Nursing and Patient Care Services

2019 Annual
Learning Check
 Module 1:
International Patient
Safety Goals (IPSG)
 1 Identify Patients
Correctly

6 Reduce the 2 Improve

Risk of Patient
Effective
Harm resulting
Communication
from Fall
IPSG

5 Reduced the 3 Improve the

Risk of Health Safety of High Alert
Care-Associated Medications
Infection

4 Ensure Safe
Surgery
 International Patient Safety Goals

A patient Is Patient Identifiers at

identified by Makati Medical Center
2 Identifiers :

Patient’s Hospital
Full Name Birthdate Number
 International Patient Safety Goals

Different Hospital Bands

WHITE RED Yellow Green

In or out patient Allergies Risk for Fall Parents/
Guardian

BLUE PINK
Baby Boy Baby Girl
International Patient Safety Goals

Specimen Critical Test Medication

Diet or Snacks
Collection communication Management

Diagnostic or Surgical
Telephone Orders Documentation
Treatment Procedure
International Patient Safety Goals

Admission’s office,
Newborn Services, or the
For Patient ID Band
respective out-patient
Units

For patient with

more than one Medical Records
patient ID number
 International Patient Safety Goals
Improve Effective Communication

Verbal and Telephone Orders

Verbal Telephone
Physician Physically present Physician is in another location

Must be signed by the Physician consultant/ fellow within 48 hours

WHAT? WHO? WHEN NOT ALLOWED?

▪Read back & Verify ▪ Physician ▪ Non-formulary

▪Records directly to Consultant Drugs
medical chart ▪ Fellow can give ▪Chemotherapeutic
▪Pronounce numerical telephone in urgent agents
digits separately cases ▪ Voice mail relay of
▪Medication order: ▪ Fellow/ resident is test results
physician must spell it allowed ONLY for
out emergency situation
 International Patient Safety Goals
Improve Effective Communication

Critical Test
Urgent test whose results are determined an as
critical to the patient’s subsequent treatment
decisions.
Requirements in Receiving Critical Test Results
Validates Correct Patient Document accurately
Read Back and Verify
using 2 Identifiers including Date & Time

When Do you Relay Critical Results?

Within 15 minutes (for life threatening) upon
availability or completion of diagnostic test
For non-life threatening result, relay within the shift.
International Patient Safety Goals
Improve Effective Communication

Critical Test
How is Critical Test Result relayed?

Resident-on- Ordering
1 Med Tech duty Physician

Laboratory Resident- Ordering

2 Test Print Out Nurse
on-duty Physician
 International Patient Safety Goals
Improve Effective Communication

Handover Communication
Minimum data must be
I • Introduce Self communicated during hand-off

S • Situation Patient Two Identifier

Diagnoses and Current condition of

B • Background the patient

Recent changes in condition or

A • Assessment Treatment

What to Watch for in the next interval

R • Recommendation of care
 International Patient Safety Goals
Improve Effective Communication

Handover Communication
When Does Handover of Patient Care occurs?
Nurse Change-of-Shift or RN to Physician and Vice
Temporary Assignment Versa
Between Different Levels of In-patient to Diagnostic or
Care Treatment Units

During Patient Transfer

Person to Person Communication is preferred but if not possible

hand
over via phone call is acceptable
 International Patient Safety Goals
Improve Safety of HAM

High Alert Medications – “HAM”

Are drugs that pose a heightened risk of causing significant
patient harm when they are used in error.

HIGH ALERT MEDICATION

Double Check Drug and
Strength

HIGH ALERT LABELS

International Patient Safety Goals
Improve Safety of HAM

How are HAM Stored ?

With HAM stickers and stored separately from other
1 medications
Neuromuscular
Insulin Heparin Narcotics
Blockers

2 Concentrated Electrolytes are controlled

TSMC approved its presence on

KCL is removed in regular units selected units

3 High Alert Sticker must be placed on all medications

 International Patient Safety Goals
Improve Safety of HAM

How are HAM Administered

1 Validated by most senior (experienced) RN prior

administration – 2 RN check done at bedside

2 Infusion Pumps are use for HAM on Intravenous

route
Independent check of infusion pump settings and
3 concentration – before start of infusion, every bag change and
every setting change (2 RN check)
 International Patient Safety Goals
Ensure Safe Surgery

How do we Ensure IPSG 4?

Repeated Check and Validation using a SURGICAL SAFETY CHECKLIST

WHEN Applicable ?
Prior to any surgical and invasive
procedures are performed in:

Operating Room Delivery Room Endoscopy

Cardiac
Other procedural
Radiology Catheterization
unit
Lab
Bedside procedure : Tracheostomy, Bone Marrow Aspiration,
Paracentesis,, Thoracentesis, Lumbar Puncture
 International Patient Safety Goals
Ensure Safe Surgery

Element and Phases of the Surgical Safety Checklist

During or immediately
Before Surgical after the wound
Before Induction
Incision closure BUT before
of Anesthesia
removing the patient
from OR/DR theatre

Sign In Time Out Sign Out

 International Patient Safety Goals
Ensure Safe Surgery

Surgical Markings

WHEN? Prior HOW? Surgeon’s

Procedure Initial
Right or Left Distinction
Multiple Structure or Levels

WHO? Performing WHAT? Site

or assisting Marking Form is
physician constantly use
 International Patient Safety Goals
Ensure Safe Surgery

When is Site Surgical Marking Not Required?

Single Organ Cases

Interventional Cases
Procedure performed on
natural body orifice without
laterality

Premature infant
 International Patient Safety Goals
Reduced the Risk of Healthcare-associated Infection

Hand Hygiene
Makati Medical Center personnel follow the WHO guidelines on hand hygiene in healthcare
International Patient Safety Goals
Reduced the Risk of Healthcare-associated Infection

5 Moments of Hand Hygiene

International Patient Safety Goals
Reduced the Risk of Healthcare-associated Infection

Personal Protective Equipment (PPE)

Donning Removing
Boots / Shoe cover Gloves

Gown Cap & Face Shield

Gown & Boots/ Shoe

Mask, Cap & face shield
cover

Gloves Mask
 International Patient Safety Goals
Reduce the Risk of Patient Harm
resulting from Fall

When do you do Fall Risk Assessment?

After a change in
On admission to
During Transfer Patient’s Medical
the Facility
Status

On regular interval
After a Fall depending on fall
Risk
 International Patient Safety Goals
Reduce the Risk of Patient Harm
resulting from Fall

What are the ways to help prevent and manage fall?

Determine Fall Risk using “Fall Risk Assessment Form”

Frequency of Fall
Fall Risk Score
Assessment

Adult| 0-6
Low Risk Pedia| 7-11
Every 4 hours

Adult| 7-19
High Risk Pedia| 12 and Every 2 hours
above
 International Patient Safety Goals
Reduce the Risk of Patient Harm
resulting from Fall

What are the ways to help prevent and manage fall?

Communication of Level of Risk

Physicians

Nurses

Patient and Family

Other members of
Healthcare
 International Patient Safety Goals
Reduce the Risk of Patient Harm
resulting from Fall

What are the ways to help prevent and manage fall?

Risk Reduction Measures

ADULT
Low Fall Safety Risk
Measures Pediatrics
High Fall Safety Risk
Measures
Obstetrics
Reference: Fall and Injury Prevention Management
NS-DPP-PSG-003
 International Patient Safety Goals
Reduce the Risk of Patient Harm
resulting from Fall

What are the ways to help prevent and manage fall?

Consistent Rounding and Effective Education

Fall Tool and Resources

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

Ensure that every Prevent fall Outline

hospital personnel who Prevent HAPI recommendations for
enter the patient room Improve pain nursing management of
assesses environment management patient who fell
safety at every patient Address healthcare
encounter needs
 International Patient Safety Goals
Reduce the Risk of Patient Harm
resulting from Fall

What are the ways to help prevent and manage fall?

Post Fall Management Protocol

Render Care and Communication
Assess the Notify the CN
intervention as and education Post Fall Huddle
patient and Physician
ordered to patient

After a fall, post-fall protocol assessment is implemented and any immediate

measure to protect the patient

NOTE: For incidences of Head Trauma – RN must monitor

Neurologic Vital Signs every 15 minutes for the first hour. If
stable, every hour until evaluated by the Physician
 Module 3:
Fall, Pressure Injury &
Pain Management (FPP)
 Fall Prevention and Management

Dx
Predisposing Factors LOC

Fall
Medication
Environment
Fall Prevention and Management
Process Flow
Patient Admitted to
Makati Medical Center

Fall Risk Assessment

1. MMC Fall Injury Risk Assessment Tool for Adult Patients
2. Humpty Dumpty Scale Fall Assessment Tool for Pediatric
Patients

Presence
of Fall Risk
Factors

Low Risk for Fall Injury High Risk for Fall Injury
Implement Universal Fall Implement Universal Fall Precautions
Precaution PLUS High Risk Preventive Measures
 Fall Prevention and Management
High Risk for Fall
All patients in:
▪ Operating Room ▪ ED Acute Critical and Medical
o Preoperative, Intraoperative and
Postoperative (PACU) ▪ Neuropsychiatry
▪ Kidney Unit ▪ Maternity Units with
▪ Endoscopy roomed-in infants
▪ Operating Room ▪ All patients 24 hours post-
▪ Delivery Room operative
▪ Critical Care Units (MICU, Cardiac ▪ All post-sedation are
Cathlab, Neuro ICU, CV ICU) considered as High Risk for
▪ Oncology Fall

Nurse in charge shall utilize fall care plan for all high risk for fall patients
 Fall Prevention and Management
Alert Wrist Band
• High Risk for fall patients shall have a “Fall
Risk” yellow alert wrist band in the same arm as
the patient identification band.
• All neonates shall have the “Fall Risk” yellow
wrist band to lower extremity (foot) opposite to
the patient identifier.
 Fall Prevention and Management
Risk Reduction Measures
Adult Pediatric

• Assessment: • Assessment:
• Fall Injury Risk • Humpty Dumpty Scale
Assessment Tool Falls Assessment Tool
• Intervention (Care • Intervention (Care
Plan): Plan):
• Low Risk • Low Risk
• High Risk • High Risk
 Fall Prevention and Management
POST FALL MANAGEMENT
• Notify Physician / Charge Nurse / Nurse
Manager / Clinical Nursing Director and the
Vice-President of Nursing & Patient Care
Services
• Accomplish Post Fall Huddle Tool
• For Head Trauma
The RN will document a neurological assessment every 15 minutes for
1st hour post fall on Neurological Assessment Form
If the patient remains stable a neurological assessment is documented
every hour until evaluated by the Physician
 Pressure Injury
A localized injury over a bony prominence that results in pressure or pressure in
combination with shear

Contributory Factors • chronic/acute illness

• sensory impairment
• level of consciousness
• age (up to 65 and less than 5)
• Medications
• malnutrition
Intrinsic • dehydration/fluid status
• immobility
• incontinence
• skin condition/ageing skin/history
of pressure ulcer
• weight

• Pressure
• Shear
Extrinsic • Friction
• Moisture
 Pressure Injury Staging
If Pressure Ulcers were apples
 Pressure Injury Staging
If Pressure Ulcers were apples
 Pressure Injury Staging
If Pressure Ulcers were apples
 Pressure Injury Staging
If Pressure Ulcers were apples
 Pressure Injury Staging
If Pressure Ulcers were apples
 Pressure Injury Staging
If Pressure Ulcers were apples
Pressure Injury Process Flow
Patient
Admitted

Risk assessment and

skin inspection

Prevention and Interventions /

Education Management

Re-assessment
 Pressure Injury Assessment Tool

Braden Scale Risk Braden – Q Scale

Assessment Tool Assessment Tool
{above 8 years old} {above 7 years old}

Neonatal- Infant
Braden Scale
Measurement Tool
{9 months and
below}
 Pain Definition and Classification
The International Association for the study of pain
defines pain in the following way:
• Pain is “an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage.”
Classification of Pain
Duration Cause Mechanism
▪ Acute (Less than 3 • Cancer ▪ Nociceptive
months) • Non-Cancer ▪ Neuropathic
• Chronic ( More
than 3 months)
• Acute pain on
Chronic Pain
 Nociceptive vs. Neuropathic
Nociceptive Neuropathic
▪ Most common after an • Damage or abnormal
injury function of the nervous
▪ Sometimes called system
“Physiological Pain” • Sometimes called
▪ Stimulation of pain “Pathological Pain”
receptors in the injured • Tissue injury may not be
tissues obvious
▪ Pain is localized (Sharp, • Not well localized
throbbing or aching) (Shooting, burning,
numbness, pins and
needles)
 Approach to Pain Management

RAT Approach
▪ R= Recognize
▪ A= Assess
▪ T= Treat Adopted from the
Pain Society of the Philippines, Faculty
of Pain Medicine, Australian and New
Zealand College of Anesthetics
Pain Degrees and Intensity Scales
 Pain Re-assessment
Parameter Time of Re-assessment
(Pharmacologic Intervention)
Regular Pain Assessment Every 4-hours

IV (Intravenous) Analgesics Within 15 minutes after

administration

Oral Analgesics Within 60 minutes after

administration
 Start
Pain Management
Patient enters Makati
Algorithm
Medical Center

A
Patient undergoes Pain
Screening
Activate Adult/Pediatric
Monitor for Care Plan
With
NO presence of pain
Pain? every shift
Reassess Patient
YES

Use Comprehensive Document Reassessment

Pain Assessment Form

END

A
 Module 4:
Quality and Patient Safety
▪ Review of Quality Principles
▪ Prevention of Hospital Acquired
Infections (HAIs)
▪ Medication Management and
Prevention of Errors
▪ Effective Specimen Handling
Review of Quality Principles
Quality
“..is a way of thinking about work,
how you approach work every day
for yourself personally, for those
you work with and ultimately and
for those who depend on you for
delivering quality service
(Robert Lloyd, IHI 2016 )

Patient Safety
The absence of preventable
harm to a patient during the
process of health care.
(WHO, 2017)
 It is necessary for an
organization’s survival
Because of the 4 C’s

Customer

Cost

Competition

Crisis
Promoting safe and
effective practices

1
Shared
Governance –
Speak-up
campaign
Nursing Care Delivery Model

High Quality Care for

Every Patient.
Every Time.
Promoting safe and effective practices

Quality goal of the hospital is a shared

2 responsibility

“it is not simply nursing’s work or quality’s

work; it is the work of the whole organization.”
 Best Practices in Nursing Practice

3 Purposeful Clinical Rounding

Improve the patient experience through the use of a structured

hourly rounding routine.

“ Just 5 minutes”
 Best Practices in Nursing Practice
Work with physician and other allied health
4 professionals

Nurse-Physician Collaboration and Partnership

 Best Practices in Nursing Practice

Providing ongoing, visible and useful

5 feedback to engage staff effectively

Periodic scorecard and quality boards

Huddle messages and quality campaigns
Focus group discussions and staff training
 Sustaining Culture of Safety

Implement a system where front-line nurses’ concerns and

1 ideas are heard and reflected in improvement strategies

Support nurses to collaboratively work in a team as a

2 change agent.

3 Implement a ‘just culture’

 Hospital Acquired Infections
Different Types:
An infection caught while
hospitalized. This is also Ventilator Associated
called nosocomial Pneumonia (VAP)
infections that are caused
by bacteria.

Remember: Since Catheter-Associated Urinary

antibiotics are frequently Tract Infection (CAUTI)
used within hospitals, the
types of bacteria and their
resistance to antibiotics is Central Line-Associated
different than bacteria
Bloodstream Infection (CLABSI)
outside of the hospital.

ALERT!
Nosocomial infections can
Surgical Site Infection (SSI)
be serious and difficult to
treat.
INFECTION PREVENTION CARE BUNDLE
Ventilator-Associated Pneumonia ( VAP )

Assess Extubation
Readiness Daily

Keep Head
Avoid Equipment
Elevated at 30 – 45
Contamination
degrees

Perform Oral Care

Regularly
 INFECTION PREVENTION CARE BUNDLE
Central Line Associated Bloodstream Infection (CLABSI)

Maximal Daily review

Hand hygiene barrier includes:
precautions ▪ Prompt
removal of
unnecessary
Daily review lines
Chlorhexidine
of line skin antisepsis ▪ Line secure
necessity
and dressing
Optimal clean/ intact
Catheter
site
Selection
 INFECTION PREVENTION CARE BUNDLE
Catheter-Associated Urinary Tract Infection (CAUTI)

Use a small
bore Cather indication
Catheter as ▪ Urinary
Possible Obstruction and
Retention
Insert ▪ Urine Output and
Observe Monitoring
CAUTI catheter
standard prevention ONLY when ▪ Peri-operative Use
precaution
indicated ▪ Assistance in
pressure injury
healing
Obtain
specimen
aseptically
 INFECTION PREVENTION CARE BUNDLE
Surgical Site Infection (SSI)

Give
Maintain Post- Prophylactic
Use Surgical Control of
operative Antibiotics
Clippers Blood Glucose
Normothermia within 1 hour
before surgery
 Care and handling Specimen
RN must incorporate specimen management needs
when developing plan of care.
▪ Specimens must be collected and handled in a manner
that protects and preserves the integrity of the
specimen.
▪ Containment and transport of the specimen must be
completed in a manner that protects and secures the
specimen and prevents exposure of health care
personnel to blood, body fluids, or other potentially
infectious materials.
NOTE: Maintains the confidentiality and protect
patient information.
 Care and handling Specimen
• Nurses must wear the proper PPE when handling
formalin
NOTE: The PPE must be worn when pouring formalin into
containers or when the risk of exposure exists.
▪The face shields must not be substituted for eye
protection; both should be worn.
• The RN must thoroughly wash his/her hands and
forearms after handling formalin.
Medication Management and Prevention of Errors
Appropriateness Review
▪ All medication orders shall be maintained in the patient’s medical record.
▪ A pharmacist reviews and assesses all medication orders before
dispensing except:
1. during emergencies
2. when the ordering physician is present for ordering,
administering and monitoring of the patient ( for example in the
operating theatre or the emergency department)
3. with oral, rectal or injectable contrast in interventional radiology or
diagnostic imaging where the medication is part of the procedure,
and
4. for specific treatment circumstances where established
procedures exist for the use of an approved list of medications.
▪ For floorstok medications, critical drug appropriateness review is done by
the nurse in conjunction with the review prior to administration (first
dose verification) when the same individual will administer the medication.
▪ In such cases, the clinical pharmacists conduct drug appropriateness review
within 24 hours.
Safe Administration of Medication
▪ First dose verification at the time of
administration is done by the nurse to check that the
medication is exactly as ordered or prescribed.

▪ Two- RN check
Before the start of preparation, infusion and before
administration of the medication, blood and blood
products, factor concentrates and blood derivatives.
 Prevention of Medication Error
REMEMBER:
• Antibiotic Stewardship Program of Makati Med
• Clarify with immediate superior or clinical pharmacist
when you are unsure about any medication order
• Do not accept verbal orders except in emergency
• Medication brought from home by patients must be
reviewed
• Report any serious adverse reactions experienced by
patients especially new added medications
• Keep all medication storage areas under lock and key
• Check temperature of drug refrigerator
• Do not accept any drug samples from drug
representatives
 Module 5:
Nurses Responsibility
in Clinical Emergencies
Out of Hospital In-Hospital
 Medicine Rapid Response Team
• Refers to the medical group that responds to call
when the bedside nurse activates the rapid
response protocol
• Established to provide intervention for patients
with clinical deterioration with the goal of
preventing in-hospital cardiac arrest
• The team is composed of the 1st year, 2nd year
and 3rd year medical residents.
 Background

On August 21, 2015, the

Resuscitative Services Program was released to
ensure that the basic life support is
implemented immediately upon recognition of
cardiac or respiratory arrest
and advanced life support
is initiated less than 5 minutes.

This includes the Maxicart and Pediacart drill.

 Policy

All in-patients who manifest any of the

specified warning signs are recognized and
immediate appropriate intervention must be
provided through an efficient referral system
to prevent worsening of the patient’s
condition and prevent cardiopulmonary
arrest.
 Warning Signs

These are signs which will

prompt the bedside nurse to
activate the rapid response
protocol
 Sudden increase in Systolic
Blood Pressure (SBP) to more
than 170mmHg / Diastolic
Blood Pressure (DBP) more
than 130mmHg

Sudden Drop in Systolic Blood

Pressure (SBP) by more than
30mmHg from baseline
 Heart rate
<40,
>120 per minute from
a normal cardiac rate
(CR) of 60-100bpm

Chest pain
Respiratory rate <10,
>30 per minute

O2 Saturation
decreased 90%
despite supplements
Urine output of <50ml in 4
hours
Altered
Mental
Status
Seizure
 RRP Team Composition
Team Member Responsibilities
CCU RN Administration of Emergency Drugs
and Medications ordered by the
medicine team during the incident
Bedside RN or Medicine Transcription
Charge Nurse
Senior Medicine Team Leader
Resident Confers treatment plan with the
attending physician
Five (5) Types of Rapid
Response Protocol:
Medicine – General Adult
Pedia – General Pediatric
Trauma – for surgery and
emergency/accidents
Neuro – for strokes/neuro
affectations
 Warning signs must be
verified by the Charge
Nurse / Nurse Manager
prior to activation of the
protocol.
1000
 Process
Process Flow
Flow
Adult

Pedia
Adult

Pedia
 Maxicart

An urgent emergency response

procedure for unexpected or expected
cardio-pulmonary arrest of an adult
patient.
An urgent call for assistance for
cardiopulmonary resuscitation.
 CPR

Cardiopulmonary Resuscitation

Procedure to restore circulation, airway

and breathing of a patient in cardiac or
pulmonary arrest
 Policy
Maxicart is called when an adult patient is in
unexpected cardiorespiratory arrest provided
there is no “Do Not Resuscitate” (DNR)
physician order or signed document by patient
or his/her relatives.
In all areas of the hospital, basic life support is
implemented IMMEDIATELY upon recognition
of cardiac or respiratory arrest and advanced
life support is implemented in LESS THAN 5
MINUTES.
 Maxicart Team Composition
Team Member Responsibilities
Team Leader • Assigns roles to team members
• In-charge of overall medical
management of resuscitation,
diagnostic and therapeutic
decision-making
• Determines the number of staff
needed while other personnel will
stay at the vicinity as requested
Compressor • Perform cardiac compressions
 Maxicart Team Composition
Team Member Responsibilities
Airway • Obtains and maintains airway with
continuous ventilation
• For intubation (as needed)
Defibrillator • Operates AED/Defibrillator
• Monitors vital signs
Code Recorder • Records time of interventions and
medications
Medication • Assigned for IV/IO Access and Drug
Administration
• Prepares all emergency medications
 Maxicart Team Composition
Team Member Responsibilities
Primary Nurse • Assists physician by providing all the
supplies/materials needed and
confirms drug administration
Crowd Control • Manages crowd and ensures safety
and security of patient and
healthcare workers
 Rapid
Maxicart
Response
For deteriorating For pulseless or
patients unconscious patients
To prevent To return
cardiopulmonary spontaneous
arrest circulation
 Opening the Airway
Head Tilt, Chin Jaw Thrust
If with suspected neck or spine
Lift injury
 Avoid Hyperventilation
During respiratory arrest, the ACLS provider should
avoid hyperventilating the patient.

For patients with a perfusing

rhythm, deliver 1 breath every
5 to 6 seconds
 Use of Bag Valve Mask
The entire lower lips MUST be inside the mask. Not
only will you not get a seal if the lip is outside, you
risk injuring the mucosa.
Finger Positions Are Key:
Thumb and Index finger form a “C”, the other three
will form an “E”
 Pulseless Rhythms

PEA- Pulseless Electrical

Activity
Symptomatic/ Asymptomatic
Bradycardia?

Idioventricular Rhythm

Junctional Rhythm
 V-Tach With
Pulse

SVT With Pulse

A-Flutter HR>100

A-Fib in RVR
 Atropine Sulfate
INDICATION: Drug of choice for Symptomatic
Bradycardia

DOSAGE: 0.5 mg IV every 3-5 minutes

Maximum Dose of 3mg
 Epinephrine
INDICATION: Asystole
Pulseless Ventricular Tachycardia
Ventricular Fibrillation
Pulseless Electrical Activity
DOSAGE: CARDIAC ARREST
• 1 mg IV every 3-5 minutes (AHA guidelines)

RESPIRATORY DISTRESS/ ANAPHYLAXIS

• 0.3-0.5 mg (0.3-0.5 mL of 1:1,000 solution) IM or
SC every 15-20 minutes to 4 hours

SHOCK
• 2-10 mcg/minute by continuous IV infusion.
 Dopamine
INDICATION: Cardiogenic and septic shock
Low doses may be useful in patients
with low C.O or renal impairment.
Higher doses are used for inotropic
support to increase HR and CO of
patients in cardiogenic shock or severe
cardiac failure
DOSAGE: Renal Perfusion: 1-3mcg/kg/min
 Adenosine
INDICATION: Narrow Complex Tachycardia

DOSAGE: • 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.
• The second 12 mg dose may be
repeated once if needed (maximum
30 mg dose).
 Amiodarone
• Used to treat atrial and ventricular dysrhythmias
INDICATION: • Refractory Ventricular Tachycardia
• Wide Complex Tachycardia (With Pulse)
• Pulseless Ventricular Fibrillation
• Pulseless Ventricular Tachycardia

VF/Pulseless VT:
DOSAGE: • 300mg IVP over 30 sec
• May repeat once at 150mg in 3-5 min
• Max. cumulative dose: 2.2g IV/24hrs
V-Tach with pulse
• 150mg in100cc D5W /over 10 min, may repeat if
necessary
Maintenance infusion:
• Initially 1mg/min X 6 hours, then 0.5mg/min x 18
hours
 Defibrillation

The process of delivering shock

to correct life-threatening
arrhythmias of the heart.
Monophasic: Biphasic:
360J Initial – 120J-200J
Subsequent –
Higher
 Post-Arrest Care

Therapeutic
Hypothermia
34⁰C – 36⁰C
Post-Arrest Care
Post-Arrest Care
Post-Arrest Care
 Module 6:
Restraint Care
Management
Restraint
Any manual/physical method that may use mechanical
device (material or equipment) attached or adjacent to
the patient who may immobilize or reduces the ability
of a patient to move his/her body parts freely.

*Maximum observation - is ordered for any

patient whose condition presents a potentially imminent
an severe risk of harm to self or others. One staff member
is assigned to observe one patient.

*Maintaining the patient’s rights, dignity and well-being

are a primary consideration when restraints are used.
 Type of Restraints

Two-point
Full/four side
Mittens extremity
rails Up
restraints

Four-point Five-point
Manual
extremity extremity
restraint
restraints restraint
• All type of restraints needs physician’s evaluation and order
prior to application & discontinuation
 Principles in Restraint Management
▪ A physician order is required
▪ Restraints will NOT be employed as punishment, for the
convenience of staff or as a substitute for treatment
programs.
▪ The use of a restraint is limited to emergencies
• Imminent risk of a patient physically harming him/her self,
staff or others
• Less restrictive non-physical interventions have been found
to be ineffective or not viable.
▪ Chemical restraints are not permitted.
 Principles in Restraint Management
▪ In all acute clinical interventions with patients,
the least restrictive, safest and most effective
measures will always be employed.
▪ Show of force/team approach techniques are
the preferred interaction in behavioral
management.
▪ The use of towels to prevent spitting or biting is
prohibited.
▪ A patient may never be placed in a locked room
while in restraints.
 Determine type and ▪ Medical vs. Violent or
Self-destructive
Restraint purpose of Behavior

Protocol Restraint Require

Overview
▪ Order of restraints
Initiation of Restraints ▪ Physician Assessment
( NP and All Units) ▪ Proper Documentation

Observation and Release of

Assessment
Restraint Care
Restraints

Documentation

Staff and Patient Debriefing

 1 Two Point Restraint
Observation Restraint Care
EVERY 2 hours and as needed

*Release and reposition

restraints one at a time.
EVERY 15 minutes for two
Additional measures:
hours then hourly
• Keep two (2) upper side rails
thereafter and as needed
up when patient is in bed.
• EVERY shift: measure Intake
and Output and record vital
signs
 2 Four Point Restraint
Observation Restraint Care
EVERY 2 hours and as needed

*Release and reposition

restraints one at a time.

EVERY 15 minutes and as Additional measures:

needed • Decrease external stimuli
• Keep side rails down
• EVERY Shift: measure
Intake & Output
3 Four and Five Point Restraint
AVOID USED ON NON- PSYCHIATRY UNITS

Observation Restraint Care

EVERY
• 2 hours for adult
• 1 hour for adolescent
EVERY 15 minutes and as • 30 minutes for
needed
children & as needed

*Release and reposition

restraints one at a time.
 2 RN Check and Restraints
Performed at the bedside each time
*Goal: to verify that restraint application is
appropriate and correct.
1. Alternative measures instituted and assessment
of effectiveness documented in the medical
record.
2. A complete and signed order stating the type
and reason for restraint.
3. The second RN performing the validation must
document this review by co-signing the
restraint initiation note.
Transporting Patient on Restraints

•Patients transported in restraints

must be accompanied by a
physician and nurse who is
competent in restraint care
See nursing policy on Transporting of Patient (NS-DPP-COP-049).
 Documentation of observation
RN caring for the patient will document in the
patients behavior in the medical chart record:
▪ date, time and name of physician notified
▪ description of the facts justifying the
incident
▪ type of restraints used and any conditions
for maintaining the restraints
▪ reasons why less restrictive interventions
could not be used