Nursing essential policies and procedures of practice specified per department

The policies and procedures are reviewed and updated every two (2) years and include but are not limited to the following

NR.9.1 Patient admission procedure.

NR.9.2 Basic hygiene of patients and skin care.

NR.9.3 Role in Patient and Family Rights and Responsibilities.

NR.9.4 How to transcribe physicians orders.

NR.9.5 Guidelines on how to assess, teach, and evaluate patient education provided to patients.

NR.9.6 General Infection Control policies.

NR.9.7 How to call a physician.

NR.9.8 Transfer policy, internal and external.

NR.9.9 Discharge policy.

ADMISSION DIAGNOSIS: - ADMISSION SOURCE: - MODE OF ARRIVAL- PAST MEDICAL/ SURGICAL HISTORY:

INFORMATION SOURCE:

USUAL MEDICATION - LAST DOSE

LOCATION OF MEDICATION: - VALUABLES:

Physician Notified of Patients Arrival:

ORIENTATED TO UNIT ENVIRONMENT

HEARING VISION LANGUAGE

INITIAL OBSERVATIONS (ON ADMISSION TO UNIT)

Height: Weight: Blood Sugar Level: O2 Saturations

Temperature: Pulse: Respiratory Rate: BP - SPo2

CARDIOVASCULAR

Apical Heart rate: _________ bpm regular R L R L R L irregular Radial Pulse: Pink

Pedal Pulse: Pale Odema: Y N Location:Mottled Pitting Y N Blue Other: Pacemaker, Internal defibrillatorsCap Refill 40 Unable to take oral feeds Caries -Dentures -Full Partial

PAIN ASSESSMENT

Yes No Pain Present Pain Score (0-10): _________ Pain Location:______________________ If Score > 4, See Pain Assessment Form

INTEGUMENTARY

NB: For all wound assessment please refer to Wound Care Assessment Form. Skin: Rash - Bruises - Diaphoresis - Petechiae Skin Colour: Normal - Pale - Jaundiced -Mottled Skin Turgor: Adequate - Poor Hair: Clean -- Lice Vascular/ Dialysis Devices: -- Port-a-cath CVC - Permacath Peripheral Cannula AV Fistula/ Graft -Tenckhoff Catheter

GENITOURINARYAble to void: Continency Aids: Diapers Distended Bladder -Sanitary Pads Pain -Burning Catheter Size - Frequency Supra Pubic catheter -Urine Clear-Urinalysis -Genital abnormality Colour- Required Genital discharge - Cloudy LMP ___________ Regular Y N Pregnant Y N Gravida____ Para____

MUSCULOSKELETAL

Range of Movement: Active Contractures: Nil Deformities: Nil Passive Present Present -Restrictd Location: _ Location:___ Limb:Paralysis: Nil Ambulatory Devices: Y N Present -Type: Location:_ With patient At Home

FUNCTIONAL SCREENING If patient needs assistance with any of the following, refer to rehabilitation Date:___________

Physical Therapy Mobility in bed Transfers Walking Occupational Therapy Eating Toileting Washing Dressing Transfers Speech Therapy Swallowing

FALLS (REFER TO FALLS RISK ASSESSMENT)

Tick if identified risk factor : Altered Mental Status Mobility Medication History of falls Special toileting needs

PSYCHOSOCIAL

Unusual concerns about patients physical/social status: Y N Physician Notified: ___________(Date/Time) SOCIAL SERVICES SCREENING: Refer to social services if any of the below apply Date:_________ Y N Y N Inadequate Family Support

Patient/family lifestyle change due to illness

PSYCHOSOCIAL

Unusual concerns about patients physical/social status: Y N Physician Notified: (Date/Time) SOCIAL SERVICES SCREENING: Refer to social services if any of the below apply Date:_________ Y N Y N Inadequate Family Support Patient/family lifestyle change due to illness Equipment/supplies needed at discharge Living conditions do not support treatment plan Non adherence to treatment plan Explain: ________________________________________ Follow-Up Required ________________________PATIENT EDUCATION - See Patient Education Form (IPER)