Chapter 7:

Nursing Care Service Management

Contents
Section 1: Introduction.............................................................................................................................2
Section 2: Operational Standards for Nursing Services Management......................................................3
Section 3: Implementation Guidelines......................................................................................................2
3.1. Organizational structure of the Nursing Care Service................................................................2
3.2. Nursing Workforce Plan............................................................................................................3
3.3. Team Work................................................................................................................................5
3.4. Nursing Process and it’s components................................................................................................5
3.5. Nursing Assessment...................................................................................................................6
3.6. Nursing Diagnosis/ Problem Identification................................................................................6
3.7. Purposes of Nursing Diagnosis..................................................................................................7
3.8. Differentiating Nursing Diagnoses, Medical Diagnoses, and Collaborative
Problems...........................................................................................................................................7
3.9. Nursing Care Plan....................................................................................................................11
3.10. Implementation of the Plan....................................................................................................12
3.11. Nursing Evaluation of the plan..............................................................................................13
3.12. Accountability and Responsibility.........................................................................................14
3.13. Nursing Ethics.......................................................................................................................15
3.14. Communication and Documentation......................................................................................16
3.15. Patient Education...................................................................................................................16
3.16. Medication Management.......................................................................................................17
3.17. Nursing care practice audit....................................................................................................21
3.18. Purposes of Nursing Audit.....................................................................................................21
3.19. Shift Nursing Services handover and round..........................................................................23
3. 20. Nursing Station.....................................................................................................................23
3.21. Skill lab..................................................................................................................................23
4. Chapter Summary...............................................................................................................................24
5. Annexes..............................................................................................................................................25
 5.1. Monitoring & Evaluation Tools...................................................................................................25
5.2. Nursing Assessment Format........................................................................................................27
6. Source Documents................................................................................................................................5

Section 1: Introduction
Nursing care service is an essential part of the hospital system in improving the
health outcomes of individuals, families and communities. Nursing is a
profession that ensures the successful implementation of interventions that
welcome and nurture life, promotes or restores health, enables the means to
improve the quality of life, dignified and peace full death. Nursing encompasses
autonomous and collaborative care of individuals of all age, families, groups and
communities, sick or well and in all settings.

Nurses are expected to provide quality nursing care for the public with safe and
ethical manner. They are fully accountable and responsible for their entire
practice. To ensure quality nursing services in any health facility, nursing
workforce is expected to be motivated, competent and compassionate.
Nursing staff work closely with their own team and with other health
professionals, making sure patients’ care and treatment is coordinated.

As individuals, members and coordinators of inter-professional teams; nurses

bring client–centered care close to the communities where they are needed most.
Thereby contributing greatly in improving the health outcomes of those under
their care as well as improving the overall cost effectiveness of health care
system. Understanding the individual’s needs, giving care with dignity and
humanity, showing compassion and sensitivity, and provide care in a way that
respects all people equally is expected.
Section 2: Operational Standards for Nursing Services Management
1. The hospital has established nursing care service management structure and
job description including reporting relationships.
2. The hospital has a nursing workforce plan and sets standardized nurse to
patient ratio in each service area.
3. The hospital has written Protocol describing the responsibilities of nurses for
implementing nursing process.
4. All admitted and emergency patients/clients have a nursing process that
describes holistic nursing interventions.
5. All hospital nurses comply with the professional code of conduct and ethics
which governs their professional practice.
6. The hospital has established guidelines for verbal and written communication
about patient/client care to work as independent, inter dependent and
collaborative team work.
7. The hospital has standardized procedures and practice for the safe and proper
administration of medications by nurses or designated clinical staff.
8. The hospital has conducted regular nursing care practice audit and the
findings are linked with QI projects.
9. The hospital has implemented nursing shift regular handover and rounds.
10. The hospital has a centralized nursing station set-up in each ward with
adequate space, equipment and consumables.
11. The hospital established skill lab and regular need based capacity building
program for nursing staffs.
Section 3: Implementation Guidelines
Implementation is the steps which involve action or doing and the actual caring
out of in each specific standards, protocols and guidelines. The implementation
Guide design to explain how to intervene each standards, additional tools and
documents and capacitate professional knowledge and skill to perform a specific
intervention and to achieve the agreed standards.

3.1. Organizational structure of the Nursing Care Service

The hospital has established nursing care service management structure and job
description including reporting relationships.

Nurses play a pivotal role in any health facility. Encompassing the largest
workforce in hospitals, nurses act as direct caregivers who serve a hospital
twenty-four hours a day, seven days a week. This gives a unique perspective on
hospital operations. Nurses should be allowed to assume managerial roles that
will enable them to make decisions affecting patient/client care at the case team,
unit and department levels

Given the complexities of hospital management and the direct relationship

between hospital operations and patient care, nursing responsibilities have
expanded to include a greater managerial role. This includes assuming an
increased role in hospital leadership and contributing to effective decision-
making within the overall hospital structure, as well as within case teams,
wards/units or departments.
 Nursing Director (matron) is a member of the senior management team (SMT)
and responsible for the overall function of nursing activities in the hospital.

Nursing Director is responsible for the overall function of nursing activities in

the Hospital and accountable to the Medical Director.

The ward head nurses are responsible for the administrative and nursing
functions in the specific Ward/Unit. It is essential that within a case team,
ward/unit there exists a clear management structure that delineates the ultimate
roles and responsibilities within the given team and clinical setting, determining
who has clear authority over certain decision-making processes.

Each nurse in the hospital has written job description singed and attached in
his/her file. Copy of the job description should be given to each nurse.

The hospital should implement supervision and delegation mechanism.

Clinical supervision is “a formal process of professional support and learning

which enables individual practitioners to develop knowledge and competence,
assume responsibility for their own practice and enhance client/patient protection
and safety of care”.

Student nurses should practice under the supervision of preceptors or word

nurses

Nurses may delegate tasks and responsibilities to junior nurses, student nurses or
parallel position nurses. Before delegating, he/she must ensure that anyone they
delegate to, is able to carry out the responsibility of what she/he delegates, and
must provide adequate supervision to ensure that the outcome of any delegated
task meets required standards.

Senior Nurses should have responsible for junior nurses on professional practical
knowledge and skill development all the time.

.
3.2. Nursing Workforce Plan

Shortages of appropriate nursing staff or inappropriate distribution of available

staff adversely affects the quality of patient care. The effect of inappropriate
nursing workforce planning will lead to staff dissatisfaction, burnout and nurse
turnover which in turn contributes to poor quality of nursing care. As the result,
health care associated infection and mortality will increase.

The hospital should establish a nursing workforce plan that:

 Establishes minimum nurse to patient ratios for each inpatient ward/service,

taking the skill mix of staff into consideration,
 Identifies priority areas where the nurse count must at all times meet the
minimum ratio requirements (for example intensive care/high dependency
units, post-operative recovery, emergency department, etc.)
 Establishes a procedure for transferring nurses across clinical settings, or
calling in extra nurses from home in order to maintain minimum nurse to
patient ratios, especially in the priority areas.
 To determine the minimum nurse to patient ratio the following factors to be
considered include:

 The severity of the clinical condition of patients,

 The intensity of nursing care needed, for example the frequency of nursing
interventions such as observations, medication administration, wound care,
stoma care, bathing etc.,
 The number of admissions and discharges,
 The availability of technology (patient monitors, beepers etc.),
 The skill mix of staff, availability and responsibilities of caregivers.

There should be a minimum of a registered professional head nurses in-charge of

each ward/unit that has relevant knowledge, skills and experience with
compassion and respect to manage a ward/unit and the nursing staff therein. The
nurse management team, together with hospit
 .0al management should determine the minimum nurse to patient ratio for the
unit. The ratio should be kept under review and amended as necessary.

The hospital nursing workforce plan should address the mechanism to

answer/cover when there is vacant nursing schedule as the result of sick leave,
maternity leave, annual leave and other problems.

The nursing workforce plan should also consider the role of nurses in outpatient,
inpatient and specialty clinics and the nursing contribution to hospital
management and governance structures (such as quality committees, infection
prevention committees etc.).

3.3. Team Work

Nursing practice must have teamwork, an on-going interaction between members
of the multidisciplinary team, the patients, patients’ relatives and hospital
managers. In working with colleagues and hospital management, the nurses must
be:

 Work with collaborate the patients and their caregivers, plans and decisions
related to patients, colleagues in the formulation of overall goals.
 Work with other members of the multidisciplinary team in caring for patients.
 Consult with other health care providers on patient care, as appropriate,
 Make referrals, including provisions for continuity of care, as appropriate,
 Collaborate with other disciplines in teaching, consultation, management, and
research activities as opportunities arise
 Participate in an organized sub quality Improvement team, and Nurses should
assume responsibility for monitoring, evaluating and reporting of their activities
within the sub quality Improvement and nursing Audit team.

3.4. Nursing Process and it’s components

The nursing care process is an organized, systematic and holistic approach

through which nursing care provision is organized to achieve patient/client
centered care. The nursing process involves Nursing Assessment, Nursing
 Diagnosis, Nursing Planning, Nursing Implementation and Nursing Evaluation
of care (ADPIE). This should be done in collaboration with the patient/client,
family and community. Assessment: the nurse collects comprehensive data
pertinent to the patients’/client’s health or situation.

3.5. Nursing Assessment

Nursing Assessment is the gathering of information about patients physiological,

Psychological, Sociological and spiritual status by a licensed registered Nurse. A
nurse collects and documents critical data regarding patient/client health status.
This assessment remains accessible to the entire health care team during the
course of the client/patient stay and beyond, in order to assist the team in
determining proper client care and treatment. In the nursing assessment, the
nurse gathers and examines both Subjective and Objective data.
 Subjective data are what the patient/client actually states (e.g. "I'm tired").
These are his/her feelings and perceptions.
 Objective data are concrete, observable information and investigation.

Sample Examples:

Subjective data ObObjective data:

"I feel sick.” Blood pressure of 110/70 mm Hg.

"I have a stabbing pain in my side." Rash on right arm
"I wish I were home." Walks with a limp
"I feel like nobody likes me." Ate all of his breakfast
Urinated 150 ml clear urine
3.6. Nursing Diagnosis/ Problem Identification

What is a Nursing Diagnosis?

A nursing diagnosis is a clinical judgment concerning human response to health
conditions/life processes, or vulnerability for that response, by an individual,
family, group, or community. A nursing diagnosis provides the basis for the
selection of nursing interventions to achieve outcomes for which the nurse has
accountability. Nursing diagnoses are developed based on data obtained during
the nursing assessment and enable the nurse to develop the care plan.

3.7. Purposes of Nursing Diagnosis

The purpose of the nursing diagnosis is as follows:

 Helps identify nursing priorities and help direct nursing interventions

based on identified priorities.
 Helps the formulation of expected outcomes for quality assurance
requirements of third-party payers.
 Nursing diagnoses help identify how a client or group responds to actual
or potential health and life processes and knowing their available
resources of strengths that can be drawn upon to prevent or resolve
problems.
 Provides a common language and forms a basis for communication and
understanding between nursing professionals and the healthcare team.
 Provides a basis of evaluation to determine if nursing care was beneficial
to the client and cost-effective.
 For nursing students, nursing diagnoses are an effective teaching tool to
help sharpen their problem-solving and critical thinking skills.
3.8. Differentiating Nursing Diagnoses, Medical Diagnoses, and
Collaborative Problems

The term nursing diagnosis is associated with three different concepts. It may
refer to the distinct second step in the nursing process, diagnosis. Also, nursing
diagnosis applies to the label when nurses assign meaning to collected data
appropriately labeled with NANDA-I-approved nursing diagnosis. For example,
during the assessment, the nurse may recognize that the client is feeling anxious,
fearful, and finds it difficult to sleep. It is those problems that are labeled with
nursing diagnoses: respectively, Anxiety, Fear, and Disturbed Sleep Pattern.
Lastly, a nursing diagnosis refers to one of many diagnoses in the classification
system established and approved by NANDA. In this context, a nursing
diagnosis is based upon the response of the patient to the medical condition. It is
called a ‘nursing diagnosis’ because these are matters that hold a distinct and
precise action that is associated with what nurses have the autonomy to take
action about with a specific disease or condition. This includes anything that is a
physical, mental, and spiritual type of response. Hence, a nursing diagnosis is
focused on care.
COMPARED: Nursing diagnoses vs medical diagnoses vs collaborative
problems:
A medical diagnosis, on the other hand, is made by the physician or advanced
health care practitioner that deals more with the disease, medical condition, or
pathological state only a practitioner can treat. Moreover, through experience and
know-how, the specific and precise clinical entity that might be the possible
cause of the illness will then be undertaken by the doctor, therefore, providing
the proper medication that would cure the illness. Examples of medical
diagnoses are Diabetes Mellitus, Tuberculosis, Amputation, Hepatitis,
and Chronic Kidney Disease. The medical diagnosis normally does not change.
Nurses are required to follow the physician’s orders and carry out prescribed
treatments and therapies.

Collaborative problems are potential problems that nurses manage using both
independent and physician-prescribed interventions. These are problems or
conditions that require both medical and nursing interventions with the nursing
aspect focused on monitoring the client’s condition and preventing the
development of the potential complication.

Actual nursing diagnoses should be written as a three-part statement(s)

which includes:

1. The problem (P)

2. Its cause or etiology (E)

3. Signs and symptoms (S)

The PES format describes the problem and its etiology, together with data (signs
and symptoms) that validate the chosen diagnosis. To write a diagnostic
statement for an actual nursing diagnosis, link the problem and its cause by using
“related to” then add “as manifested by” or “as evidenced by” and state the major
signs and symptoms that validate the diagnosis.

Example:

Problem Etiology (cause)

Symptom/Sign

“Ineffective airway clearance related to incisional pain as manifested by poor

cough effort’

Potential Diagnosis should be written as a two part statements which include:

problem and etiology.

Nurses may also note that a patient/client has certain risk factors that put him/her
at risk of a particular nursing diagnosis. These risk factors and the related
‘potential diagnosis’ should be documented so that the nursing care plan can
include actions to prevent the problem. For example: ‘at risk of impaired skin
integrity due to patients’ age, weight, immobility and confinement to bed’. The
care plan would then include action to prevent irritated or broken skin such as
regular turning, massage etc.).

3.9. Nursing Care Plan

After the nursing diagnoses and collaborative problems have been identified,
they are recorded on the plan of nursing care.

The care plan is a record of interventions that will address the identified
problems. It should be based on the problem identification and the diagnoses,
and should be individualized or tailored to the patient’s/community’s health
problems. The care plan guides each nurse to intervene in a manner congruent
with individual or community needs and goals and provides outcome criteria for
measurement of progress.

This phase entails the following:

1. Assigning priorities to the nursing diagnoses and collaborative problems.
2. Specifying expected outcomes.
3. Specifying the immediate, intermediate, and long-term goals of nursing action.
4. Identifying specific nursing interventions appropriate for attaining the
outcomes.
5. Identifying interdependent interventions.
6. Documenting the nursing diagnoses, collaborative problems, expected
outcomes, nursing goals, and nursing interventions on the plan of nursing care.
7. Communicating to appropriate personnel any assessment data that point to
health needs that can best be met by other members of the health care team.
The plan of nursing care serves as the basis for implementation:
The immediate, intermediate, and long-term goals are used, and, are the focus for
the implementation of the designated nursing interventions. The following
aspects of nursing care should be considered when developing and implementing
a nursing care plan:
 Four key steps to care planning:

 Patient assessment. Patient identified goals

 Planning with the patient. How can the patient achieve their goals?
 Implement. ...
 Monitor and review.

3.10. Implementation of the Plan

Nursing interventions are actions a nurse takes to implement their patient

care plan, including any treatments, procedures, or teaching moments
intended to improve the patient's comfort and health.

Examples of nursing interventions include discharge planning and education, the

provision of emotional support, self-hygiene and oral care, monitoring fluid
intake and output, ambulation, the provision of meals, and surveillance of a
patient's general condition

There are three types of nursing interventions:

 independent,
 dependent, and
 collaborative.

The care plan should be implemented by all nurses who care for patients/clients.
Hence, all staff should be familiar with the care plan and should ensure that the
activities described in the care plan are carried out during each shift.

In implementing the care plans, nurses should use a wide range of interventions
designed to promote, maintain, and restore mental and physical health.

All nursing interventions are patient-focused and outcome-directed and

implemented with compassion, confidence and a willingness to accept and
understand the patient’s responses. Although many nursing actions are
independent, others are interdependent, such as carrying out prescribed
treatments, administering medications and therapies, and collaborating with other
health care team members to accomplish specific expected outcomes and to
monitor and manage potential complications. Such interdependent functioning is
just that—interdependent. Requests or orders from other health care team
members should not be followed blindly but should be assessed critically and
questioned when necessary.

The Nursing interventions/implementation should be:

 For each admitted patient, the nursing process form should be attached and
the assessment should be completed immediately after admission.
 Based on current knowledge and principles of relevant preventive and
therapeutic modalities.
 Selected based on the needs and /or desires of the individual or community.
 Selected according to the nurse’s level of practice, education and
certification.
 Implemented within the established plan of care.
 Performed in a safe, ethical and appropriate manner.
 Adapted to changing patient needs and situations.
 Reviewed in order to recognize the progress or lack of progress and,
reassignment of priorities is required towards identified goals.
 Nurses should document progress reports at the end of each shift which
should consist of nursing interventions, patient/client responses,
patients/clients emotional adjustment and rendered patient/client education.

3.11. Nursing Evaluation of the plan

Evaluation is the process of determining the extent to which the set goals have
been achieved. The nurse must evaluate the results to determine whether the
interventions were effective or not. Nursing care evaluation is a dynamic process
involving change in the patients/clients health status over time, giving rise to the
need for new data, different diagnoses, and modifications in the plan of care.

As new problems arise they should be entered on the Problem Index List and
related goals and activities should be established to address the problem.
Similarly, if a problem is resolved, this should be recorded on the Problem Index
List to indicate that goals and activities related to that particular problem are no
longer necessary.

Nursing Evaluation involves the following activities:

1. Have the goals of the care plan been achieved?

2. If not, why not? Were the goals realistic?
3. Was the client/patient committed to the goals?
4. Was there enough time to achieve the goals?
5. Did other problems arise that impeded progress?
6. Which interventions were consistently performed as prescribed?
7. Have any new problems developed that have not addressed?
8. Could more have been achieved than originally hoped?
9. Should new goals be set?
10. The action plan should be checked at intervals, randomly by the nurse
supervisors/head nurses and should be documented.

3.12. Accountability and Responsibility

1. The nurse remains accountable for his/her own practice as well as for the
delivery of the care plan and for ensuring that the overall objectives are met.
2. Reassessing the condition of the person in their care at appropriate intervals
and determining that it remains stable and predictable;
3. Observing the competence of the caregiver(s) and determining that they
remain competent to perform the delegated task of care, safely and
effectively.
4. Hospitals should ensure that nurses have access to and are trained on how to
use resources (including equipment and consumables) correctly and cost-
effectively. Nurses are responsible for forecasting stock-outs of nursing
 formats and other consumables on the ward, and should inform the
appropriate party of the need for additional resources to prevent stock out.

3.13. Nursing Ethics

Ethics and code of conduct Provides:-for the professional standards for nursing
activities, Concerned with fundamental principles of right and wrong, what
people ought to do and inform our judgments and values and help individuals
decide on how to act. Ethics determines the characteristics of a profession and is
also called as a “code of conduct” which protects the nurses and the patients
from legal and ethical issues. The International council of nurse’s code of ethics
is grouped into four distinct areas.

o Promote health,
o Prevent illness,
o Restore health, and
o Alleviate suffering.

Principle of Nursing Ethics

 Respect the Autonomy: - individuals have a right to self-determination,
which is to make decisions about their lives without interference from others
and respecting a client’s rights, values and choices is synonymous to
respecting a person’s autonomy. Informed consent is a method that promotes
and respects a person’s autonomy.
 Beneficence and none maleficence: - , Doing good by providing health
benefits to the patients and don’t harm or hurt your clients .
 Justice:-Equal and fair distribution of resources, based on analysis of benefits
and burdens of decision. Justice implies that all citizens have an equal right to
the goods distributed, regardless of what they have contributed or who they
are. Promote justices ensuring fair allocation of resources. Example:
appropriate staffing or mix of staff to all clients and priority treatments for
the clients in pain)
 Privacy and Confidentiality:-Privacy belongs to each person and, as such, it
cannot be taken away from that person unless he/she wishes to share it.
Confidentiality, on the other hand, means that the information shared with
other persons will not be spread abroad and will be used only for the purposes
intended.

3.14. Communication and Documentation

The hospital should establish clear guidelines for both verbal and written forms
of communication for in-patient, Emergency; Outpatient and Delivery Case
Teams.
a) Written communication: This includes the written documentation of all
findings, progress, care and treatment provided to the client by the
multidisciplinary team. A written record permits immediate access to all
information related to the patient’s care and facilitates the exchange of
information between all members of the case team.
b) Verbal communication: this entails the act of reporting and conversing with
other members of the health care team regarding the client’s progress and
status.
Verbal orders will only accepted in emergency situation. The nurse will
only accept verbal orders in an emergency situation in the presence of two
nurses. However the verbal order should be translated to written document by
the responsible HCWs within 24 hours.

3.15. Patient Education

Nurses should give health education for all patients, also incorporate family
members and other caregivers who often play a strong role in facilitating patient
care in coordination with the medical staff. One suggestion to improve the family
and staff relationship is with the use of a Patient Caregiver Contract, whereby the
relationship is formalized between families/caregivers and medical staff.
3.16. Medication Management

It is the nurse’s responsibility to safely administer the medications to a patient as

ordered by the physician. Nurses should be aware of the desired outcome,
dosage, preparation and side effects of each prescribed medication.

Procedure
1) Physician Order: A physician’s order is required for the administration of
all medications. There are several types of orders:
 Standing order: To be carried out as specified until it is
canceled by another order (including PRN
orders).

 Single order: To be carried out only once, as directed.

 Stat order: To be carried out immediately.

 Verbal order: An order that has been communicated through

the phone or verbally. These orders are reserved for times
when the physician is unable to reach the patient’s medical
record. Verbal orders can only be taken by a nurse, who must
immediately transcribe the verbal order into the Physician
Order Sheet. Verbal orders from a physician to a nurse must
be told to 2 nurses simultaneously in order to ensure that
instructions are clearly understood and verifiable. All verbal
orders must be co-signed by the physician within 24 hours.

Physician orders need to include the following information when they are
transcribed into the Physician Order Sheet in order to be considered
complete. Orders are not to be carried out unless all of these elements are
present including OXYGEN order and administration. If an element is
missing, the physician who issued the order should be called to complete the
order.
 Date and time: When the order was written.
 Full name of the medication: Either the chemical or generic
name can be used without abbreviations.
 Dosage: Specify the amount of medicine to be given.
Abbreviations are discouraged.
 Concentration: If the medication is to be diluted in IV fluid,
the amount and type of diluent/s ordered.
 Duration: If the medication is to be given over a period of
time, such as IV administrations, the duration of the infusion
ordered should be recorded by the physician. Nurses should
then translate and document the duration of infusion into
number of (micro) drops per minute.
 Time and frequency: The time of day and how often a
medication is to be given, as ordered by the physician. The
nurse who transcribes the order will identify the specific time
that the medication is to be given by following a standardized
schedule.
 Route: For medications that can be given in several ways, the
route of administration needs to be clearly written.
 Physician Signature: Is to be clearly written immediately
following the order.
 OXYGEN : Flow rate (liter/min), mode of delivery, Target
Saturation, frequency of monitoring,

2) Transcribing the Order: Medication orders are transcribed by the

nurse from the physician order sheet to the Medication
 Administration Record. The nurse will document that the order has
been transcribed by putting a signature next to the order.

The nurse is responsible for questioning the physician regarding any medication
order or element of an order that is in his/her judgment an error. The perceived
error may be in the drug ordered, dosage, route, time and/or frequency to be
given.

3) Administration of Medications: The following steps should be

followed by the nurse when administering medications. Two
processes are outlined which differ based on whether the medication
is stored at the patient’s bedside or in a central cabinet. There are
three distinct steps to administering medications: preparation,
administration and documentation. Each step requires safety checks
to ensure that the right drug is given to the right patient.
4) The Right Rule of Medication Administration
- The Right Patient
- The right Medication
- The right Rout
-The right Dose
-The Right Time
- The Right Reason
- The Right Documentation
- The Right Response

Medications in a Cabinet
All prescribed patient medication should be stored in a place where protected
from affecting its potency and only managed by the authorized nurse/HCWs.
Central medication storage is the recommended medication management.
When the nurse deliver the medication to the patient always follow bill of drugs
(the right patient , the dose, the right rout, the right time and right medication)

4) Administration:
 The nurse who prepares the medication should always be the
nurse who administers the medication.
 During administration, medications should never be out of the
sight of the administering nurse.
 The nurses shall facilitate for OXYGEN availability, stock out
and confirm fully prescribed as other medication in specific
ward/Unit.
 It is the nurse’s responsibility to confirm that they are giving
the correct drug to the correct patient. When the nurse arrives
at the patient’s bedside, the nurse must confirm using two
methods that the patient is properly identified.
 Check the name on the Medication Administration Record
with the patient’s posted name.
 Ask the patient to repeat their name.
 Once the correct patient is verified, administer the medication.
If it is an oral medication do not leave it for the patient to take
later. The nurse needs to observe all medications being taken
to assure that the medication has been adequately
administered.
 If a patient refuses a medication, the physician should be
notified and it should be clearly documented in the medical
record.
 5) Documentation: Immediately following the administration of a
patient’s medication, the nurse who administered the medication must
document on the Medication Administration Record that the
medication has been given. The nurse must document the time that
each drug was given and then sign and initial the record including
OXYGEN.

3.17. Nursing care practice audit

The nursing care practice audit should be part of the overall hospital quality
improvement project.

Nursing practice audit is one of the tools to ensure the clinical effectiveness of
nursing care patients/clients receive. Refer to Clinical Governance chapter for
more information on clinical audit process.

3.18. Purposes of Nursing Audit

 Evaluates nursing care patients/clients receive.

 Promotes quality improvement of nursing care.
 Improves quality of record keeping.
 Focuses on care provided and not on care provider.
 Contributes to research.

There are two methods of nursing audit

1. Retrospective Review - this refers to an in-depth assessment of the quality of

care after the patient has been discharged. The patient’s chart is the source of
data.

Retrospective audit is a method for evaluating the quality of nursing care by

examining the nursing care, as it is reflected in the patient care records for
discharged patients. In this type of audit, specific behaviors are described then
they are converted into questions and the examiner looks for answers in the
record. For example, the examiner looks through the patient's records and asks:
 Was the problem solving process used in planning nursing care?
 Was patient data collected in a systematic manner?
 Was a description of patient's pre-hospital routines included?
 Were laboratory test results used in planning care?
 Did the nurse perform a physical assessment? How was the information
used?
 Did the nurse write nursing orders? And so on.

2. Concurrent Review - this refers to the evaluations conducted on behalf of

patients who are still undergoing care. It includes assessing the patient at the
bedside in relation to a per-determined criterion; interviewing the staff
responsible for this care and reviewing the patient’s record and care plan.

Criteria to conduct nursing audit

 Define patient population
 Identify a time framework for measuring outcomes of care
 Identify commonly recurring nursing problems presented by the defined
patient population
 State patient outcome criteria
 State acceptable degree of goal achievement
 Specify the source of information
 Determine the design and type of data collection tool

3.19. Shift Nursing Services handover and round

 hospital implements shift based nursing services (the
hospital should implement based on the area setup ,staff
conveniences and available resources they can arrange the
3 shift hrs)
  Nursing staffs conduct and participate in all types of
patient rounds: Grand Round, Nursing Round and hand
over shift round based on developed round protocol,
hourly round for critical patients and document the
process.

3. 20. Nursing Station

 The Hospital should have Nursing Station with the

presence of necessary equipment and supplies to
accomplish nursing care practice in each unit and the
unit has equipped for specific minor procedures.
 The Nursing station equipped with necessary relevant
and updated guidelines, policy, protocols, magazine,
books, studies, computer with internet access.

3.21. Skill lab

Skill Lab refers to specifically equipped Practice Rooms functioning us training

facilities offering skill/based training for the practice of clinical skills prior to
their real life application.
The following groups will be benefited from Skill Lab:

 New graduated nurses

 Student nurses
 Assigned but found incompetent during Nursing Audit ( Sample of skill
Lab Equipment’s and supplies are annexed)
4. Chapter Summary
A nurse is a caregiver for patients and helps to manage physical needs,
prevent illness, restore health and alleviate suffering. To do this, they need
to observe and monitor the patient, recording any relevant information to aid in
treatment decision-making.

Nurses help people and their families cope with illness, deal with it, and if
necessary live with it, so that other parts of their lives can continue. Nurses do
more than care for individuals. They have always have been at the forefront of
change in health care and public health.

In addition, a nurse employs an appropriate strategy to establish a good rapport

with a patient and is able to understand a patient’s condition in such a way that
they can motivate him or her to actively participate in every nursing activity.
Each nursing activity should consider patient safety. Nurses are responsible for
preventing patients from falling and from developing pressure ulcers, urinary
tract infections, and nosocomial infections. They provide education and
information regarding the procedures involved in nursing interventions
beforehand and involve patients for their own safety; effective communication
is the key to patient safety.

In conclusion, strengthening nursing care will greatly contribute the highest

health outcome and efficiency in the health care system of a country.
5. Annexes

5.1. Monitoring & Evaluation Tools

Hypoxic Patient Registry

Region ____________________Zone
__________________Woreda_______________Name of Health
Facility ________________

Name of Ward/
Department/Un_________________________________ Month and
year ______________ sure
Registration Patient Name Kebele/ Sex Age Wt Date of Patient SpO2 Patient Treatment SpO2 at Date of
number Village admissi diagnosed at received outcome discharge discharge
on to have admiss oxygen
(1. Cured 2.
hypoxia ion therapy:
Improved/o
by:
n follow up
 5.2. Nursing Assessment Format

Patients’ Nursing Process Documentation

Name: Father Name: HOSPITAL

Address:- City: Sub city:
Kebele: House no.
Ward:
_____________________________________
MRN: Age:
Bed No.:
Tel. No.:
___________________________________

Personal Details

 Male  Female Nationality: Ethnic group:

Language:

Marital Status: Religion:

Occupation (previous and current):

Patient’s support

1. Name: 2. Name:

Relationship: Relationship:
Address: Tel No.: Address: Tel No.:

City: Sub city: City: Sub city:

Kebele: House no. Kebele: House no.

Health Perception/Management

Patient’s understanding of reason of admission:

Significant Others’ understanding reason for admission:

Understanding of Medication (what, how and why) Patient is taking before admission (incl. “over the
counter” and known allergies)
Drug name Dose Freq. Drug name Dose Freq.
 Role and Relationships

_______________________________________________________________

Discharge Arrangements and Other Social Details

Lives alone?  Yes  No Comments:

__________________________________________

 Yes  No Comments:
Employee?
__________________________________________

 Yes  No Comments:
Self-employed? __________________________________________

 Yes  No Comments:
________________________________________
Dependents?

 Yes  No If no, please state who helps with & how many
Is patient independent?
times per week:

Cooking: __________ Washing / Dressing: __________

Shopping: _________ Cleaning:

____________________

Other: ____________ Other: _____________________

Ability to Pay for treatment: __________

Vital sign

Vital Sign Additional For Pediatrics

Respiratory Rate MUAC(Med-Upper-Arm-Circumference)

Blood Pressure Head Circumference

Pulse Rate Immunization Status

Temperature Growth Monitoring

Pain score

Weight

Height

Patient Assessment for Activity of Living

1. Cognitive and Perceptual

 Level of consciousness
 Reflexes (Eye , hand grasp and movement of extremities)
 Sensorial (eye, ear, nose, tongue and skin)
 Pain
 Cognition (primary language, speech deficit and any LD)
2. Activity and Exercise

 Breathing – respiratory
patterns, lung sounds,
cough, oxygen supplement,
any respiratory tubes
 Circulation: Peripheral
pulse, cardio vascular
check, chest pain, jugular
ventilation, history of
murmur, pacemaker

 Special diet
 Pattern of daily food
 Fluids intake
 Appetite
 Weight
 Nausea and vomiting
 GI Pain
 Condition of mucous membrane
 Dental condition
 Skin (warm, dry, cold, moist, thurgor)
 Mobility
 Colour (pink, pale, dark, jaundice,
cyanosed,)
 Odema
  Wound/drainage/dressings
IV Line

3. Nutrition and Metabolism

4. Elimination-Urine and faeces Assessment results

 Usual time of bowel movement

 Any recent changes in elimination
 Any excess perspiration
 Bowel sounds
 Abdominal tenderness
 Stoma (type)
 Any brut
 Use of anything to manage bowels
(laxatives, enema, suppositories, home
remedies, etc.)
 Urinary pattern (frequency, character,
amount, incontinence, retention, nocturia,
etc.)
5. Psychological Care
Coping with stress

 Response to stress
 Relaxation methods
 Support groups/ counselling resources

6. Spiritual/Dying
Value and belief:

 Cultural practice (yes or no)

 Religious practice(yes or no)
 Familial traditions (yes or no)
 Would you like your religious leader to be contacted?
(yes or no)

7. Sleeping
Sleep/rest pattern:

 Adequacy of sleep(yes or no)

 Difficulty of sleep(yes or no)
 Factors affecting
sleep/rest…….
Methods to promote
sleep………

8. Sexuality and Reproductive

Female : menopausal ( yes or no),
Menstrual pattern:,
Date of LMP:,
Use of contraceptive(type)
Monthly self-breast examination
Vaginal discharge/bleeding, lesion

Male
Monthly testicular examination
Prostate problems
 Penile discharge

Summary subjective data Summary objective data

NAME OF ACCEPTING/RECEIVING NURSE: _________________ DATE: ___________

TIME: ___________

SIGNATURE AND DESIGNATION OF ADMITTING NURSE:

Nursing Diagnosis or Problem Index List

Full name___________________________________ Age __Sex____ MRN: Tel. No.: Ward: Bed No.:
Problem no Diagnoses/ problems Date identified Signature and Date Signature
designation resolved and
designation
 Nursing Care Plan

Full name___________________________________ Age __Sex____ MRN:

Tel. No.: ________________________________Ward:___________________ Bed No.:_______

Date and Proble Goals Expected outcomes Interventions Signature

Time m No and
designation
Implementations

Full name___________________________________ Age __Sex____ MRN:

Tel. No.: ________________________________Ward:___________________ Bed No.:______

Date Problem No Implementations Interventions Signature

Identified and
and Time designation
Progress note
Progress report no. ____ Shift: Morning  Afternoon Night Date___________ Time___
Signature_____________ Subjective:
____________________________________________________________________________
_______________________________________________________________________________
_______Objective:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
___________________________________________________
Analysis/ Assessment: Plan:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
________________________________________
Progress report No. ____: Shift: Morning  Afternoon Night Date___________ Time____
Signiture______
Subjective:______________________________________________________________________
______________________________
_______________________________________________________________________________
Objective:
_______________________________________________________________________________
_______________________________________________________________________________
______________________________________________
_____________________________________________________________________________
Analysis/ Assessment:
_____________________________________________________________________________
Plan:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
____________________________________ Progress report No. ____:Shift: Morning 
Afternoon Night Date___________ Time___ Signature______
Subjective:______________________________________________________________________
______________________________
_______________________________________________________________________________
Objective:
_______________________________________________________________________________
_____________
_______________________________________________________________________________
__________________ Analysis/ Assessment:
_____________________________________________________________________________
Plan:
_______________________________________________________________________________
__________________
_______________________________________________________________________________
__________
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