis: Spontaneous net movement of solvent molecules through selectively
permeable membrane into a region of a higher solute concentration, in the direction that
tends to equalize the solute concentration on the two sides
3. Ultrafiltration: Water moving from high pressure to an area of lower pressure. This
process is much more efficient at water removal than osmosis

Before the patient enters the treatment area:

1. Patient assessment (Screening for COVID)
2. Cleared for covid → Weigh the patient
3. Treatment area

Assessment (build rapport) → listen to lung sounds → check condition of access → signs of
edema (lower extremities) → set up the device

COMPLICATIONS
1. Hypotension
a. Removing large volume of fluid → dec blood volume → low BP
b. Intervention: trendelenburg position (raising of lower extremities) Rationale:
backflow circulation, blood to concentrate on heart
c. If not corrected even after meds, temporarily stop the dialysis
2. Muscle cramps
a. Rapid removal of water, electrolyte disturbances, shift in electrolytes, not
common
b. Intervention: Muscle stretching, placing feet on the opposite direction
3. Clot formation - common complication because blood is outside
a. Temporarily stop the ongoing dialysis
4. Disequilibrium syndrome - naninibago si body sa sudden change ng blood/ electrolyte
levels
a. Rapid shift of water
b. S/SX: N/v, headache, restlessness
5. Hypoglycemia- due to poor nutrition, and decrease glucose clearance
a. The solution used in dialysis is low in glucose content
b. Intervention : Orange juice, hard candy (15 minute rule) worst condition: D50
water
6. Hypertension
a. Sodium retention: water retains → inc BP
b. Function of Kidney: Regulation of BP/ RAAS (disrupted due to kidney disease)
7. Stroke during dialysis
8. During chills: check temp (febrile/afebrile)
a. Could mean: Access site might be infected, water, or febrile
b. Reverse Osmosis (RO): product water and reject water

WHAT TO REMEMBER:
● Dialysis for 4 hours
● Right hand - if left hand dominant and vice versa

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 ● AV graft - opposite (less than 5 mins pressure application)
● AV fistula (Assess access first) - same side (5-10 mins apply pressure)
● Palpate (thrill) and auscultation (bruit)
● Lidocaine - Intradermal, so no pain will be felt by patient
● Backflow in the syringe- means inside the artery
● Artery - blood going away
● Blue- venous line (upper spart)
● Red-arterial (nasa baba)
● Green- pressure of dialyser
● Artificial kidney: dialyzer
● Stethoscope: assess bruit
● DIALYZER IS BEING USED FOR 10X
● SINGLE used dialyzer offer better clearance (better health outcomes)
● Bloodline is single used
● Gauge 16 large bore needle
● 1kg overweight or underweight after the procedure: refer to MD

ACCESS CARE
1. Always assess patient access before and after each treatment: check if they can fill the
thrill → if none, indicates problem
2. Keep access clean at all time: at risk for infection
3. Check for the arm precaution: assess wrist band, to know if left or right arm precaution

HEALTH EDUCATION: Access care food and water intake

Hemodialysis diet General hemodialysis

- Designed to reduce the amount of Diet prescription
fluid and waste that builds up in ● 1.2 grams protein/kg/day
between hemodialysis treatment ● 2 grams sodium
● 2 grams potassium
● 800 mg phosphorus

Types of protein

Animal Protein Plant protein

- Has all the essential amino - Lacking in one or two essential amino acids;
acids; - Incomplete protein
- A complete protein - Low-biological protein
- High-biological values (ability of - Sources are legumes (peas, green beans),
food to be absorbed quickly, the grains, nuts, seeds soya products
higher the value the better: - Combine different plant proteins to make it
EGG highest, sweet potato complete; baked beans with bread, milk on
lowest) cereal
- Sources are meat, poultry, fish, - Much healthier than animal ones
milk, eggs, and cheese

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 Sodium Potassium
- Main function is to balance the - Is an essential mineral and electrolyte
amount and distribution of water in our it is involved in heart muscle
bodies, playing a key role in the contractions, heart function, and
control of our blood pressure regulating water balance.
- Most people consume about 3,400 - 1 cup spinach - 840 mg
milligrams of sodium a day - 1 small banana 350 mg
- Experts recommend that people - 1 cup tomato 430 mg
consume less than 2,300 mg sodium - 1 cup milk 380 mg
per day. This is equal to a teaspoon of - 1 medium kamote ba to 695 mg
salt. - 1 cup yogurt 579 mg
- “Eat less than 1500 mg/day sodium as
part of the definition of ideal Potassium chloride
cardiovascular health” (AHA 2010) - Used to reduce sodium in food
- Main ingredient of mast salt
Read food labels substitutes
Use the 5-20 rule: - Salt-substitutes with potassium
- 5% daily value (120mg) of sodium or - Low potassium salt substitutes
less per serving is a low salt choice - Spice it up! (marjoram, tarragon,
- 20% daily value (480 mg) of sodium oregano, thyme, rosemary, garlic)
or more per serving is a high salt
choice
- Banana - 2mg sodium
- Fast Food breakfast sandwich - 1,360
mg sodium!
- The more processed, the higher the
sodium

Phosphorus TYPES OF PHOSPHORUS

- Is a mineral present in every cell of 1. Organic
your body a. Meat, dairy products, nuts,
- Is in your bones and tissues seeds, etc
- Keeps the bones strong and healthy b. 40-60% absorption
- Helps make energy and helps move 2. Inorganic
muscles a. Used mainly as a preservative
in most processed foods
High phosphorus foods b. 90% absorption
- All dairy products
- Dried beans and lentils
- Processed meat
- Chocolate
- Cola, Dr. pepper and beer
- Muffins, biscuits or pancakes from mix
- Liver or organ meats
- Nuts and seeds

Fluid limit
- Anything that turns liquid in room temperature
- Ex. water, soup, ice, gelatin, juice, ice cream

ENTERAL NUTRITION( EN) using oRAL NUTRITION SUPPLEMENTS (ONS) andTUBE

FEEDING (TF) offers possibility of increasing or ensuring nutrient intake when normal food
intake is inadequate

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