Daily Patient Census

The daily patient census allows the movement of patients in the service to be recorded 24
hours a day. The responsibility for filling out the form is the direct responsibility of the
head of the service. It is an important instrument for assigning personnel.
All “entries” and “exits” that occur in the hospitalization room being counted will be
recorded, but only after they have been carried out, that is, the entry will be recorded at the
moment the patient occupies the bed provided and the “exit” ” since I vacated it and left the
room. If a patient is admitted from another level of care in the hospital, it constitutes a
transfer admission to that level of care, but should not be considered an admission to the
facility. The census day is considered equal to the calendar day, that is, it covers a period
between 0 and 24 hours, according to Technical Standard No. 152. Bed and patient
management information standard.

Daily Bed Census

Hospital bed: It is one installed and available 24 hours a day for regular use by hospitalized
patients during their stay in the establishment. Beds for staff on duty, pre-delivery, delivery
room, procedure room, emergency rooms, minor surgery, laboratory, x-rays, blood bank,
normal newborns, post-operative recovery and those intended for outpatients are excluded.
Normal provision of beds: These are the beds assigned to the establishment by the
competent authority, installed and available 24 hours a day for the hospitalization of
patients, which function regularly during periods of normal activity. The provision is not
affected by temporary fluctuations, that is, beds that are added or removed for short periods
of time.
Available beds or working beds: is the number of beds actually installed in the hospital, in
conditions of immediate use for the care of hospitalized patients, regardless of whether they
are occupied or not. The number of beds available may vary daily due to:
• That the number of beds be increased due to increased demand, state of emergency,
etc. Conversion beds (for example, due to a winter campaign or another health emergency)
must be considered available beds in the functional unit to which they were intended and
will be reduced in the functional unit of origin.
• Those that are out of service for reasons of disinfection, room repair, temporary
closure due to lack of resources, etc. are not counted as available beds.

Daily hospital admission: is the formal acceptance of a patient by the hospital for medical
care, observation, treatment and recovery. Every admission to the hospital involves the
occupation of a hospital bed, the maintenance of a medical history to record all the care
provided and an IEEH. Babies born alive or dead in the establishment, people who die
while being transferred to the establishment, and people who die in the establishment's
emergency unit should not be considered income.
Occupied beds: it is the permanence of a hospitalized patient occupying a hospital bed,
during the period between 0 hours and 24 hours of the same day. The admission and
discharge of a patient on the same day should be considered an occupied bed day.
Days of stay: It is the total number of days that the patient remained hospitalized in the
establishment and corresponds to the number of days elapsed between the date of
admission and the date of discharge.
Steps to carry out a daily census of beds and patients: The admission unit must deliver daily
to the statistics unit, a copy of each of the Statistical Reports of Hospital Discharges (IEEH)
corresponding to the hospitalizations of the previous day, which must be Sort by levels of
care, with the purpose of monitoring the bed and the patient and validating the data from
the daily census of beds and patients. The admission unit is responsible for generating the
hospital discharge statistical report, IEEH, when the patient is ordered to be hospitalized.
• Census date.
• Identification of functional units.
• Existence of patients from the previous day.
• Patients admitted from outside the hospital.
• Patients admitted due to transfer from other functional units of the same hospital.
• Discharge patients.
• Patients transferred to other functional units of the same hospital.
• Deceased patients.
• Number of beds occupied.
• Number of unoccupied beds, but in conditions of use.
• Compare the names of the admitted patients with those that appear on the list of
hospital admissions provided by Admission.
• Check that the daily census of beds and patients in each room or functional units is
complete before notifying available beds.
• Verify that in each functional unit the existence of patients at 0 hours (balance from
the previous day) coincides with the existence at 24 hours (balance for the next day) of the
previous day's census.
• Delivery of information to Statistics for incorporation into the REM series.

Hospital indicators:
• Average days of stay: is the average number of days of hospitalization for each
patient in a given period of time. It measures how many days on average a patient is
hospitalized from admission to discharge.

Total days of stay of discharged patients in a given period

Total expenditures for the same period

• Average available beds: is the average number of beds that were in operation each
day in a given period. It is obtained by dividing the days of beds available in the month by
the number of days in the month.

Total bed days available in a given period

Total days of the same period

• Bed turnover rate: measures the number of patients who pass through a hospital bed
in a given period of time.

Total expenses in a given period

Average number of beds available or in work for the same period

• Fatality rate or mortality rate: it is the relationship between the number of deaths
that occurred during a period in an establishment and the number of discharges during the
same period.

Total discharges due to death in a given period * 100

Total expenditures for the same period

• Replacement interval: it is the average time that a hospital bed remains unoccupied
between the discharge of one patient and the admission of another.

(Total days of beds available – total days occupied)

Total expenses

• Occupational index or percentage of occupancy: it is the average number of beds

that were occupied daily during a period, expressed as a percentage. It is an indicator of the
use of the bed resource and from it it allows adjusting the planning and use of the bed. It is
useful to determine the average number of patients that have been treated in a period.

Total days of beds occupied in a given period *100

Total number of bed days available or in operation

Intensive Care Sheet

Each institution has its formats in general, they cover complex special care, by evaluating
them the quality of care is known. Documentation of the nursing process is evident by
demonstrating the complexity of care and the need to promote knowledge, motivation and
recognition programs.
ICUs are sections of hospitals that have specialized equipment and highly qualified
personnel to treat patients suffering from serious illnesses or injuries. Patients may be
admitted to the ICU after being in an emergency department or another section of the
hospital, after surgery, or after being transferred from another healthcare facility.
Equipment commonly used in the ICU.
• The monitors: measure body functions, such as breathing and heart rate. In general,
they have alarms that are activated to notify the ICU staff in case these functions are not
within normal parameters.
• Intravenous catheters (tubes) are inserted into patients' veins to give them
medications, fluids, and nutrition as needed. A nasogastric tube may be inserted through the
nose and into the stomach. The urinary catheter is used to drain urine from the bladder.
• Mechanical respirators (also called ventilators) are machines that help the patient
breathe through a tube that is inserted through the mouth or nose into the windpipe and
connected to the respirator.

Disorders that can be treated in the ICU

• Acute respiratory distress syndrome: This is sudden lung failure that often requires
the use of a respirator. It is caused by other diseases, such as infections or serious injuries.
• Asthma: is the obstruction of the airways that causes difficulty breathing, wheezing,
tightness in the chest and cough.
• Chronic obstructive pulmonary disease: makes it difficult to exhale. It is generally
caused by lung disorders related to smoking, such as emphysema and chronic bronchitis.
• Pneumonia: is an infection of the lungs that can interfere with breathing.
• Respiratory distress syndrome: Can develop in babies whose lungs are not fully
developed, causing difficulty breathing.
• Sepsis: is a very serious infection of the blood or tissues.
• Trauma: These are injuries, for example, due to a car accident that generally require
surgery.

ICU care team

• Doctors: Critical care doctors are trained in all aspects of caring for seriously ill
patients.
• Nurses: ICU nurses are specially trained to care for seriously ill patients and provide
24-hour bedside care and monitoring.
• Respiratory therapists: Monitor patients' breathing and use equipment, such as
respirators, needed to improve breathing.
• Physical Therapists: Help patients maintain flexibility and muscle strength to
prevent disability and speed recovery.
• Nutritionists: evaluate patients' food and fluid needs.
• Social workers: Help patients and families resolve various issues related to serious
illness, including financial and psychological problems, and provide assistance with
rehabilitation after discharge from the hospital.
• Pastoral care staff: Provide spiritual and emotional support to patients and families.

Basic Nursing Functions

• Management function: allows you to manage material, human and financial care
resources, with efficiency and quality criteria.
• Care function: occurs in 100% of critical care nurses and provides timely,
comprehensive and individualized care through the application of nursing methodology
(nursing care process).
• Teaching function: it is divided into patient education and team education. The
training of future Nursing professionals must also be an objective for Critical Care Nursing,
since this training results in the quality and excellence of those who will eventually carry
out their work in our units.
• Research function: as a fundamental element of nursing science that allows
generating knowledge to apply in practice and taking new problems that arise from that
practice to investigate.
Daily care
• Participate in the Nursing relief to know the evolution of our patient during the last
24 hours, with special interest in the immediate reality (the last shift).
• Apply the planned care for our patient.
• Apply prescribed medical treatment and collaborate with the physician in diagnostic
and therapeutic procedures.
• Complete the unit's Nursing records: chart, care plan, progress sheet, etc.
• Monitor and record vital signs.
• Act in situations of immediate life threat.
• Monitor the patient's nutrition: tolerance, type of diet, sensation of appetite.
• Provide an adequate response to the demands of the patient and family and ensure
that they have the resources to send them to us.
• Mobilize the patient safely when indicated (postural changes, getting up from the
chair)
• Ensure correct patient hygiene, especially before and after meals (hands, mouth) and
whenever the circumstance requires it (diarrhea, vomiting, diaphoresis...)
• Ensure correct compliance with isolation measures by staff, patients and family
members.
Patient hygiene:
• Complete hygiene will be carried out at least once a day and as many times as
necessary. The entire Nursing team responsible for that patient will collaborate in it (nurses
and auxiliary care technicians in Nursing, before starting the hygiene, the nurse will be
informed of the patient's condition and all those particularities of the patient that must be
taken into account during the technique (patient with high ICP, poly-trauma, post-cardiac
surgery, arrhythmias, etc.)
• During the hygiene of the bedridden patient, the nurse will be especially responsible
for the correct mobilization and manipulation of the patient, paying special attention to the
protection of airways, drains, tabulators, dressings, etc.
• In the case of hygiene and mobilization of intubated patients, the nurse will
maintain manual fixation of the endotracheal tube throughout the mobilization process to
prevent its accidental displacement. In the event of any respirator alarm, the hygiene
process will be stopped and the situation that caused the alarm will be resolved (aspiration
of secretions, accidental disconnection, lack of sedation and/or relaxation.

Income Book
It is the set of technical-administrative activities carried out in a hospital to admit the
patient, whose objective is to offer care according to their needs or problems through
appropriate and specific resources. It is considered admission of the patient to any service
that includes (surgery, internal medicine, pediatrics, etc.) Because his or her state of health
requires appropriate treatment for that condition (surgical treatment, or medication-based
treatment).
The entry routes can occur through the emergency department, outpatient clinic, or
specialty office.

Types of income
• Scheduled admission: this is when the patient requires hospital care prior to
controlling their condition at different levels.
• Emergency admission: this is when the patient requires immediate assistance due to
the sudden onset of an acute condition or due to an accident.
• In-hospital admissions: if the patient comes from another hospital unit. It is when
the patient is admitted from another hospital unit. for example when the patient comes in
for a general consultation.

Nursing care upon patient admission

to) You are greeted with kindness and escorted to your room
b) Identify the user
c) Fill out admission forms with personal information
d) The room is prepared and must be clean and tidy.
and) You are informed in a clear, brief and understandable way about the rules that must
be respected in the unit, the hospital regulations.
F) Unify criteria on how you like to be called to gain the patient's trust.
g) Carry out an initial assessment of the patient.
h) Place the patient's identification bracelet.
Yo) The clinical record is integrated.
j) The patient's admission is recorded, as established.
k) Vital signs and somatometry are taken.
l) You are given the location and orientation.
m) Give the patient bathing equipment and clothing, help him when taking a bath and
when dressing.
n) Observe the general condition of the patient, install him in his bed.
either) Store the patient's personal belongings in the closet or bureau.
p) Make a package and the respective list of the patient's values, which must be signed
by the patient and the nurse to be deposited in the box or given to family members.
q) Notify the doctor of the patient's arrival.

Requirements
• Medical order for hospitalization
• Old clinical history if you have one, new medical history folder if you are
hospitalized for the first time, except in the adult, pediatric, or neonatal critical care unit.
• In adult critical care units, interconsultation with acceptance by the specialist doctor.
Equipment
• Sheet for taking and recording vital signs.
• Complete medical history
• Clothing and toiletries necessary for hospitalization.

Procedure:
• Greet the patient and companion by name and introduce yourself.
• Conduct an interview with the patient and/or family, explain the procedure and
obtain their consent, request a signature in the ac-f034 informed consent format.
• Review these documents to ensure they apply to the patient.
• In the critical care unit, newborn unit, if the patient arrives referred from another
institution, IMI or chronically ventilated, ask the ambulance staff to make the
administrative entry at the emergency window. If the patient is referred from the ventilated
chronic unit, verify that he or she brings the complete medical history.
• In patients coming from the ventilated chronic unit, verify that you have admission
criteria such as patients requiring inotropic vasopressor support.
• Broad spectrum antibiotic support requirements
• Isolation of contact, invasive monitoring, patients with hemodynamic instability,
surgical emergencies.
• Blood product transfusion requirements
• If the patient is admitted for a surgical procedure: o verify authorization of the
procedure. Or inform the doctor on duty of the patient's admission. If the patient is critical
care:

Hospital Income
It includes a series of technical-administrative activities that are carried out in health
centers to admit the patient and whose objective is to provide care, depending on their
needs or difficulties through appropriate and specific resources.
Scheduled admission: this is when the patient requires hospital care and prior to condition
controls at different levels.
Emergency admission: this is when the patient requires immediate assistance due to the
sudden onset of an acute condition or due to an accident.
In-hospital admissions: if the patient comes from another unit of the patient. It is when the
patient is admitted from another hospital unit. For example, when the patient comes in for a
general consultation.
Goals
• Achieve the adaptation of the patient and/or family to the hospital environment in
the shortest possible time, with personalized and humane treatment.
• Offer the information required by the patient and/or family.

Requirements for your entry

Private Patients
Provide information about your personal data:
• Present identity card.
• Sign the Authorization and Responsibilities document that authorizes the Hospital
and its doctors to provide you with diagnoses, treatment and rehabilitation.
• Sign the regulations and rehabilitation.
• In the case of a scheduled check-in, you have the option of pre-registering the room
for the day of your check-in.

GENERALITIES
• Give the patient bathing equipment and clothing; help you when you take a bath and
when you get dressed.
• Observe the general condition of the patient; install it on your bed
• Store the patient's personal belongings in the closet or bureau.
• Make a package and the respective list of the patient's values, which must be signed
by the patient and the nurse to be deposited in the box or given to family members.
• Notify the doctor of the patient's arrival
ANNEXED DOCUMENTATION.
• pharmacy voucher
• Nursing clinical record sheet
• Medical indication sheet
• Patient identification sheet.
• Daily movement of patients.
• Logbook recording income and expenses of the service.

HOSPITAL DISCHARGE / HOSPITAL DISCHARGE

Hospital discharge refers to the technical-administrative procedures that are carried out
when the patient leaves the hospital according to the type of discharge.
GOALS:
• Teach the patient and family the knowledge and skills necessary to continue care at
home
• Guarantee home care, communication and interrelation with primary care
• Deliver the relevant clinical/legal documentation for leaving the hospital area.

Registration Plan
Both discharge due to improvement and voluntary discharge require a discharge plan that
must begin upon admission to a health institution to consolidate self-confidence and
independence.
Objectives of the patient's discharge plan for improvement or voluntary are:
• Offer continuity of care at home
• Encourage the patient in self-care activities
• Maintain the patient's physical activity
• Reduce readmissions as much as possible
• secondary complications

Necessary Equipment:
• Nursing and medical discharge report.
• Printed for ambulance (if necessary)
• Medication (if necessary)
• Means of transportation (wheelchair, stretcher, etc.)

Types of Expenses.
Discharge due to improvement
It is the discharge of the patient from a health institution when their recovery is satisfactory.

STEPS:
• prepare discharge plan
• record data related to the patient's discharge in the clinical record documents
• provide clothing for you to wear or help you
• notify the social work department and the admission service
• transfer the patient to the admission service taking the clinical record
Voluntary discharge
This may occur for economic reasons, transfer to another institution or dissatisfaction with
the care provided or maladjustment in the hospital environment.

Steps
• Prepare discharge plan
• Record data related to the patient's discharge in the clinical record documents
• Verify the signing of the consent and response document (to delimit responsibilities)
• Provide clothing for you to wear or help you
• Notify the social work department and the admission service
• Transfer the patient to the admission service taking the clinical record
Egress due to leak
When the patient leaves the hospital without medical authorization. The role of the nursing
staff is to provide the necessary information on the procedures to follow in the event of a
leak, requiring the clinical record.
Steps
• Notify immediately
• Make nursing notes on the date and time of the patient's escape
• Send the file to the social work department
Discharge due to death
It is the discharge of the patient who has died. The role of nursing staff is to provide
guidance to family members on the administrative procedures that must be followed in the
event of death.
• The nursing staff consists of providing guidance to family members on
administrative procedures.
Steps
• Listen, guide or calm family members to overcome grief over the death
• Integrate the clinical record with the corresponding annotations
• Provide postmortem care
• Transfer the corpse to the anatomopathology service.
• Guide family members about the procedures
Patient Transfer
Goals

General
• Develop a standardized protocol for action and care for the patient and family
during an intra-hospital transfer.

SPECIFIC
• Define the main functions of each component that intervenes in the different phases
of intrahospital transfer
• Outline this protocol for the correct understanding and interpretation of all
personnel involved in intra-hospital transfer.

We can define intrahospital transfer as the transfer of a patient to another hospital unit, on a
specific or momentary basis, to perform a diagnostic or intervention test, as long as it is
carried out inside the hospital facilities where the patient is admitted. This intrahospital
transfer will require one or other conditions depending on the needs and condition of the
patient.

In every intrahospital transfer we can differentiate three stages, in which the different
professionals who will provide care to the transferred patient will intervene. The three
essential stages in any transfer are:

• Preparation for the transfer or Pre-transfer Stage

It is the stage prior to the transfer in which the patient and family are informed about the
need, risks and benefits of the transfer. This stage is carried out in the unit where the patient
is admitted and the personnel in charge of care in this phase are the unit staff. The functions
of each professional will be established later.
• Patient transfer and stay in the testing unit.
It is the phase of transferring the patient from their admission unit to another unit or to
perform a complementary/diagnostic test, while this test is performed and the subsequent
transfer to the unit of departure. The accompanying staff will be in charge of ensuring the
patient's safety, as well as the early identification of any alteration in the patient's condition
and their prompt action to minimize vital risks to the patient. The functions of each
professional will be established later.

• Reception of the patient in the unit where the patient was admitted.
This is the arrival of the patient to the unit from which they left to perform the test, where
the staff of said unit will receive the patient, family and staff accompanying them during
the transfer. The functions of each professional will be established later.

Types of Intrahospital Transfers.

We can classify IT:

• Regarding the purpose of the transfer

Transfer from one unit to another
Transfer to carry out a complementary test

• Regarding the needs of the patient being transferred

Group 0. Patients who do not require the accompaniment of healthcare personnel during
their transfer
Group 1. Patients in a stable hemodynamic situation with only the need for basic
monitoring
Group 2. Patients in an unstable situation who would require invasive monitoring (arterial,
pulmonary catheter, ICP, etc.), pulse oximetry and continuous drug perfusion.
Group 3 would include patients from group 2 with dependence on mechanical ventilation.

Transfer of stable patients.

This type of transfer refers, according to the previous classification, to group 1 patients.
The accompanying staff will be the staff of the unit where the patient is admitted or the
DUE of the Transfer Team of the Infanta Margarita Hospital (ET), if the The on-call
supervisor deems it appropriate or due to saturation of the unit where the patient is located.

Transfer of Critical Patients

Due to the characteristics of these patients, the risk of intrahospital transfer (IT) is high.
The causes of IT in critically ill patients are multiple, but the most frequent are the
performance of diagnostic tests (CT, MRI, angiography, ultrasound, etc.) and transfers to
the Operating Room.
The scientific evidence (1) reflects that during the IT the following critical incidents have
been observed, understood as those situations that alter or could seriously alter the baseline
hemodynamic state of the transferred patient:

Among the most frequent are the following:

-Temporary monitoring disconnections (ECG, pulse oximeter, etc.…)
-Physiological alterations: Hypotension or hypertension and hypoxemia-desaturations
-Secretions.
-Consequences of a poorly sedated patient (movement, agitation, maladjustment to
respirator, TOT bite, hypertension, etc.…)
-Portable respirators with malfunction or empty oxygen cylinder.
-Excessive waiting time at the elevator door due to misuse of the elevator, therefore
extension of the transfer time.
-Lack of coordination with the receiving service, as it is busy when the patient arrives.

The following are noted as exceptional incidents:

-Disconnection or exit of nasogastric or urethral tubes.
-Exit of central venous or arterial catheters
-Cardiorespiratory arrest or arrhythmias with high life risk.
-Accidental extubation.
-Syringe infusion pumps without battery.
-Exit of the contents of drains, or accidental removal of the same. In our hospital there is
currently no protocol for the adequate and standardized preparation of the transfer, which is
why the need to carry it out arises due to:
-High frequency of transfers.
-Increase in the care overload that occurs in the Unit during the transfer time, in the care
professionals.

Holiday program
The staff vacation role is prepared, taking into account the criteria that allow the use of
their rights and at the same time ensure the proper functioning of the service.
Criteria
• Establish a numerical balance of absence in the different months.
• Nursing staff must complete the pre-vacation exam.
The vacation role will take into account:
• The needs of the service.
• The needs of the worker.
• The choice of the worker option; It will be held in a meeting with mandatory staff
attendance.
• Special situations will be seen separately and must be recorded in the Meeting
Minutes to avoid problems.

PROGRAMMING PRINCIPLES
• The same standards and procedures must apply to all employees.
• Calendars must be communicated to staff as far in advance as possible.
• Desirable time off, such as vacation days and holidays, should be distributed equally
among all staff.
• The same productivity should not be expected from the employee temporarily
assigned to a patient unit.
• Schedule changes should be kept to an absolute minimum.
• The employee must be provided with sufficient time between work shifts to allow
him or her to take reasonable rest.
Plans Nursing Staff Vacation Rotation Plan
• It is essential to calculate and distribute substitute personnel
• It is very important to intersperse vacation periods, so that a very long period does
not elapse between them.
• Given that the staff calculated for the service does not work all year round, it is also
necessary to calculate the substitute nursing staff, which is done as follows:

• To cover vacations, one nurse for every ten nurses in the service.
• To cover 6 and 7 days, one nurse for every 6 nurses.

Nursing Staff Rest Rotation Plan

It organizes the distribution of personnel per day, the necessary personnel for sixth and
seventh day substitutions are foreseen, the number of personnel needed daily in the services
is determined with certainty.
Given that the staff calculated for the service does not work all year round, it is also
necessary to calculate the substitute nursing staff, which is done as follows:

• To cover vacations, one nurse for every ten nurses in the service.
• To cover 6 and 7 days, one nurse for every 6 nurses.

Medication Request
To request medicines as vital not available, and in order to improve the process, the
applicant must make the request by attaching on magnetic media (CD) the request form for
vital medicines not available for a patient, several patients or clinical emergency. , in
addition to the documents that have been attached to the applications submitted, such as:
For a specific patient:
The request may be made by the patient himself or by a legally constituted public or private
natural or legal person after compliance with the following requirements:
• Full name of the patient and their identification document.
• Active ingredient in its generic name and composition of the medicine.
• Medical formula and summary of the medical history indicating the dose, duration
of treatment, name of the medication and quantity, which must be signed by the treating
physician, with indication and number of his or her professional card.
• Copy of the corresponding consignment receipt

For more than one patient:

It may be any legally constituted public or private entity, duly authorized for the
distribution of medicines in accordance with current regulations or those that modify or
replace them.
The documentation that you must attach is the following:
• Certificate of free sale or certificate adjusted to the requirements provided by the
World Health Organization, WHO, for products in international trade;
• Certificate of existence and legal representation of the applicant;
• Analysis certificate

LIQUID BALANCE SHEET

It is the quantified relationship of the inflows and outflows of fluids that occur in the body
at a specific time, including insensible losses.
Goals

Control the patient's fluid intake and loss, for a certain time, to contribute to the
maintenance of hydroelectrolyte balance. Exactly plan the water intake that replaces the
body's basal, previous and current losses.
Liquid control sheet containing the following data:
• Name of patient.
• Balance sheet start date and time.
• Income section that specifies the oral and parenteral route.
• Output section that allows the recording of pH values are important to detect the
hydroelectrolyte balance. urine, feces, vomiting, drainage, etc.
• Column for total income, expenses and partial balance per shift.
• Space for total balance of 24 hours.
• Graduated test tube or container for quantification of outputs.
• Graduated feeding containers.
• Weighing machine.
• Disposable gloves.
Procedure before measuring intake and elimination:
• Review medical indications.
• Have the intake and excretion form on hand.
• Prepare all the necessary material and move it near the patient.
• Handwashing.
• Put on gloves.
•
Procedure during intake and elimination measurement:
• Greet and address the patient in an affectionate manner and provide an environment
of trust and security.
• Explain the procedure to the patient and ask for their collaboration to report intakes
and eliminations that are beyond the observation of the nursing assistant; the same one that
must be pending for exact and effective control.
Measure and record all intakes
• Measure and record all oral fluids taken during each 6- or 8-hour shift.
• Add the partial quantities in turn and obtain the total volume of liquid; record on the
balance sheet.
• Assess parenteral and other intakes (generally by the nurse).
Measure fluid removal.
Measure all eliminations, diuresis, vomiting, diarrhea, sweating, bleeding..., due to the
importance of diuresis, it will be done accurately.
Measure urine output in the patient with a catheter
• In patients with a catheter, the bag must be emptied every 8 hours, in each shift,
then the three shifts are added together, obtaining the total in 24 hours, and recorded on the
corresponding sheet.  With an affectionate attitude, greet the patient and explain the
procedure.
• Place the graduated container under the diuresis bag.
• Clamp the tube inserted into the Foley catheter, above the bag.
• Open the faucet of the diuresis bag, emptying the urine into the graduated container,
placing the outlet end inside it.
• After emptying the bag, turn off the tap and clean it with a gauze soaked in
antiseptic solution.
• Unclamp the connection tube of the probe with the bag.
• Check that there are no kinks in the tube, which could cause obstructions and
prevent the passage of urine.
The responsibility and skill of the nurse is shown in the adequate filling out of the forms for
the control and balance of fluids, which are special treatments in certain patients.

NEWBORN IDENTIFICATION CARD.

Depending on the hospitals, there are different procedures that are applied simultaneously
to guarantee the identification of the newborn:
The baby's identification measures are put in place in the delivery room, from the moment
of birth and once the newborn has been stabilized, to avoid confusion for the baby from the
moment it comes into the world. They are normally performed by the midwife or medical
professional attending the birth. Any other identification method adopted later is not valid if
correct identification has not been made from the first minutes of life.
-Placement of identification bracelets for the mother and newborn.
¬ -Issuance of an identification card.
-Taking blood samples from mother and newborn.
All these actions are carried out at the time of delivery, and the child should not leave the
delivery room under any circumstances without having been correctly identified.
Placing identification bracelets for the mother and newborn:
Two identical bracelets will be placed on the mother and child including the following
information:
-Name and surname of the mother.
-Date of delivery.
-Sex of the newborn.
-Barcode.
-Issuance of an identification card

Taking blood samples from the mother and newborn

The purpose of taking blood samples is to preserve them so that, in the event that there is a
reasonable doubt about the identity of the newborn that cannot be resolved by another
procedure, we can proceed to genetic analysis of the samples to verify the mother-child
relationship.

The taking of the samples, like the previous measures, will be carried out inside the
delivery room, using blood from the umbilical cord once cut and in the presence of the
person accompanying the mother during delivery, or a health professional in case of
impossibility of family presence.

The samples will be deposited in a suitable support for maintenance under ambient
conditions.
Their conservation period is usually one year, after which the hospital proceeds to destroy
them.

The institution where the birth takes place guarantees that the samples will only be used, if
necessary, to carry out the genetic analysis for the purposes of verifying the mother-child
relationship and not for paternity tests or for other purposes.

DAILY WORK REPORT AT THE SUPPLY CENTRAL

Medical supplies constitute a substantive pillar in the development of health service
provision activities. Its management has undergone different modifications in the control
and operating system during recent years.
The shortage of basic medicines and healing materials in the first level of care units, which
has an impact on the provision of medical services that do not satisfy the basic health needs
of the population.
Health supplies constitute one of the essential elements in the provision of Health Services,
for this reason and like the production of the services offered by this type of institutions,
these require to be evaluated through monitoring that reflects the level of supply and
availability in health units, in this sense it is necessary to design and establish our own
evaluation instruments consistent with our reality, since it is one of the main challenges. In
addition to identifying the main problems faced by this process.
Goals
Evaluate the process of supply and supply of medical supplies from the request to their
supply in the medical units (Health Centers and Mobile Units.
Features
• Obtain the items required for the supply
• Maintain equipment, materials and equipment in good working condition.
• instrumental.
• Provide supplies, equipment and instruments for Assistance Services.
• Perform appropriate preparation and sterilization techniques for materials and
equipment
• Maintain the existence of supplies necessary to cover services 24 hours a day, 365
days a year.
• Comply with established control systems.
• Maintain the inventory of instruments and equipment existing in the service.
Nurse activities
• Applies and/or assumes established provisions, standards and procedures.
• Requests and records material supplies assigned to Assistance Services.
• Monitors the fixed funds established in the services.
• Controls the distribution of consumables, exchange materials, instruments and
equipment.
• Monitors and records sterilization controls.
• Prepare material, gloves and packages for sterilization.
• Maintains good interpersonal relationships with the health team

ROTATION AND DISTRIBUTION PLAN OF NURSING STAFF

Personnel rotation and distribution constitutes an important part of human resources
management and, therefore, must consider its direct or indirect effects on job performance.
Rotation occurs when there is a lack of personnel in a certain service, without considering
the worker's family environment, it does not include an economic incentive and is
perceived by nurses as a generator of professional growth. The evaluation of job
performance relies on the subjectivity of the evaluators.
The distribution and shifts of staff are reflected in the table.

Work distribution model prior to the implementation of the alternative model that we
present
The nurse on the regular morning shift has an assignment of tasks or functions. When one
of the nurses on rotating shift (and who should be in the morning) is absent for some
reason, the morning nurse takes charge of the patients admitted to their beds that day.
¬ Nurses on rotating and night shifts are assigned beds per shift, one is assigned 12 and
another 14 beds respectively. They are always assigned the same beds during the different
shifts they work.
Distribution of work after application of the method
• ¬Tomorrow nurse: will continue to perform duties and will be associated with all
patients. Although later a modification is carried out to solve one of the problems
identified.
• ¬ Nurses on rotating shift: they are primary for some patients and associates for
others.
• ¬ Nurses on night shift: they are associates.

Aim:
Achieve timely and appropriate rotation and distribution of nursing human resources based
on patient assessment.
Determine the relationship between rotation and job performance of nursing professionals
Rotation and distribution plan:
• Nursing staff
• Shifts
• Guards

MISCELLANEOUS REPORTS
Various reports Important The attached report models are merely illustrative and are not
mandatory. The public accountant from now on, interchangeably the "accountant" will
determine, based on his professional judgment, the content and wording of his reports. In
cases where modified opinions or conclusions must be presented, the guidelines of the audit
report models can be followed and adapted to each situation, as appropriate. The review
report templates prepared under the corresponding figures approach contain the following
educational paragraph. They are an integral part of the financial statements mentioned
above and are presented with the purpose of being interpreted exclusively in relation to the
figures and information of the current interim period.
Importance:
The attached reports are merely illustrative and are not mandatory. The public accountant
from now on, interchangeably the "accountant" will determine, based on his professional
judgment, the content and wording of his reports.
Audit of a single financial statement or of a specific element, account or item of a financial
statement. Balance of an accounting account, without an audit having been carried out or a
report issued on the set of financial statements
Audit of summary financial statements: Summary financial statements prepared from a set
of financial statements on which an audit report with a favorable opinion has been issued
Review of financial statements for interim periods: Financial statements for interim periods
- Significant misstatements of non-generalized effect corresponding figures

PAE
The Nursing Process, also called Nursing Process (PE) or Nursing Care Process (PAE), is a
systematic method of providing efficient humanistic care focused on achieving expected
results, based on a scientific model carried out by a Nursing professional. . It is a systematic
and organized method for administering individualized care, according to the basic
approach that each person or group of them responds differently to a real or potential health
alteration. It was originally an adapted form of problem solving, and is classified as a
deductive theory in itself.
Features of the PAE:
• It has universal validity.
• Use terminology that is understandable to all professionals.
• It is centered on the patient, marking a direct relationship between the patient and
the professional.
• It is oriented and planned towards the search for solutions and with a clear goal.
• It consists of five cyclic stages.
The use of the nursing process allows the creation of a care plan focused on human
responses. The nursing process treats the person as a whole; The patient is a unique
individual, who needs nursing care focused specifically on him and not only on his illness.
The nursing process is the application of the scientific method in the care practice of the
discipline, so that systematized, logical and rational care can be offered, from a nursing
perspective. The nursing process gives the profession the category of science.
Objectives of the PAE:
• Serve as a work instrument for nursing staff.
• Give the profession a scientific character.
• Encourage nursing care to be carried out in a dynamic, deliberate, conscious,
orderly and systematized manner.
• Trace evaluable objectives and activities.
• Maintain constant research on care.
• Develop your own knowledge base, to achieve autonomy for nursing and social
recognition.
The nursing process involves skills that a nursing professional must possess when he or she
has to begin the initial phase of the process. Having these skills contributes to the
improvement of the nursing professional's attention to the patient's health, including the
patient's level of health, or their state of health.
• Cognitive or intellectual skills, such as problem analysis, problem solving, critical
thinking, and making judgments regarding client needs. Included among these skills are
those of identifying and differentiating current and potential health problems through
observation and decision making, by synthesizing previously acquired nursing knowledge.
• Interpersonal skills, which include therapeutic communication, active listening,
sharing knowledge and information, developing trust or creating good communication ties
with the client, as well as ethically obtaining necessary and relevant information from the
client which will be later used in the formulation of health problems and their analysis.
• Technical skills, which include the knowledge and skills necessary to properly and
safely handle and maneuver the appropriate equipment needed by the client when
performing medical or diagnostic procedures, such as assessing vital signs, and
administering medications.
PHASES OF THE PAE

1. ASSESSMENT PHASE
The assessment consists of collecting and organizing data that concerns the person, family
and environment in order to identify human and pathophysiological responses. They are the
basis for subsequent decisions and actions.
The professional must carry out a complete and holistic nursing assessment of each of the
patient's needs, regardless of the reason for the encounter. Usually, an assessment
framework based on nursing theory or the Glasgow scale is used. This assessment considers
problems that can be both real and potential (risk).
The following Nursing models are used to gather the necessary and relevant patient
information to effectively provide quality nursing care.
• Gordon's Functional Patterns of Health
• ROY adaptation model
• Models of body systems
• Virgina Henderson Needs Model
• Maslow's Hierarchy of Needs
We can obtain the data from two sources:
• Primary sources: observation, physical examination, interrogation (direct or
indirect), laboratory and office studies.
• Secondary sources: clinical record, bibliographic references (articles, journals,
clinical practice guides, etc.)
The interview is a planned conversation with the patient to learn about their health history.
On the other hand, it is a process designed to allow both the nurse and the patient to give
and receive information; It also requires communication and interaction skills; It is focused
on identifying the answers.
Interview objectives:
• It allows you to acquire the specific information necessary for the diagnosis.
• Facilitates the nurse/patient relationship by creating an opportunity for dialogue.
• It allows the patient to receive information and participate in identifying problems
and establishing objectives.
• Helps determine specific areas of investigation during the other components of the
assessment process.
2. DIAGNOSIS PHASE
Nursing diagnoses are part of a movement in nursing to standardize terminology that
includes standard descriptions of diagnoses, interventions, and outcomes. Those who
support standardized terminology believe it will help nursing become more scientific and
evidence-based. The purpose of this phase is to identify the patient's Nursing problems.
Nursing diagnoses are always referred to human responses that cause self-care deficits in
the person and that are the responsibility of the nurse, although it is necessary to take into
account that the fact that the nurse is the reference professional in a nursing diagnosis does
not mean This means that other health professionals cannot intervene in the process. There
are 5 types of Nursing diagnoses: Real, risk, possible, well-being and syndrome.
3. PLANNING PHASE
Planning consists of the development of strategies designed to reinforce the responses of
the healthy client or to avoid, reduce or correct the responses of the sick client, identified in
the Nursing diagnosis. This phase begins after the diagnosis is formulated and concludes
with the actual documentation of the care plan. It consists of four stages:
1. Establishment of priorities, based on Kalish's or Maslow's hierarchy.
2. Elaboration of objectives.
3. Development of nursing interventions.

4. Plan documentation.
The Nursing Care Plan is an instrument to document and communicate the patient/client's
situation, the expected results, the strategies, indications, interventions and the evaluation
of all of this. There are different types of care plans, among them the following stand out:
Individualized: Allows you to document the patient's problems, the objectives of the care
plan and the nursing actions for a specific patient. It takes longer to prepare.
Standardized: According to Mayers, “it is a specific care protocol, appropriate for those
patients who suffer from normal or foreseeable problems related to the specific diagnosis or
disease.”
Standardized with modifications: Allows individualization by leaving open options in the
patient's problems, care plan goals, and nursing actions.
Computerized: They require prior capture in a computer system of the different types of
standardized care plans; they are useful if they allow individualization for a specific patient.
4. EXECUTION PHASE
In this phase, the nursing plan described above is executed, carrying out the interventions
defined in the diagnosis process. Implementation methods should be recorded in an explicit,
tangible format in a way that the patient could understand if they wanted to read it. Clarity
is essential as it will help communication between those who are assigned to carry out
Nursing Care.
5. EVALUATION PHASE
The purpose of this stage is to evaluate progress toward the goals identified in the previous
stages. If progress toward the goal is slow, or if regression has occurred, the nursing
professional should change the care plan accordingly. Instead, if the goal has been
achieved, then care can cease. New problems may be identified at this stage, and the
process will restart again. It is part of this stage that measurable goals must be established;
failure to establish measurable goals will result in poor evaluations.
The entire process is recorded or documented in an agreed format in the nursing care plan
to allow all members of the nursing team to carry out the agreed care and make additions or
changes.

NURSING RECORDS AND NOTES

Nursing records and notes are written documents of a legal nature that ensure that care and
procedures were carried out during your shift to your subject of care, in addition, they
provide us with important data to guarantee the continuity of said care.
It is a document to support nurses in achieving good systematization of Nursing Care, for
research, auditing and legal support of nursing professionals. Because it is such an
important issue for our professional category, we always need to reflect on it and also know
how to make a good nursing note.
In addition to containing the procedures, the document reflects the general condition of the
subject of care and for this it is necessary that you always keep in mind what needs to be
recorded, remember that you must evaluate the patient in the cephalocaudal direction, that
is, from the head to the legs. feet. Taking into account these 3 premises:
• 1 Characteristics: everything that was observed in the patient (skin, head, neck,
trunk, upper and lower limbs, genitals). For example: the subject of attention presents
edema in the lower extremities, extravasation in the upper extremities, paleness of the
integuments, etc.
• 2 Maintains: This refers to all devices that the patient literally maintains. For
example: subject of care with a central venous catheter in the subclavian, fixed, last
healing, presents signs of infection, peripheral catheter in etc.

• 3 Refers: all patients inform us during data collection. For example: Reports pain in
the abdominal region, pain.
In this section it is also important to note the orientation given to the patient, the
behaviors adopted and the results thereof.
What we should write down write down during the turn.

Once the first nursing note was made, we were able to imagine the patient's general
condition, without having to look at him. In order for me to imagine all the assistance
provided and how the patient was during the shift, it is necessary to register.
what should I write down?
• Procedures carried out, observations made, whether they are already standardized,
routine and/or specific;
• All care provided: record of nursing and medical prescriptions fulfilled, in addition
to routine care, security measures adopted, referrals or sector transfers, among others.
• Medications administered
• Guidance provided;
• Interactions with the patient, patient response to the care prescribed by the nurse and
the behavior adopted in each situation;
General characteristics of nursing notes:
• They must be legible, complete, clear, concise, objective and chronological;
• It must be preceded by date and time, contain the signature and identification of the
professional at the end of each record;
• They must be recorded immediately after the care provided, the guidance provided
or the information obtained; especially in the case of the application of medications.
• They must not contain traces, between lines, blank lines or spaces;
• You should not use concealer or any way to erase the record made, as it is a legal
document.
Also:
• If an erroneous entry occurs, use the term “I say” between commas. For example: he
maintains a peripheral venous catheter in his right hand, I mean, left.
• After each nursing recording schedule, the identification of the professional or
signature and seal must be recorded, as recommended by the institution. To find the
required information about your ID or seal, click here.
• The nursing notation form must include the fully filled out header: patient data
(name, age, sex, and hospital RG), and complemented with date, bed number, and
infirmary. You can use the printed label or, failing that, manually fill in the header of the
form with this data.
• The annotation must contain subsidies to allow the continuity of nursing care
planning in the different phases and for the care planning of the multiprofessional team;
What not to do in nursing notes?
• Do not use the verbs in the gerund, how to do, eating, walking, talking.
• Do not start with the word "subject of care" (formerly patient), because it is usually
redundant; it is evident that the notes are about him.
• Do not write down on non-standardized forms for annotation.
Doing so voids the document, leaving you without backup!

NURSING STANDARDS
Standards of practice (standards of care) are the criteria used to determine what a nurse
should or should not do. Standards can be defined as "a benchmark of achievement that is
based on a desired level of excellence." Standards of care measure the degree of excellence
in work and describe a competent level of nursing care.
A standard is a model of established practice that is commonly accepted as correct. Nurses'
care is governed by standards of care.
Failure to adhere to state regulations related to the delegation of nursing tasks due to lack of
nursing, unauthorized personnel, and patient misidentification may also be the basis for
legal liability regarding nursing standards of care.
Under the SOC, a licensed nurse shall, in a complete, accurate, and timely manner, report
and document the elder's evaluation or observations, the care provided by the nurse for the
client, and the client's response to that care. Nurses assume a risk of liability if they fail to
monitor a patient or to recognize changes in the patient's condition. Failure to recognize the
importance of the changes or to communicate clearly and promptly to the treating physician
could endanger the patient.
Scope of the Technical-Administrative Standards:
These standards are mandatory in all Health Units, for the provision of services in the
public, social and private sectors. Lists the guidelines for the organization, provision of
services and development of all activities that constitute sexual and reproductive health
services.

CLINICAL AND DIAGNOSIS RECORD SHEET

A well-organized and scientifically based nursing clinical record sheet: facilitates the
systematized and integrated recording of clinical data, integrates the records under national
and international regulatory criteria, and allows the use of standardized language for staff.
Nursing clinical records make up written evidence of the care provided to the patient. They
are par excellence a means of communication and coordination between health
professionals. Their correct execution allows for continuity of care and patient safety.
What does a clinical nursing record keep?
Nursing clinical records make up written evidence of the care provided to the patient. They
are par excellence a means of communication and coordination between health
professionals. Their correct execution allows for continuity of care and patient safety.

Types of medical history that exist today

• Emergency (Emergency Part): It is carried out during a medical emergency.
• Consultation: The most common model is the history taken in the doctor's office.
• Hospitalization: History taken during the patient's hospital stay.

Who has access to clinical records?

That this document belongs to the doctor or health institution in whose care the patient is.

What should a clinical record keep?

The patient's full name, identity card, age, address and social security must be clearly
identified. In the clinical records the record must be clear, legible with language consistent
with the understanding of what is written.

Objective: Build and validate an instrument to evaluate the quality of clinical nursing
records.
Methodology: Starting from the variable quality of the clinical nursing records, the search
for information regarding the subject was carried out in various databases. As well as the
standards for the Certification of Health Care Establishments of the General Health
Council. With this, the regulations for filling out the format of clinical nursing records,
prepared by the Subdirectorate of Nursing belonging to a Third Level Medical Care Unit of
the public sector, were considered. An instrument was built that measures the quality of
clinical nursing records (lacks) in its three dimensions: structure, continuity of care and
patient safety.

KARDEX
It is a clinical document for the exclusive use of the patient, where the treating medical staff
and nursing staff update and stay aware of the medication, schedule and diagnoses.
It is completed with a pencil to facilitate editing, offering practicality and ease for better
data manipulation.
The kardex contains information such as: biographical data, diagnoses, updated medical
orders, treatment completion dates, allergies and precautions.
GOALS
• Define the general objective of patient care.
• Plan the actions to be carried out based on the nursing diagnosis.
• Facilitate communications between the nursing team and other disciplines.
RULES
• The nurse prepares the cardex card for every patient at the time of admission to the
service, will begin the care process and will record the data in the cardex during their work
shift.
• The nurse leader of the team in each work shift will complement and keep the
cardex card of all patients updated.
• The nurse will insert a red card into the cardex, where she will initiate the situations
that are necessary to highlight such as critical conditions of the patient, special
preparations, admissions and discharges.

NURSING REPORT
It is a report that is made through verbal communication at the end of the shift; which
consists of the presentation of all the events that occurred during the patients' shift. Its
purpose is to guarantee the continuity of care and to improve the quality of care for users, in
addition to its progress, as well as aspects that must be kept in mind and that must be
monitored in the care of patients in the hospital. service.
It includes all the aspects obtained in the round, that is, it will provide attendees with
objective information about the events that occurred during the round. The method of
transmitting the information is through the kardex, and it must be done in the living room
(nursing station) or in an area away from interference or interruptions from patients, people
or strange noises. This report, which is carried out at the change of shift, must be attended
by all staff, where each member is informed about everything that happens to the patient
and can intervene if necessary in order to complete the information.

It is useful since it provides information about what has happened to the patients during the
shift and allows them to plan care mentally, but this requires the nurse's problem-solving
ability and application of knowledge, which can thus offering or giving better care
according to their needs. The Nurse can prepare his report by taking notes when he receives
the previous report, and in turn the nurse who enters the service.

INTENSIVE CARE SHEET

It consists of the collection of all the data of the critically ill patient regarding their physical
and mental health status, from the day of their admission to the service, in the ICU or in the
intermediate care unit until the day of their discharge for some reason. .
Characteristics
The information must be:
1. Integra
2. Accurate
3. Exact
4. Brief
5. Objective
6. Updated
7. clear
8. Recorded chronologically
9. Readable when not using a computing device

Purpose
Assistance
1. Individualize or personalize nursing care for the critically ill.
2. Identification of the evolutionary changes that occur in the state of the critically ill
patient.
3. Compilation of information in an orderly manner about the health status of the
critically ill patient.
4. Help the patient and their family to integrate into the hospital environment.

Research and teaching

1. Epidemiological research instrument.
2. Continuous training instrument.

Completion of the intensive nursing admission report

Includes
1. Verification of the identity of the critically ill patient.
2. Information to the patient and/or family about the procedure to be performed.
3. Identification of the critically ill patient.

Nursing checks:

• Correct identification of the critically ill patient.

• Clinical documentation of the critically ill patient collected and organized.
• Every shift change, the nurse must review the prescribed medical treatment.
• Avoid omission and repetition of data, having to write down everything that is
relevant to the nursing care of the critically ill.
• Differentiation of real observations from subjective impressions; These may be
valid and useful, but they could never be value judgments.
• Correct, clear and concise notes.
• Each drug administered must be recorded at the time, corresponding to the exact
time (except in cases of emergencies).
• Information ordered and following a chronological sequence.
• Monitor the use of abbreviations and acronyms that are not universally accepted.
• ICU technology control

VOUCHER TO EQUIPMENT CENTER

The Equipment and Sterilization Central (CEYE) is a service of the Medical Unit whose
functions are: Obtain, centralize, prepare, sterilize, classify and distribute consumer
material, exchange, surgical clothing and surgical medical instruments to the healthcare
services of the Medical unit. The objective of the CEYE is to ensure the adequate
distribution of equipment, materials and instruments in a timely manner and with the
optimization of time and resources, so that in an uninterrupted manner (24 hours a day and
365 days a year) the items required by medical-surgical services are provided to achieve
their activities.

• It is important to document the procedure carried out to know the consumption,

maintenance and conservation needs.
• Statistical data allows calculation based on real needs.

Distribution of CEYE areas:

Red or contaminated area

It is where the reception of items that have already been used for decontamination takes
place. This area must have a dividing wall from the other areas to prevent potentially
contaminated air from circulating in all directions.
Blue or clean area

It is where the selection and packaging of items to be sterilized is carried out. In this area,
work tables and clean products that have not yet been sterilized must be located.
Green or barren area

It is where all the sterile packages are stored, ready for use. Only the shelf with sterile
packages should be located in this area.
Characteristics of the CEYE physical plant
a) Floors, walls, ceilings and ceilings made of materials that are easy to maintain and clean.
b) Artificial lighting; It must be arranged in such a way that it does not allow shadows.
c) Mechanical ventilation; essential, due to the production and escape of heat and water
vapor and the production of lint from gauze, clothing and paper. For reasons of asepsis,
natural ventilation is not recommended.