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General Nursing orientation handbook
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CHARLOTTE MAXEKE JOHANNESBURG ACADEMIC HOSPITAL Nursing Training and Practice Clinical Teaching Unit
Developed by: Clinical Teaching Department/Unit
Revision 1 Revision2
Table of Contents
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Introduction and Background………………………………………………………………………………….
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Overview of the Nursing services………………………………………………………………………………………
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Evidenced Based Practice……………………………………………………………….
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Dress code………………………………………………………………………………….
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Role of Ethics in nursing…………………………………………………………………………………………
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Nursing process and patient care planning ……………………………………………
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Interpreting and recording of Vital data………………………………………………..
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PSI and Quality Improvement planning……………………………………………………
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Customer service……………………………………………………………………………….
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Consent and pre-operative preparation………………………………………………………………………....................
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Skin integrity and wound care………………………………………………………………..
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Overview of nursing disaster plan……………………………………………………………
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Multi-generational and Cultural diversity in the workplace……………………………..
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Emergency preparedness………………………………………………………………………
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Work place Violent and conflict Management……………………………………………….
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CPD and competency based assessments…………………………………………………..
Introduction and Background General Nursing Orientation and Induction (GNOI) is a formal process to orient newly appointed nursing personnel to the organization, nursing department, philosophy of nursing and resources available to support nursing practices and professional development. The orientation program is run over a two-week period and different department ranging from HR to asset management are invited to present topic relevant to nursing. The program aims to provide the newly hired nurses with the needed skills, knowledge and attitude to practice with confidence, competence, commitment and to improve the patient and staff safety, in accordance to SANC and OHCS accreditation standards
Purpose 1. To provide a solid foundation for new employees to assist them in who seek to find a foothold in a new organization and act as reference whilst performing their assigned duties.
OVERVIEW OF NURSING SERVICES Vision of CMJAH Excellent quality healthcare services for all.
Mission Statement The Nursing Department of Charlotte Maxeke Johannesburg Academic Hospital strive to provide quality patient care to the communities with caring as our underlying core value characterized by: Compassion •
Competence
•
Confidence
•
Conscience
•
Commitment
Leading to satisfied patients, communities and staff.
Nursing Care Model
Holistic Nursing Care Associated withFlorence Nightingale
Patient- centred care
Institute of medicine
Evidenced-based nursing care Associated with the Joanna Briggs Institute
Holistic Nursing care
Physical Management of Pain Control of Distressing symptoms
Social
Serving Nutritious food Daily analysis of nutritional requirements
Acceptance as part of a group
Psychological Reassurance to pomte a feeling of safety amd security
Encouraging sense of belonging
Helping rediscover a sense of worth and self esteem
Treated with dignity as fellow human being
Spiritual Oppotunity to forgive and forget Encourage to end quarrels and reconcile Getting ready to depart in a calm and peaceful frame of mind
Patient Centred care
Respect for patient's preferences co-odination and integration of care Information and education Physical Comfort Emotional Support Involvement of Family and Friends Continuity and Transition Access to Care
Evidenced based Nursing Care
(EBN) is an approach to making quality decisions and providing nursing care based upon personal clinical expertise in combination with the most current, relevant research available on the topic.
Evidence based Education
Evidence based Regulations
Evidence based Policy
Evidence Based care I CARE 4 U Values ❑ To show INTEGRITY • I am always dressed in proper uniform and I am always well groomed. •
I wear distinguishing devices and name badge so patients can identify me.
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Doing the right thing right even when no one is looking- following set protocols
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I keep patient information confidential
❑ To show CARE •
I take care of the needs of my patients
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I always seek consent to show compassion
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I listen to my patients and their relatives' concerns
❑ To show ACCOUNTABILITY •
I keep accurate records of care provided to my patients
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I utilize my time effectively to ensure that I don’t claim unnecessary overtime
❑ To show RESPECT •
I always greet everyone and I call my patients by their last name
•
I respect my patient’s wishes
❑ To show EQUITY •
I always treat my patients equally and I do not discriminate regardless of race, religious or political affiliation and creed.
4 COMPONETS OF NURSING ❑ Patient Care: •
I plan for the care of my patients (Nursing Care Plan)
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I arrive on time to take hand over and I participate IN NURSING CARE ROUNDS
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I always function within my scope of practice
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I always advocate for my patients as it is my fiduciary duty
❑ To show Leadership/Management •
I provide active supervision over my sub-ordinates
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I walk the talk (Role Modeling), succession planning
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Talent grooming
❑ Teaching/education •
I educate my patients and their relatives about their condition and treatment
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I will regularly educate and train my staff to ensure they provide current care
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Encourage and allocate staff to attend planned in-service trainings
❑ Research •
I participate in research in an effort to improve on patient care to realize the vision of my hospital(EBP)
❑ UNITY •
I function within a multidisciplinary team
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Collaborate to ensure my patients receive the care they require
AIDET •
The acronym AIDET stands for five communication behaviours: Acknowledge, Introduce, Duration, Explanation and Thank you.
•
It is an evidence-based communication model created by the Studer Group to improve verbal and nonverbal communications within hospitals (April,17 2015)
Benefits of AIDET
References Chief directorate nursing I CARE 4 U values Vision and mission of CMJAH https://www.oneviewhealthcare.com/the-eight-principles-of-patient-centered-care/ https://www.practicalnursing.org/importance-holistic-nursing-care-how-completely-care-patients Mrs K. Maubane: Clinical Facilitator: Operating Theatres
DRESS CODE IN THE HEALTH PROFESSION Definition Dress code is a set of rules pertaining to the manner in which a registered practitioner will dress in clinical setting (Nursing Act NO. 50 of 1978) Dress code must uphold the image of the nursing profession. It consists of three distinctive characteristics which are: 1. Personal Protective Equipment(PPE) It is determined and prescribed by the Occupational Health and Safety Act 85 of 1993. The employer must provide PPE taking into account the safety needs of the health care worker and practitioner. 2. The Professional Distinguishing Devices They are issued by South African Nursing Council (SANC) to a person registered under the nursing Act no 50 of 1978 as amended. Different distinguishing devices for different levels of registered practitioners. The registered practitioner must always wear them whilst on duty. 3. Professional Dress code as determined by the institutional policy and the Clinical setting e.g. navy-blue slacks and white shirt for ward staff or theatre scrub suits • The employee must wear clean set of clothing on a daily basis and if during the performance of her duties, the uniforms become soiled then they must be changed immediately or as soon as possible • Clothing should fit properly while also allowing for the necessary range of movement. • Your dress code can vary depending on the employee’s job and even the type of the unit you work in. • Long hair should be tied up. • Keep hair clean, neat and tidy.
• • • • •
Nails must be kept short and no nail polish Avoid heavy perfumes, aftershave and other strong smells. Men must be clean –shaven or neatly trimmed moustache. Flip flops, sandals, and other open-toed shoes they put employees at risk for tripping and falling. Any open toed shoes need doctor’s prescription.
References •
SOP on dress code for CMJAH employees
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Handcraft services .com/blog/dress code
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Public service act 1994 as amended.
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SANC nursing act no. 50 of 1978
Ms. Matabane A. Clinical Facilitator: Renal
EVIDENCE BASED PRACTICE •
A systematic process by which clinical decisions are made using: –
Best available research evidence
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Clinical expertise
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Patient preference
(Houser, 2011, Malcolm, 2016, Spruce, 2015, Thorsteinsson, 2013). •
EBP is used because of benefits such as improved patient, family and caregiver outcomes. EBP can also improve provider (i.e., nurse, physician, etc.) and hospital outcomes.
•
EBP leads to the ‘gold standard’ or best treatments
Steps of EBP
Step 0 • • • •
Cultivate a spirit of inquiry Lay the groundwork for EBP Identification of a clinical problem (Not a researchable problem but a clinical problem supported by the best available evidence)
Step 1 •
Ask clinical questions in PICOT format
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P-patient /population, place and problem
• • • •
I -intervention C -comparison O-outcome T- time
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The PICOT format provides an efficient framework for searching electronic databases
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In adult patients with total hip replacements (Population), how effective is pain medication (Intervention) compared to aerobic stretching (Comparison) in controlling post-operative pain (Outcome) during the perioperative and recovery time (Time)?
Step 2 •
Search for the best evidence
• • • • •
Identify key words from the PICOT PICOT allows for the search to be very specific Avoid searching for hundreds of abstracts, most of them irrelevant Inclusion and exclusion criteria Databases
Step 3 Critically appraising the identified evidence for its validity, applicability, and relevance. 1. Are the results of the study valid? 2. What are the results and are they important? 3. Will the results help me care for my Patients? •
Keep the valid and reliable studies
• •
Evaluate these studies Synthesize all the studies to determine if they come to similar conclusions, thus supporting an EBP decision or change
Step 4 •
Integrate the evidence with clinical expertise and patient preferences and values
• • •
• Research evidence alone is not sufficient to justify a change in Clinical expertise Patients’ preferences and values
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Management support
• • •
Stakeholder involvement Implementation of EBP Budget constraints hinders implementation of EBP
practice.
Step 5 Evaluate the outcomes of the practice decisions or changes based on evidence • Monitor and evaluate any changes in outcomes • Positive effects can be supported • Remedial actions for negative effect Disseminate EBP results • Share the experiences with colleagues and their own or other health care organizations • EBP rounds in your institution • Presentations at conferences
Resources to utilize when applying knowledge of EBP •
A good starting point is publication databases such as Medline, Cinahl, PubMed, Cochrane library etc
• • • • • • • • •
Peer-reviewed health care journals: Nursing Research Journal of Advanced Nursing Research in Nursing and Health Specialty nursing journals Government organizations National organizations Policy Statements Practice Guideline
References • •
Holland, K & Rees, C. 2010. Nursing: Evidence Based Practice Skills. 1st edition. Oxford University Press. New York
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Melnyk, B. M., Fineout-Overholt, Stillwell, S. B & Williamson, K. M. (2010). The Seven Steps of Evidence Based Practice. Following this progressive, sequential approach will lead to improved health care and patient outcomes. AJN, 110(1). pp: 51-53. Melnyk, B.M & Fineout, E. (2015). Evidence-Based Practice in Nursing and Healthcare. A guide to best Practice.3rd Edition. Wolter Kluwer: London www.googlescholar
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Ms Dube B: Clinical Facilitator: Neuro- ICU
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CODE OF ETHICS FOR NURSING PRACTITIONERS Code of Ethics is an integral part of the nursing profession and forms the foundation thereof. This Code of Ethics for Nursing in South Africa reminds all Nursing Practitioners of their responsibilities towards individuals, families, groups and communities i.e. To protect, promote and restore health, To prevent illness, To preserve life and To alleviate suffering As the Code is premised on the principles of respect for life, human dignity and the rights of other persons, its application is to be considered in conjunction with all applicable South African laws as well as international policy documents which include, but are not limited to the Universal Declaration of Human Rights, International Council of Nurses (ICN) Code of Ethics, the Patients’ Rights Charter and all other nursing and healthcare policy frameworks providing direction and guidance for responsible practice in nursing This Code of Ethics is the foundation of ethical decision-making. It assists both the practitioners and healthcare users with:
Identifying ethical values and principles that form the foundation for professional conduct
Providing the framework for reflection on the influence of ethical values on the behaviour and interaction between nurses and the public, stakeholders and healthcare user
Providing the framework for ethical decision-making for practice
Indicating to the public, stakeholders and healthcare users the standards and ethical values they can expect nurses to uphold; and
Providing guidance to professional conduct or ethical committees regarding decisions relating to unethical behaviour
Ethical Principles have to be upheld at all times by all Nursing Practitioners in whatever role they fulfill as direct or indirect patient care providers.
Such ethical principles include, but are not limited to the following:
Autonomy
Beneficence
Justice
ETHICAL PRINCIPLES
Caring
Altruism
NonMaleficence
Fidelity
Veracity
Justice – Nurses are at all times expected to act fairly and equitably where there is competition of interest among parties, groups or individuals e. g. interests may be, related to access of healthcare resources. Nurses should therefore pursue justice and advocate on behalf of vulnerable and disadvantaged healthcare users and should be able to justify their decisions and actions.
Non-maleficence – This requires a nurse to consciously refrain from doing harm of any nature whatsoever to healthcare users, individuals, groups and communities.
Beneficence – Nurses are required to do good and to choose the “best option” of care under given circumstances and act with kindness at all times.
Veracity – is the principle of truth telling? This principle requires the nurse to act with truthfulness and honesty and to ensure that the information provided to and on behalf of the healthcare user is always in the best interest of the healthcare user. Veracity is a dual concept that refers to both the duty to disclose pertinent information and the obligation to respect confidentiality
Autonomy – Respect for the autonomy of eligible persons (healthcare users) to make their own decisions and choices in matters affecting their health.
Caring – Nurses are required to demonstrate the art of nurturing by both applying professional competencies and positive emotions that will benefit both the nurse and the healthcare user with inner harmony
ETHICAL DILEMMAS ▪
Termination of pregnancy
▪
Trading of products of conception and other human parts; e.g. human placentae
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Participation in and/or conducting clinical research
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Conscientious objection, meaning entitlement to consciously refuse to participate in activities and treatment that nurses believe, on religious or moral grounds, are unacceptable and/or questionable, ethically, morally and legally
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Situations of conflicting values (diverse cultures, sexual orientation, etc.
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Conflicts between individual, social and professional values
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Participating in moonlighting activities and in so doing, compromising the nurse’s ability to provide quality care
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Euthanasia
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Intimidation and violent acts in the workplace
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Participating during strikes and boycotts and in so doing, compromising quality nursing care
NURSE’S ROLE IN ADVOCACY
Advocacy in nursing is very important for quality care and patient satisfaction. It involves supporting patients in many ways.
The following are some advocacy techniques and strategies: ▪
Have the information patients need or know how to obtain it.
▪
Present necessary information to patients clearly, concisely and in terms they can understand.
▪
Respect people’s wishes even when they conflict with our own.
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Stay objective at all times.
▪
Encourage patients to make their own choices about their healthcare
SANCTIONS
Failure to adhere to the provisions of the Code or violations thereof, attracts the same sanctions as those of non-adherence to the regulations/rules regarding acts and omissions and may bring your fitness to practice into question and endanger your registration to practice.
QUICK 5 FINGER TEST to determine if an action is ETHICAL
Is it legal?
Will I read about my decision in the newspaper?
Is it in line with my personal, organizational and professional values?
Is it fair to all?
Can I live with my decision?
References
ICN Code of Ethics for Nurses, 2012
Muller, M. 2009. Nursing dynamics. 4th edition. Sandown: Heinemann
Pera, S & Van Tonder, S. 2011. Ethics in healthcare. 3rd edition. Lansdowne: Juta
South African Nursing Council.2013. Code of ethics for nursing practitioners in South Africa. Pretoria
Ms Zwane S.
Clinical Facilitator: Obstetrics and Gynaecology
NURSING PROCESS AND PATIENT CARE PLANNING (DEFINITION, BENEFITS and STEPS) DEFINITION: The Nursing process is a systematic, rational method of planning and providing nursing care. Its goal is to identify a client’s health care status and actual or potential health problems, to establish plans to meet the identified needs, and to deliver specific nursing interventions to address those needs. BENEFITS OF NURSING PROCESS: Provides an orderly & systematic method for planning & providing care
Enhances nursing efficiency by standardizing nursing practice Facilitates documentation of care Provides a unity of language for nursing profession Is economical Stresses the independent function of nurses Increases care quality by using deliberate actions
THE 5 STEPS OF THE NURSING PROCESS The nursing process is a scientific method used by nurses to ensure the quality of patient care. This approach can be broken down into five separate steps: ADPIE A =Step 1: ASSESSMENT
The first step of the nursing process is assessment. During this step the nurse gathers information about a patient's psychological, physiological, sociological, and spiritual status. This data can be collected in a variety of ways. Generally, nurses will conduct a patient interview. Physical examinations, referencing a patient's health history, obtaining a patient's family history, and general observation can also be used to gather assessment data. Patient interaction is generally the heaviest during this evaluative phase. THE TOOLS FOR PHYSICAL ASSESSMENT: These include, the otoscope, thermometer, stethoscope, penlight, sphygmomanometer, bladder scanner, speculum, and eye charts. Besides the interviewing process, the nursing assessment utilizes certain techniques to collect information such as observation, auscultation, palpation and percussion. D=Step 2: DIAGNOSING The diagnosing step involves a nurse making an educated judgment about a potential or actual health problem with a patient. Multiple diagnoses are sometimes made for a single patient. These assessments not only include an actual description of the problem (e.g. sleep deprivation/anxiety or pain) but also whether or not a patient is at risk of developing further problems. These diagnoses are also used to determine a patient's readiness for health improvement and whether or not they may have developed a syndrome. The diagnoses phase is a critical step as it is used to determine the course of treatment. COMPONENTS OF THE NURSING DIAGNOSTIC PROCESS ACTUAL PROBLEMS: Actual problems have a three-part statement. 1. State the problem or nursing diagnosis... 2. “Related to” phrase or etiology... 3. Defining characteristics – symptoms or “manifested by” … Situation: Client develops alopecia after receiving radiation. Nursing Diagnosis: Body image disturbance related to loss of hair manifested by verbalization of a fear of rejection.
POTENTIAL PROBLEMS: Potential problems are two-part statements which describe an individual, family or group’s responses to a situation or health problem. Two-part statements refer to 1. Potential diagnoses/problem ……. 2. “Related to” phrase or etiology and no symptoms are available. Situation: A client has a hip fracture and is on strict bed rest. Nursing Diagnosis: Potential for alteration in skin integrity related to immobility P=Step 3: PLANNING
Once a patient and nurse agree on the diagnoses, a plan of action can be developed, you will plan a course of treatment that takes into account short- and long-term goals. If multiple diagnoses need to be addressed, the Registered Nurse will prioritize each assessment and devote attention to severe symptoms and high-risk factors. Each problem is assigned a clear, measurable goal for the expected beneficial outcome. Most treatment plans will include interventions conducted by the medical staff (e.g., suturing, medication prescription, IV fluids) followed by steps taken by the patient to ensure proper recovery.
I= Step 4: IMPLEMENTATION The implementing step is where the nurse follows through on the decided plan of action and puts the treatment plan into effect. This typically begins with the medical staff performing any needed medical interventions. This plan is specific to each patient and focuses on achievable outcomes. Actions involved in a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient or performing necessary medical tasks, educating and instructing the patient about further health management, and referring or contacting the patient for follow-up. Implementation can take place over the course of hours, days, weeks, or even months. Implementation is when you put the treatment plan into effect. E=Step 5: EVALUATION Once all nursing intervention actions have taken place, the nurse completes an evaluation to determine the goals for patient wellness have been met. The possible patient outcomes are generally described under three terms: patient's condition improved, patient's condition stabilized, and patient's condition
deteriorated, died, or discharged. In the event the condition of the patient has shown no improvement, or if the wellness goals were not met, the nursing process begins again from the first step. All nurses must be familiar with the steps of the nursing process. A nurse must use these 5 steps every day in her profession as Nursing Process is her core function. COMPONENTS OF THE NURSING DIAGNOSTIC PROCESS ACTUAL PROBLEMS: Actual problems have a three-part statement. 1. State the problem or nursing diagnosis... 2. “Related to” phrase or etiology... 3. Defining characteristics – symptoms or “manifested by” … Situation: Client develops alopecia after receiving radiation. Nursing Diagnosis: Body image disturbance related to loss of hair manifested by verbalization of a fear of rejection. POTENTIAL PROBLEMS: Potential problems are two-part statements which describe an individual, family or group’s responses to a situation or health problem. Two-part statements refer to 1. Potential diagnoses/problem ……. 2. “Related to” phrase or etiology and no symptoms are available. Situation: A client has a hip fracture and is on strict bed rest. Nursing Diagnosis: Potential for alteration in skin integrity related to immobility
BENEFITS OF USING THE NURSING PROCESS 1. Continuity of care 2. Prevention of duplication 3. Individualized care 4. Standards of care 5. Increased client participation 6. Collaboration of care RECORD KEEPING PRINCIPLES IN THE OPERATING THEATRES viz: The BLACK FACTS • • • • • • • • • •
B: Black ink L: Legibility A: Accuracy C: Clarity K: Keep safe F: Factual A: Approved abbreviations C: Concise T: Timely S: Signed
Ms Naidoo: Clinical facilitator Surgery
INTERPRETING AND RECORDING VITAL DATA •
One of the traditional roles of Nurses involves surveillance.
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This includes watching patients for changes in their condition.
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Early recognition of clinical deterioration and nursing care planning
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Protection from harm or errors.
SURVEILLANCE •
Traditionally Nurses relied on five vital signs to assess their patients:
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Temperature
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Pulse
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Blood pressure
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Respiration and oxygen saturation
RESPIRATORY RATE •
Hypercapnia
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Hypoxemia
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Acidosis
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Cardiac output
OXYGEN SATURATION •
Haemoglobin level
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Circulatory system
TEMPERATURE •
Age of the patient
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Pathophysiology i.e. infection
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Medication
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Take into consideration the differences according to anatomical sites oral vs axillary
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Environment temperature
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Pain
PULSE •
Should be counted for thirty seconds
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Consider the strength, regularity.
BLOOD PRESSURE •
Intravascular volume
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Hydration status
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Vascular tone
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Contractility of the heart
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Viscosity of the blood
URINE OUTPUT Diabetes mellitus Cardiac dysfunction Sepsis Vascular disease Liver disease Urine output is an Indirect reflection of renal function status
May be the first clinical indication of fluid and electrolyte imbalance if left untreated may lead to renal failure In adults normal urine output is at least 0,5ml/hr.
Ms. G. Mnisi Clinical Facilitator: Paeds
PATIENT SAFETY INCIDENTS Definition of terms Patient safety: The reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum. Near miss: An incident which did not reach the patient. No harm incident: An incident which reached a patient but no discernible harm resulted. Harmful incident (adverse event): An incident that results in harm to a patient that is related to medical management, in contrast to disease complications or underlying disease. Severity Assessment Code 1: Serious harm or death that is/could be specifically caused by healthcare rather than the patient’s underlying condition or illness Severity Assessment Code 2: Moderate harm that is/could be specifically caused by healthcare rather than the patient’s underlying condition or illness Severity Assessment Code 3: Minor or no harm that is/could be specifically caused by healthcare rather than the patient’s underlying condition or illness Error: The failure of a planned action to be completed as intended (i.e. error of execution) or the use of a wrong plan to achieve an aim (error of planning). Errors may be errors of commission of omission, and usually reflect deficiencies in the systems of care.
PRINCIPLLES OF MANAGEMENT OF PATIENT SAFETY INCIDENTS All health facilities should have a system in place to manage PSIs according to the following principles: 1. Just culture Staff that report patient safety incidents should be free from fear of victimisation solely for reporting PSIs. The Just Culture supports a “learning organisation” that investigates 2. Confidential The identities of the patient, reporter or institution should be kept anonymous and only known to staff directly involved in the management of a PSIs as well as managerial staff that are indirectly involved in the further management of the incident. 3. Timely Reports are analysed promptly. Once the organisation is notified of PSIs, investigation should be conducted immediately. 4. Responsive Participating organisations commit to the immediate implementation of recommendations. 5. Openness about failures Patients and their families/support persons are offered an apology and told what went wrong and why. 6. Emphasis on learning The system is oriented towards learning from mistakes and consistently employs improvement methods for achieving this.
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•
•
•
•
•
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Step 1: Identifying the Patient safety incident •
Reporting by Health professionals
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Inpatient medical record review
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Focused teams
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External sources
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Record review on follow-up of patients
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Patient Experience of Care Survey
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Safety walks
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Use of data
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Research studies
Step 2: Immediate action taken •
Provide immediate care
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Make situation safe
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Gathering basic information
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Notify SAP and security where applicable
Step 3: Prioritization •
Severity Assessment Code (SAC) 1
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Severity Assessment Code 2
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Severity Assessment Code 3
Step 4: Notification •
Record keeping: Patient Safety Incident (PSI) management form and PSI register
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Initial notification to province/district for SAC =1 and SAC =2&3 to management
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Initial notification (disclosure) to patient
Step 5: Investigation •
Description of incident
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Interviews of staff members/ patients
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Root Cause Analysis, includes actions to be taken
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Conclusion by Patient Safety committee
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Recommendations
Step 6: Classification •
Incident Identification: Patient, date and time, location, agent
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Incident type
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Incident Outcome
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Action
•
Reporter
Step 7: Analysis •
Analyze data according to type of incident
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Analyze data according to incident outcome
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•
•
Analyze data according to agent (cause) involved
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Calculate and analyses PSI indicators
Step 8: Implementation of recommendations •
Health establishment Patient Safety Committee monitors implementation of recommendations
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Provincial/ district Patient Safety committee has an oversight function to monitor implementation of recommendations
Step 9: Learning •
Feedback to patient / family (post analysis disclosure)
•
Feedback to staff
Ms. L Magoro Clinical facilitator Adult ICU
QUALITY IMPROVEMENT •
Achieving the best possible results within available resources.
•
It includes any activity or processes that are designed to improve the acceptability, efficiency and effectiveness of service delivery.
•
It contributes better health outcomes as an ongoing and continuous cyclical process.
Five Principles of Quality Improvement •
Focus on the client
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Focus on the team
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Focus on the data
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Focus on the systems and processes to improve customer care
•
Focus on communication and feedback
QUALITY IMPROVEMENT (QI) PLAN A Quality Improvement Plan (QIP) is a document that identifies the service's goals for quality improvement and notes some strategies for achieving those goals. It helps everyone at the service to stay focused on the improvements and on implementing the strategies needed to achieve the goals
Why are QI programs important for healthcare? Quality improvement programs are critical because they drive: •
Improved outcomes for patients
•
Improved efficiency of staff
•
Less waste due to process failures
•
Process for Developing and Implementing a QIP
Selfassessment
Identify strenghts and improvements needed
Review progress
Implement improvements
Plan improvements and include them in QIP
Diagram showing the self-assessment process. It is a circular diagram to represent that it is a continuous process. The steps occur in this order: 1. Self-assessment. 2. Identify strengths and improvements needed. 3. Plan improvements and include them in the QIP. 4. Implement improvements. 5. Review progress. An arrow from 'Review progress' then leads back to 'Self-assessment', and the cycle begins again.
CUSTOMER CARE Customer Care •
It is the process of looking after customers to best ensure their satisfaction and delightful interaction with the Health Care Facility.
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Use the set of core standards to assess the current situation and to provide the baseline to compare future improvements.
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Engage in QI process, identify gaps in current provision.
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Understand the system (to uncover system barriers causing gaps), analyze causes and explore alternative ways to improve.
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Develop a plan to address the gaps and improve provision.
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Test and monitor the changes, implement successful changes.
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Sustain changes, continuous quality improvement
The Ten (10) Strategies to provide patients with superior customer service •
Start seeing patients as customers
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Be courteous and respectful
•
Never show indifference to patients
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Don’t contradict, argue or match wits
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Tell patients you appreciate their business
•
Use plain terms and simple explanations
•
Good manners will get you every where
•
Keep seeing health care as a calling
•
Stay in touch with patients
•
Keep your promises
Ms G Hudla Clinical Facilitator: Oncology
CONSENT TO SURGERY AND MEDICAL TREATMENT Various health care activities pose a risk to patients. This includes surgical procedures’ the administration of anaesthesia, the issuing of bloods and blood products… thus health care providers must ensure that a written consent is obtained when necessary COMPONENTS OF A VALID CONSENT For consent to be valid the patient must be competent to take the particular decision, have received sufficient information to make a decision and not be acting under duress A. Legal capacity has two components –: 1. Age The age component of legal capacity is determined by legislation – i.e., the age at which the law confers certain rights and obligations on individuals at different stages in their lives. See also Section 129 of the Children’s’ Act. 2. Capacity There are two overriding principles to bear in mind regarding a person’s capacity to consent to treatment A patient’s decisional capacity might also fluctuate over time – even in the course of a day – so the time at which consent is sought may be crucial. Current guidance states that the person obtaining consent must either (1) be capable of performing the procedure themselves; or (2) have received specialist training in advising patients about the procedure. B. INFORMATION The national Health Act 2003 makes it an offence to provide a health service to a User without the user’s informed consent. (See Appendix 3) **/13 Moreover, the national Patients Health Charter (2008) states: “everyone has a right to be given full and accurate information about: ■■ Nature of one’s illnesses ■■ Diagnostic procedures ■■ proposed treatment, and ■■ Costs involved For one to make a decision that affects any one of these elements.” C. VOLUNTARINESS It would be wiser to obtain informed consent at the time of listing in clinic, when the risks and benefits are often explained. The patient will feel under less pressure to proceed, and hence will not be acting under duress. Circumstances may arise where it is not easy to determine whether a patient is incapacitated or not. A woman in labor, for example, or a patient on strong analgesia is arguably not in the best position to think through their immediate options in a clear-headed manner. It is good practice, if consent was obtained in advance, to confirm consent at the time of surgery.
PREPARATION FOR SURGERY IN THE WARD ❑ Patient must have full understanding of the procedure ❑ Patient Must have agreed and signed ❑ The explaining doctor and the witnessing RN are to sign the consent NOT Dr & Dr or Dr & EN/ENA (hospital policy) ❑ If it’s a child, the surnames of the parent and that OF A child should be the same. If not, a police affidavit must be accompanying the consent. (for elective non-urgent surgery) ❑ Full body bath with soap no body lotion ❑ Dressed in theatre gown
❑ Be kept nil per OS /(starved) according dr’s orders ❑ Allergies checked, pre-med given and blood pressure meds should be given (depending on dr’s orders) ❑ All documents available and completed according to national co standards ❑ Documents: Theatre prep slip, consent form, ECG, blood results, x-rays, prescription and progress charts, asthma. (pump spray if applicable) ❑ Patient’ Valuables taken for safe keeping
WRITTEN CONSENT •
The consent is informed, clear and unequivocal
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Patient should be mentally alert and sound
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Signed by all parties with dates and times and clear designation.
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It must be witnessed by a registered nurse.
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patient may sign or put a thumb print if illiterate provided that the thumb print is done in front of the witnesses
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Name of patient and the nature of operation must be written in full. no abbreviations
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Site and side must be clear and unequivocal. no overwriting
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The relation of a person granting consent should be indicated. circle the relevant option
See hospital SOP on consent Mrs A Serobatse: Clinical Facilitator Operating theatres
SKIN INTEGRITY AND WOUND CARE FUNCTIONS OF THE SKIN •
Protection of the human body
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Sensation i.e. Transmitting to the brain information about surroundings
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Temperature regulation
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Immunity i.e. destruction of microorganisms
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Enables movement and growth without injury
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Excretion of water,urea,ammonia and uric acid
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Endocrine function e.g. synthesis of Vitamin D
PRESURE INJURIES •
A pressure injury is localised injury to the skin and other underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and or friction.
Predisposing causes of pressure injuries: (high risk patients) •
Immobility (Post-operative,paraplegics,critical)
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Inadequate nutrition
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Fecal and urinary incontinence
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Decreased mental status
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Diminished sensation (comatosed,diabetic)
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Excessive body heat
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Advanced age
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Chronic medical conditions
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Obese or emaciated patients
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Infections
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Drugs includes cytotoxic, steroids,etc
STAGES OF PRESSURE INJURIES Stage I: Nonblanchable Redness of Intact Skin Intact skin presents with non-blanchable erythema of a localized area usually over a bony prominence. Discoloration of the skin, warmth, oedema, hardness, or pain may also be present. Darkly pigmented skin may not have visible blanching. Stage II: Partial-thickness Skin Loss or Blister A partial-thickness loss of dermis presents as a shallow open ulcer with a red-pink wound bed without slough. It may also present as an intact or open/ruptured serum-filled or sero-sangineous filled blister.
Stage III: Full-thickness Skin Loss (Fat Visible) A stage III ulcer is a full-thickness tissue loss. Subcutaneous fat may be visible; but bone, tendon, or muscle is not exposed. Some slough may be present. It may include undermining and tunnelling. Stage IV: Full-thickness Tissue Loss (Muscle/Bone Visible) A stage IV ulcer is a full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. It often includes undermining and tunnelling.
Unstageable/Unclassified: Full-thickness Skin or Tissue Loss—Depth Unknown An unstageable ulcer is a full-thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, grey, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Protocol and risk assessment tools •
Hospital protocol for prevention and management of pressure injuries
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Waterlow scale - a comprehensive, user friendly scoring system which takes all the risk elements into account.
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Morse Fall Risk scale – for predicting patients at risk to falls.
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Pressure injury Interdepartmental movement form – move with each patient interdepartmental, filled and signed during handing over.
Wound assessment and appropriate dressing •
Assessment –understand wound’s underlying aetiology.
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Consider patient’s status and realistic goals for treatment.
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Manage pain and psychological needs.
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Also understanding the importance of tissue management, infection control, moisture management and epithelial edge advancement.
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Good nutrition this includes proteins and vitamin c
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Dry - moderate draining wounds include hydrogels, hydrocolloids, and Leptospermum honey and hydrogel colloidal sheets.
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If the wound is draining exudate (moderate-heavily) use alginates or foams.
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Wounds with signs or symptoms of infection use antimicrobial dressings.
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Avoiding adhesive or the use of a silicone-based adhesive may be beneficial for patients with fragile skin.
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Sloughed wounds use Leptospermum honey dressings and hydrocolloid dressings.
For extremity wounds use bandages or wraps References •
Hospital Protocol On Prevention And Management Of Pressure Injuries. Charlotte Maxeke Johannesburg Academic Hospital :16 August 2016 (Revision August 2021)
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Cutting KF,White RJ.Avoidance and management of peri-wound maceration of the skin.Prof Nurse.
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Young T. Wound debridement in the community setting.Br J Comm Nurs.2011.
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Appropriate Use of Silver Dressings in Wounds: An Expert Working Group Consensus.London:Wounds International;2012.
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Urden Linda Critical Care Nursing 5 th edition.
Compiled by Nompumelelo Sihlangu Critical care nurse. 5 February 2020 .
OVERVIEW OF THE NURSING DISASTER PLAN
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Classification of disasters •
Natural disasters
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Man-Made disasters
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Floods
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Hurricanes, Earthquakes
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War
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Bomb
The Emergency (Disaster) codes and management. PRIORITY ONE-RED •
Critically ill. Critical patients in need of immediate life-saving care
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Non-walking
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Respiratory rate 29
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Capillary refill time >2 “and/or pulse rate >120
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MANAGEMENT
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RESCUCITATION be done
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Until stabilized enough for Operating Theatres/ ICU/ High Care/ Trauma Ward
PRIORITY TWO- YELLOW TAGS •
Serious but not immediately critical. Relatively stable patients needing attention.
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Non-walking
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Respiratory rate 10-29
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Capillary refill time