INTRODUCTION

This is the standard operating procedure of the pediatric ward ELJMH

formulated after consulting all possible resource persons (physicians, nurse,

and nursing attendants). It is intended to guide all persons assigned in the

pediatric ward.

OBJECTIVES OF THE POLICIES:

1. To enable those new comers (new employees, clinical instructors, and

students) to acquaint themselves within the personnel assigned in the

pediatric ward as well as to know the set up and its routine procedure.

2. To serve as guide or reminder in case someday some routine procedures

are neglected.

3. For future reference.

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 EDUARDO L. JOSON MEMORIAL HOSPITAL

MISSION:

Demands of professional groups in rendering their skills in their areas of

expertise through availability of modern and highly technological equipment

now in use.

To enhance nurse capabilities for clinical specification through research and

training.

VISION:

Professional growth and adjustment towards the attainment of highest

standards for the delivery of health care system progressive growth in

specification and adaptation of new technological opportunities.

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JOD FUNCTIONS OF WORKERS IN THE AREA

1. Head Nurse / Senior Nurse

Is the one whom is delegated to provide nursing care, execute hospital

policies, maintain standards, cooperate with physicians, carry satisfactory

community relationship and exercise others function of an administrative

in nature.

A. Patient Care

1. Administering, transferring, moving and discharging patients.

2. Supervising and inspecting the nursing care given to all patients and

determining their general condition of their physical environment.

3. Observing the serious patient, supervising their care and determining any

special need.

4. Accompanying physician on their visit to patients, giving routine reports

of the condition of the patient.

5. Assisting physicians with examination and diagnostic measures when

indicated.

6. Safeguarding the patient by explaining to any worker in contact with her

condition reaction and any special about her.

7. Teaching patient and the instructing personnel in the technique of patient

teaching.

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B. Ward Housekeeping

1. Inspection of the entire ward and service room regularly on basis

supervision and instruction of ward personnel as well as general

maintenance.

2. Adjusting and regulating maintenance of temperature and lighting.

3. Writing requisition for repair for the upkeep of the ward.

4. Inspecting furniture, furnishing equipment and supplies for cleanliness

and general conditions.

5. Making and keeping ward inventory.

6. Writing requisition for routing supplies, new articles, exchange, repair

and condemned.

7. Making a definite plan for ward housekeeping by instructing,

supervising and coordinating the work of all personnel.

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C. Teaching and Supervision

1. Supervision of the ward personnel as a whole including non-

professional as well as professional workers.

2. Supervising, instructing of particularly new difficult procedures,

treatment or activity.

3. Supervising all written and spoken recording including patients chart

and any other type or records kept by the persons.

4. Conducting and helping to conduct conference. Rounds to the ward

personnel and for the students.

5. Demonstrating new difficult procedures to all workers.

6. Maintain the necessary equipment for the teaching such as the charts,

manuals and others.

D. Personnel Administration

1. Helping to establish present atmosphere at the ward.

2. Investigating any complains or seeming lack of cooperation between

workers.

3. Giving constructive criticism of any work individually and in group.

4. Evaluating the work of all ward personnel as part of guidance.

5. Participating in meeting, conferences, etc.

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E. Round Conferences

1. To make rounds and conferences with the unit supervisor.

2. To give accurate reports of the general condition of the ward to the

administrative staff.

3. Referring with the social worker, dietician about the case of the

patient.

F. Constant study of all records and forms so that any necessary

changes and revisions are made.

G. Performs miscellaneous activities such as going on errands if

possible locating articles.

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2. Staff Nurse

1. Receives endorsement from outgoing nurse.

2. Gives direct nursing care.

3. Indentifies needs / problems of patient.

4. Plans, gives, and evaluates nursing care.

5. Observe, examines, and interviews patients / relatives.

6. Records and reports observation to physician / senior nurse (nurse II).

7. Administers and records medications, treatment, and therapies

including patient reactions.

8. Transcribes and carries out legal orders of the physician.

9. Prepares patient for and assist physician with physical examination,

diagnostic, and therapeutic procedure.

10. Prepare records and reports according to the hospital standards.

11. Teaches and direct midwives / nursing attendants.

12. Assist on teaching, guiding, supervising nursing / midwifery students.

13. Gives health teaching.

14. Takes and records vital signs. Admits and discharges patients.

15. Executes / performs nursing techniques and procedures such as

bathing, oral hygiene, shampoo, comfort measures, moving, turning,

and positioning patients.

16. Performs irrigation, catheterization, gives enema, and shaves patients.

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17. Makes endorsement to incoming nurse.

18. Keeps and store equipment, instrument, treatment trays, and supplies

according to hospital policies.

19. Attends meetings and conferences.

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3. Nursing Attendants

1. Performs various patient care services.

2. Escorts newly admitted patients from admitting office to the hospital

room or ward, assist patients in undressing and provides necessary

hospital clothing.

3. Stores patients clothing and valuables.

4. Records temperature, pulse, and respiration rate.

5. Bathes bed patients or assist patients in bathing herself.

6. Combs hair, cleans and cuts patient nail, gives mouth washes, assists

in cleaning teeth, gives shampoo when necessary.

7. Gives alcohol rubs.

8. Feeds ill patients or assists patients with the meals, provides

nourishment when it is need.

9. Serves and empties bedpans and collects urine and fecal specimens.

10. Keeps records of patient’s intake and output when ordered.

11. Answers signal light or bell and delivers messages.

12. Assists patients in walking and transports patient to various hospital

department by means of wheelchair or stretcher (wheeling of patients)

13. Performs related duties such as:

a. Cleans rooms and equipment on discharge of patient.

b. Cleans workrooms, linen closets, and medicine cabinets.

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c. Changes cover on stretchers, examining tables and screens.

d. Collects charts, records, and reports.

e. Collects soiled linens and clean linen.

f. Cleans and sterilizes instruments and equipments.

g. Receives and escorts visitors.

h. Helps with post-mortem care.

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 GENERAL INSTRUCTIONS

I. Leaving the unit

The unit must not be left alone with any nursing personnel who will

look to the needs of the patients. During coffee break o meal time, only

one personnel is allowed to go at a time.

II. Conduct

Each personnel must behave well in the ward. Any misconduct must be

reported at once. Each worker is expected to behave in a right manner and

conduct in conformity with the regulation of the hospital.

III. Smoking

Campaign for NO SMOKING within the hospital facilities.

IV. Relationship

Nursing personnel are reminded to deal with patients accordingly. As

nurses, they must be sensitive to the need of patient. There hould be

harmonious relationship and smooth coordination among other department

to be able to give quality nursing care to patients.

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 V. Accident or Incident Report

Any accident or unusual accident in the ward must be written and

forwarded to the nursing office thru the senior nurse and the nurse

supervisor. The report must be directed, brief, and complete in sequence

what, why, and how the accident / incident occurred.

VI. Theft

Any persons within or outside the hospital, personnel, caught stealing

must be reported at once to the security officer for proper action.

VII. Watchers

They are expected to observed hospital rules and regulation.

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 POLICIES

1. The unit is provided the following for the patients:

a. Three meals

b. Pants/camisa/draw/rubber sheet, 60 mL drinking water.

2. Patient admitted in the ward are:

a. Children (0-3 years old)

3. General Policies

Report on duty before on time in complete uniform with name plate

or ID or cap if she is a nurse.

 Absenteeism – notify chief nurse or supervisor on duty day

before.

 Exchange of off duty – consent of both parties is necessary by

signing the written request to be forwarded to the chief nurse

or supervisor on duty.

 Referrals is made by nurses\maybe forwarded to the following:

a. Doctor – nurse to doctor in the same department.

b. Social worker – especially if the patient is indigent or no

relatives.

c. Others

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  Equipment that are available in the unit:

a. Suction apparatus

b. Sphygmomanometer / stethoscope

c. Ambubag

d. Oxygen gauge / regulator

 Charting focus

 Doctors order

C - carried signed with full name

A - administered

R - requested

E - endorsed

D – discontinued

I. Housekeeping activities

A. Bed linens for patients will be changed by night shift. Nursing attendant

every 5 am at such time, the patients are encouraged to attend their

personal needs as bath, sponge bath, changing clothing.

B. All bath basins, kidney basins, oxygen mask and other miscellaneous

thing left at the bedside table should be removed during linen

changing.

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C. Cleaning routine should as follows:

Daily Weekly

1. Floors 1. Screens

2. Sinks 2. General cleaning floors

3. Toilet 3. Removal of cobwebs

4. Bath room 4. Walls when grossly soiled

A. The following visiting hours should be implemented as follows:

In the morning 10:00 – 12:00 Noon

In the afternoon 3:00 – 5:00 P.M.

B. Children under 12 years of age should not be allowed to visit the

hospital nor very old not be allowed also.

C. They should never sit / lie on patients’ bed.

D. Visitors should never place street clothing such as coats or handbags

on patients’ bed now should they place their feet on chairs on stools.

E. No eating policy for the watcher at all times.

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III. Patients care practices

A. Observation of aseptic technique is mandatory in any procedure

done for the patient.

B. Isolation procedures required should be strictly observed.

C. Proper hand washing must always be observed before and after

each patient.

D. In the aseptic area – using of gown is mandatory.

IV. Care of medicines

Preparations for administering medication

A. Check the 10 R’s

1) Right Patient

2) Right Medication

3) Right Dosage

4) Right Route

5) Right Time and Frequency

6) Right Assessment

7) Right Client Education

8) Right to Refuse

9) Right Evaluation

10) Right Documentation

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 B. Check for turbidity of discoloration content in bottles and vials.

C. Do not handle pills with bare hands.

D. Never leave prepared medication unattended.

E. The nurse who prepares the drug should be the one who will

administer it to the patient.

F. Never records a medicine as given until the patient has taken it.

G. When injecting medication, prepare the skin site with approved

disinfectant.

Handling glass ampoules and multiple dose vials:

A. A glass medication ampoule should be disinfected with an alcohol swab

at the neck, allowed drying and breaking with care.

B. Use of sterile needle and syringe carefully withdraw the medication

without touching the outside of the ampoule with sterile needle.

C. Multiple dose medication vials have rubber stoppers that must

thoroughly swabbed with alcohol swab and allowed to dry before they

are entered with the sterile needle to withdraw the amount of

medication.

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 D. Multiple dose vials should be dated when opened and discarded 24

hours after that date. The following are 2 of the exemption of this

policy:

Item A – when the instruction clearly stat that a drug is stable at

room temperature, a multiple dose vials maybe kept for a period not

exceeding 30 days, if aseptic technique were observed when drug is

withdrawn.

Item B – when the vial is reserved for the same patient, it may

be under the condition as in item A.

IV. Physical Rounds

A. Chart should not be placed on patient’s bed. A chart trolley must be

provided.

B. Soap and towel should be provided in chart trolley at all times.

C. Physicians are required to do hand washing before and after

examination of each patient.

D. Individual pack of instrument for dressing and suture removal

should be in the trolley.

V. Watchers

A. Watchers are not allowed to make rounds to other rooms.

B. Only one watcher is allowed in case of patient in serious condition.

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 ROUTINE OF STANDARD ORDERS

A. Visiting Hours

Regular visiting hours id=s from 11 A.M. to 12 noon and 3 P.M.

to 5 P.M. visitors should avoid unnecessary noise.

B. Any sick person regardless of nationality, place of domicile

maybe admitted.

Hospital patient maybe admitted of the day.

C. Admitting of Patient

1. New admission must pass the nurse for the hand interview.

She/he should be treated as guest who needs good professional

care because of his illness.

2. Place comfortably in bed.

3. Inspect the general condition of the patient from head to foot.

4. Give admission baths if condition warrants.

5. Take vital signs and records.

6. Instructing patient, and relative about hospital routine explaining

the diet and therapy.

7. Adequate explanation of diagnostic procedure to be done.

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 8. The patient should be instructed to give any valuable possession

to the family or relatives.

9. Accurate and complete observations accompanied the recording

of these observations are valuable aids to the doctor in making

diagnostic and prescribing therapy.

10. Instruct companion to bring necessary article like slippers, spoon

and fork, glass plates, toothbrush, comb, thermos and toilet

paper, extra baggage is not allowed, they should be sent home.

11. Notify the kitchen about diet, if the order is NPO it should be

listed in the diet list as NPO.

12. Don’t leave any excess linen at the bed of the patient. Soiled

ones should be placed properly folded in the hamper.

D. Discharging of Patient

1. Discharging of patient when ordered by the physician.

2. Give health teaching such as:

a. Proper intake of medicine at home.

b. Proper diet.

c. Activities of patient.

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E. Transfer of Patient from Charity to Pay

1. Explain to the family that all services rendered to the patient to

the time of admission except the subsistence and

accommodation in the free ward will be paid fully.

2. Give the consent of the doctor in charge of the patient.

3. Notify the nurse in the section, mention conditions of the

patients, immediate needs and appliances that need to be

prepared before the patient arrived.

4. Inform the family about the rules and regulations particularly in

pay ward.

F. Transfer of Patient from House Physician to Private Physician

1. Get the consent of the doctor in charge of the patient.

2. Notify or inform the private physician desired by the patient to

treat him.

3. Inform the physical and family of the conditions relative to

services of private physician such as physical visits.

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 CARE AND DISPOSAL AFTER DEATH

As soon as the patient has been pronounced dead by the doctor, the

body shall be stripped, bathed and prepared for removal to the morgue.

Fill the death certificate in four (4) copies and let the doctor sign it.

Give the three (3) copies to the relatives and leave one (1) copy for hospital

records.

The clinical records of deceased patient should be completed and

forwarded to the admitting section.

The head nurse must immediately notify the relatives of the deceased

through any available means of communication deceased patients shall be

transferred to the morgue within 15 minutes after death.

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