CCU

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BANGALORE BAPTIST HOSPITAL

DEPARTMENT OPERATING MANUAL Version No: 03
Effective Date :
PM/DOM-03/CCU CORONARY CARE UNIT 07/06/18
Table of Content
Sl. No Description Page no
1. Scope of the Department. 3
2. SOP for Admission and discharge Criteria 4
3. Clinical Responsibility 7
4. SOP for patient care 8
5. General Procedure 10
6. Emergency trolley 14
7. SOP for proper documentation of entries in patient’s charts 19
8. SOP for equipment management 21
9. Linen Management 24
10. Quality Assurance Programme 25
11. Guidelines For Interpretation Of Arterial Blood Gas 27
12. Protocol for thrombolysis in acute myocardial infarction 29
13. Receiving myocardial infarction patients 31

Protocol to be followed in case of massive pulmonary
14. 36
embolism
15. Protocol to be followed in management of diabetic ketosis/ 39

ketoacidosis
16. Protocol to be followed in a case of acute ingestion of 42
poison
17. Management of Chronic Renal Failure 44
18. Care of Patient who had PTCA 46
19. Exploratory abdominal surgery 51
20. Post neuro surgery patients 52
21. Protocol to be followed in cardiac arrest 53
Reviewed & issued by: Division Head Approved by: Director(CEO)

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22. Care of patient on ventilator and weaning 55

23. Cardio-Pulmonary Resuscitation 58
24. Trans esophageal echocardiogram(tee) 62
25. SOP for pre-operative preparation of CABG-coraonary 64

artey bypass grafting
26. Permanent Pacemaker Implantation 66
27. preparation of patient for cardiac catheterization and 68

monitoring patient post cardiac catheterization
28. SOP for care of post-op CABG patients 70
29. Temporary Pacemaker 73
30. List of associated records 76
ANNEXURE
Annexure No. I Role of
1. Consultant
2. CCU resident
3. Charge nurse
4. Staff Nurse
5. Nursing Aid
Annexure No. II Organogram

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1. SCOPE OF THE DEPARTMENT

1.1. Purpose:
To ensure procedures for effective operation of CCU.
1.2. Scope:
1.2.1. To provide equality care in CCU.
1.2.2. To lay down the procedures for the process pertaining to the CCU Department
connected to the Hospital.
1.2.3. To provide quality care cardiac patients and non cardiac patients those who need close
monitoring which can not be done in the wards.
1.3. Responsibility:
The HOD to ensure the implementation of the instructions and procedures laid down.
1.4. Quality Objectives:
1.4.1. The staff will commit to provide treatment with the set standards of professionalism.
The entails confidentiality and quality care for patients. Treatment would be provided,
ensuring good accuracy care. Our patients will be treated with equality and respect.
We shall endeavour the patient’s care in CCU.
Note* -For all the general nursing procedures refer ward- nursing department operating
manual as mentioned in the Annexure IV

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2. SOP FOR ADMISSION AND DISCHARGE

2.1. Admission to CCU done following the criteria set up by the respective CCU.
2.2. Consent is taken from patients / relatives for CCU admission.
2.3. It is the responsibility of the concerned nurses (OPD, or emergency) to find out the
availability of requested bed by liaising with the ward nurses.
2.4. If admission is delayed or impossible due to bed unavailability, the CCU staff will discuss
and if appropriate, assist in the process of alternative specialized care.
2.5. Resuscitation or admission must not be delayed where the presenting condition is
imminently life threatening
2.6. Criteria for admission
2.6.1. The CCU consultant/Medical consultant in charge of CCU agrees that admission is
necessary to provide critical care support that cannot be provided in the ward.
2.6.2. Admitting rights are limited to the CCU consultant. This is a necessity in that there is
a limited number of beds, admission is via a priority system, and the CCU consultant
may be the only practitioner informed of every potential CCU admission in the
hospital.
2.6.3. Decisions about coronary care admission are clinically based. It is important to
understand what constitutes a critical care patient. Most patients fit into one of the
following categories:
a. Patients admitted for respiratory or airway support.
b. Patients requiring support of two or more organ systems, even when this does not
include the respiratory system.
c. Patients admitted for invasive/intensive monitoring, in anticipation of possible
aggressive interventions.
d. Patients with an extended post-operative recovery, allowing abnormal preoperative
physiology to reverse, with or without modulation of the normal stress response e.g.
post operative aortic aneurysm repair.
e. Patients who do not necessarily require life sustaining treatments, but whose
physiology is taken under control in order to prevent organ injury: e.g. post
anaesthesia severe sleep apnoea, spinal injury etc.

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f. Patients who have minimal physiological reserve, and who undergo acute potentially
reversible injury, requiring support until the abnormalities have been reversed and
reserve restored: e.g. COPD with pneumonia requiring ventilatory support.
g. Patients who undergo a major disruption to their physiology, due to an overwhelming
stress response to injury, or inadequate compensation to the response: e.g. major
trauma or sepsis.
2.6.4. The patient’s condition should be potentially reversible. There are circumstances in
which emergency treatment already carried out (eg: intubation and ventilation) mandate
admission to coronary care for at least a brief period even when there is no realistic
prospect of survival.
2.6.5. If bed is not available patient’s condition should be stabilized shifted to other hospital
according to transfer policy.
2.6.6. Patients should not be admitted to CCU in situations like:
a. Chronically ill patients requiring <10 liters of oxygen flow who can be managed in
wards.
b. Stable patients with long standing neurological illness with chronic bed sores where
there is a high chance of infection.
c. Patients with life limiting therapy is documented and family needs only palliative
care.
d. Stable patients who can be managed in wards.
e. Long standing cancers in which family needs only palliative care.
f. Age above 80 years where general / mental condition is poor.
g. The CCU consultant is contacted to discuss admission. This should normally be done
by the Specialist from the referring team whose involvement in the team approach is
important to patient care on the unit.
h. The in charge nurse should be contact regarding bed availability or likelihood of bed
availability.
2.7. Discharge criteria
2.7.1. Substantial resolution of the problems responsible for admission.
2.7.2. Anticipation of prolonged medical stability.
2.7.3. Elimination of need for mechanical ventilation/airway protection.

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2.7.4. Elimination of the need for invasive haemodynamic monitoring.

2.7.5. Discontinuation of medications/treatments requiring haemodynamic monitoring.
2.8. Discharge decisions
2.8.1. Discharge decisions are the responsibility of the Consultant 'on call' for the coronary
Care Unit.
2.8.2. Whenever possible discharges should be anticipated, and arrangements made in good
time, with the medical and nursing staff who will be taking over the patient's care.
2.8.3. There should be direct verbal contact with a member of the team taking over the
patient prior to transfer.
2.8.4. There must always be liaison with the ward nurses.
2.8.5. The patient's relatives should always be informed.
2.8.6. If further CCU admission would be considered inappropriate this should be recorded
in the patient's case notes. Such a decision should be discussed with the team taking
over the patient's care.
2.8.7. If the discharge is delayed for reasons of insufficient ward resources, this must be
recorded in the patient’s chart.

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3. CLINICAL RESPONSIBILITY:
3.1. The clinical approach should be that of a team effort co-ordinated by the CCU consultant.
Multidisciplinary input is vital to the process and produces better outcomes.
3.2. Patients admitted to CCU other then from medicine department will be seen by the medicine
CCU team only if formal consultation is asked. However resuscitation and emergency are
attended by the CCU team.
3.3. The CCU consultant is directly responsible for advanced support of the critically ill patients
(e.g. respiratory and cardiovascular therapy) and will act as team leader in consultation with
appropriate specialties in matters out with the CCU expertise.
3.4. In the unlikely event of any dispute over the care of a particular patient, the matter should be
resolved in the spirit of arbitration, co-ordinated by the Chief of Medical Staff.

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4. SOP FOR PATIENT CARE

4.1. Patient care is the responsibility of the head nurse and nursing team
4.2. Management of Patient Care
4.2.1. Nurse should remember that for a patient and relatives the hospital is a strange place
and they need orientation by the nurses.
4.2.2. A new patient and his/her relative should be oriented to:
a. Hospital and to the particular ward where the patient will be admitted to.
b. Routines of the hospital.
c. Rules and regulations pertaining to the patient and his/her relatives.
d. Ward equipment that may be used for the patient.
e. Ward procedure
4.2.3. Assessment of the patient’s needs and planning for the patient care. As soon as the
nurse comes in contact with the patient,
a. She should assess the need of the patient and make a plan for his/her care.
b. The nurses make use of every opportunity to collect necessary data for making
diagnosis and nursing interventions.
c. After collecting the data, she makes a plan for the care of the patient.
d. The plan is made known to all the members of her team to provide continuity of the
care.
4.2.4. The important aspects of nursing planning should include:
a. Establish a patient airway and to ensure that the patient is breathing normally.
b. To check for adequate circulation and issue perfusion (oxygenation).
c. To provide for the psychological support and meeting spiritual needs.
d. Support the activities of daily living.
e. To provide for continuous monitoring of the patient.
f. To facilitate rehabilitation of the patient.
g. To educate the patient and his/her family in the area of their knowledge deficit.
h. To provide for the comfort of the patient by eliminating pain, insomnia, boredom etc.
i. To ensure safety for the patient.

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4.2.5. Progressive patient care

a. This is organizing patient care units according to patient’s needs for medical and
nursing care instead of segregating patients according to services- medical surgical
etc.
4.2.6. Priority nursing care
a. The saving of a life depend on promptness of action “Do the first thing first”. Is the
golden rule for a successful nursing care.
4.2.7. Assignment of personnel for patient care.
a. When the nurse had made the plan of care she needs the right personnel for the
implementation of her plan.

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5. GENERAL PROCEDURE
Sl. Procedure Remark
No.
5.1. Admission 5.1.1. CCU bed charges & need for CCU admission is explained in the
emergency to the patient attenders by attending doctors and
nurses.
5.1.2. In CCU again bed charges & if required ventilator charges & lab
charges, x-ray ECG and medicines charges and extra procedure
charges are explained in details.
5.1.3. Written informed consent is taken from the nearest relatives with
time, date and sign.
5.1.4. Explanation is given to them in their own language.
5.2. Restraints 5.2.1. Before restraints are made it has been informed to the by standers
the need of it in the treatment provided to the patient.
5.2.2. It is usually made to the patient who are very restless and
disturbing the treatment unknowingly. (Eg: pulling out NG tube,
ET catheter etc)
5.2.3. Informed consent is must.
Usually all the procedures including invasive & non invasive are explained to the attenders in their
own language by doctors including indications, contra indications and cost, out come and prognosis
are explained and written consent is taken with date time and full name & signature. Few procedures
done in CCU as follows.
Sl. Procedure Indications Contra indications Complicatio
No. ns
5.3. Endotrachial 1 To protect the airway 1. Poor

intubations and 1.1 From risk of aspiration chest
ventilation. 1.2 From risk of obstruction expansi
1.3 Because sedation/ on

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anesthesia is required 2. Abdomi

to allow assessment or nal
treatment particularly distensi
in agitated or on.
combative patients. 3. Progress
2 To permit mechanical ive
ventilation cyanosis
2.1 Apnoea or bradypnoea. .
2.2 Hypoxaemia or in
adequante repiratory
effort.
2.3 Hyper carbia or
requirement for hyper
ventilation.
2.4 Cardio vascular
instability.
5.4. Tracheostomy 1. To obtain an airway and 1. When done as an 1. Obstructi
oxygenate the patient in emergency procedure on
the event of an obstructed there are no contra 2. Infection
upper airway. indications. 3. Bleeding
2. The last resort following a
failed intubation where
oxygenation is
impossible by other
means.
5.5. Intercostals Drainage of pneumothorax, 1. presence of planned Bleeding,
chest drain haemothorox, plural adhesions (lung stuck lung
insertion. effusion to the chest wall) laceration
2. coagulopathy (or surgical
thrombocytopenia) emphysema.

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5.6. Arterial line 1. Where beat to beat 1. Where blood supply Bleeding,
insertion monitoring of blood to the associated Infection
pressure is desirable. limbs is already ischemia of
2. Where regular blood compromised. the distal
sampling is require. 2. Coagulopathy part.
3. To calculate cardiac 3. Infection at the site of
output and systemic insertion
vascular resistance by
means of pulse ware
controls analysis.
5.7. Central venous 1. To measure CVP and 1.Uncorrected 1.Arterial
catheter guide fluid resuscitation. coagulopathy puncture
insertion. 2. To administer fluids, 2.Damaged or infected 2.Dysrhyth
drugs (especially skin at the point of mias
inotropes / vassoprossors insertion. 3.Pneumoth
or potassium) or TPN. 3.Being unable to lie orax
3. Where extra IV access is supine (or head down) is 4.Hemothor
required. a relative ax\
4. Frequent blood sampling contraindication. 5.Cardiac
5. For specialist Tamponade
interventions: 6.Infection
Temporary transvenous
pacing.
5.8. Lumbar puncture 1. Suspected meningitis 1.Raised ICP (Perform 1.The most
2. Subarachnoid CT head before hand) common is
haemorrhage 2.uncorrected failure
3. Peripheral neuropathy coagulopathy 2.post dural
3. Infected or damaged puncture

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skin at the point of headache

insertion. 3.Nerve
damage
4.Infection
5.Increased
ICP is
present
5.9. Sengstaken Blake Severe upper GI 1. Esophageal 1. Re
more tube insertion haemorrhage perforation bleeding
2. previous esophageal 2. Esophag
surgery eal
ischemia
5.10. Bone To obtain specimen for 1. Infectious skin at the 1. Bleeding

marrow biopsy point of site. 2. Infection
Aspiration &
Biopsy
5.11. Pleural, ascitic To obtain fluid for analysis, 1.Uncorrected 1.Bleeding
tapping therapeutic & diagnosis. coagulopthy. 2.Infections.
2. Infected or damaged
skin at the point of site.

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6. EMERGENCY TROLLEY
Sl. Drug Therapeutic Actions Indicators
No
6.1. Inj. Sodium chloride 1. Sodium Chloride is 1. Treatment of hyponatremia.
the principal salt 2. Dilution and reconstitution
involved in the of parenteral drugs.
maintenance of 3. Hydration and replacement
plasma tonicity. of fluid loss.
2. Important for
maintaining plasma
volume, promoting
membrane.
3. Stability and
electrolyte balance.
6.2. Inj sodium bicarbonate 1. Increases plasma 1. Treatment of metabolic
bicarbonate acidosis with measures to
2. Buffers excess control the cause of the
hydrogen ion acidosis.
concentration. 2. Adjunctive treatment in
3. Raises blood pH severe diarrhea with
4. Reverses the clinical accompanying loss of
manifestations of bicarbonate.
acidosis. 3. Treatment of certain drug
5. Increases the excretion intoxications hemolytic
of free base in the reactions that requires
urine, effectively alkalinization of the urine.
raising the urine pH. 4. Minimization of uric acid
6. Neutralizes or reduces crystalluria.
gastric acidity, 5. Symptomatic relief of upset
resulting in an stomach from hyperacidity

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increase in the gastric associated with peptic ulcer,

pH, which inhibits the gastritis.
proteolytic activity of 6. Prophylaxis of GI bleeding,
pepsin. stress ulcers, aspiration
pneumonia.
6.3. Inj Atropine Sulphate 1. Anti cholinergic 1. Antisialogogue for pre-
2. Anti Muscarinic anesthetic medication to
3. Parasympatholytic prevent or reduce respiratory
4. Anti parkinsonism tract secretions.
drug 2. Treatment of Parkinsonism,
5. Antidote- relieves tremor and rigidity.
organophosphates 3. Restoration of cardiac rate.
6. Diagnostic agent 4. Relaxation of uterine
7. Belladonna alkaloid hypertonicity.
5. Management of peptic ulcer.
6. Control of rhinorrhea of
acute rhinitis or heavy fever.
7. Antidote for poisoning.
6.4. Inj Adrenaline 1. Sympathomimetic 1. Treatment and prophylaxis
(Epinephrine) drug. of cardiac arrest and attacks
2. Alpha adrenergic of transitory av heart block
agonist with syncopel seizures.
3. Cardiac stimulant. 2. Syncope due to carotid sinus
4. Vasopressor syndrome.
5. Bronchodilator 3. Acute hypersensitivity
6. Antiasthmatic drug reactions serum sickness
7. Nasal decongestant urticaria.
8. Mydriatic 4. Temporary relief from acute
9. Antiglaucoma drug attacks of bronchial asthma.
6.5. Inj. Dextrose 25% 1. Glucose – elevating 1. Used in patient with

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Inj. Dextrose 50% agent (iv) hypoglycemic attacks.

2. Used in combination with
insulin to act on
hyperkalemia.
3. It can be used as a diluents
with some drugs like Inj.
Phenytoin.
6.6. Inj. Calcium gluconate. 1. Electolyte 1. Essential element of the
2. Antacid body.
2. Helps maintain the
functional integrity of the
nervous and muscular
systems. Helps maintain
cardiac function, blood
coagulation.
3. To prevent hypocalcemia
during exchange transfusion.
4. combats the effects of
hyperkalemia as measured
by ECG.
5. Improves weak or
ineffective myocardial
contraction when
epinephrine fails in cardiac
resuscitation, particularly
after open heart surgery.
6.7. Inj. Xylocard (Xylocain 1. Antiarrhythmic 1. As antiarrhythmic:
HCL IV for cardiac 2. Local anesthetic a. Management of acute
arrhythmias) ventricular arrhythmias
during cardiac surgery and

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MI.
2. As Anaesthetic:
a. Infiltration anesthesia,
peripheral and sympathetic
nerve blocks, central nerve
blocks, spiral and caudal
anaesthesia.
Articles Uses
1. Intubation tray
containing
a. Endotrachial tube of all A plastic tube used when patient require endotrachial
sizes(6-9) intubation and ventilation.
b. Stillet To provide stiffness to the endotrachial tube while using.
c. Ambu bag with mask For hyperventilating the patient & provide maximum
oxygenation before intubation, when patient is in apnea.
d. Gloves To maintain aseptic technique. Universal precaution.
e. Airways To maintain patent airway of the patient oropharyngially.
To do oral suctioning
To prevent tongue fall and bite when patient convulsing or
unconscious.
f. Dianoplaster To affix the endotrachial tube in place after intubation
g. Disposable syringes To inflate the cuff of endotrachial tubes, tracheostony tube etc.
(sterile) To load injections.
h. Lubricant jelly Has anesthetic effect
(Xylocaine)Suction Lubrication (eg: while insertion of ET tube, Na tube etc).
catheter
i. Laryngoscope with all To visualize the trachea
sizes of blades To remove excess secretion from endotrachial tube and
A device consisting of a oropharnyns
handle and a curved blade,
fitted with a light for It is an instrument used in intubation procedure to visualize the

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moving the tongue and vocal card and to introduce the ET tube
epiglottis aside in order to Also used in a difficult NGT insertion procedure.
inspect the larynx. It is used
to aid insertion of an
endotracheal tube or for
simple examination.
2. Cardiac Board Used when the patient required resuscitation. Placed under the
patient chest to provide hardness of the bed.
3. Magill’s Forceps It is an instrument used in difficult NGT insertion procedure.
(Also helps in removing broken tooth in during intubation).
Long angled forceps for use with a laryngoscope in removing

foreign bodies from the mouth and throat of an unconscious
patient.
4. Knee Hammer It is an steel instrument pointed with an rubber cork in one end
used in physical examination to check for reflexes of the
patient.
5. Tongue depressor An instrument used to depress the tongue during examination
of the oropharynx.
6. Tracheotomy tube A curved metal, plastic or rubber tube is usually inserted
through the hole which is made into the trachea. Used in failed
intubation.

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7. SOP FOR PROPER DOCUMENTATION OF ENTRIES IN PATIENT’S CHARTS

Patient documentations are legal documents. It should be accurate, clear, neat and legible
mostly in hospitals. We documents about patient’s condition, vital signs, procedures, intake
and output of the patient medications, any incidents which social service department. So we
are documenting about the patient’s social and economic status.
7.1. For documentation, there are different types of sheets used in all hospitals such as
7.1.1. Doctor’s order sheet
7.1.2. Medical therapy sheet
7.1.3. Graphic sheet
7.1.4. Nurse’s note
7.1.5. Lab investigations & x-ray sheets.
7.1.6. Progress sheet.
7.1.7. Linen checking sheet
7.1.8. Procedure sheet
7.1.9. Lab master sheet (different in CCU and other wards)
7.1.10. Oxygen usage sheet
7.1.11. Ventilator flow sheet
7.1.12. Intake and output chart
7.1.13. Summary sheet
7.1.14. Nursing care plan
7.1.15. Peripheral line assessment form
7.1.16. Doctors initial assessment form
7.1.17. Nurses initial assessment
7.1.18. Fall risk assessment
7.1.19. Admission order sheer
7.1.20. Time sheet
7.1.21. Inpatient Socio economic assessment form
7.1.22. Transfer form
7.1.23. Referral sheet
7.1.24. Consent form: if there are any special procedures, we need to inform the patient and
attender also has to get consent for it.

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7.1.25. Consultation sheet: We need to send the consultation form to the doctors to inform
there is consultation for the patient in particular ward.
7.1.26. Pre-Operating check list & emergency surgery consent: it has to send to OT before
any surgery.
7.1.27. These all documentation carries valuable information about patient and his/her
condition.

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8. SOP FOR EQUIPMENT MANAGEMENT

Coronary care unit (CCU) equipment includes patient monitoring, respiratory and cardiac support,
pain management, emergency resuscitation devices and other life support equipment designed to care
for patients who are seriously injured, have a critical or life threatening illness or have undergone a
major surgical procedure, there by requiring 24 hour care and monitoring.
8.1. Description:
Coronary care unit equipment includes:
8.1.1. Patient monitoring
8.1.2. Life support and emergency resuscitation devices.
8.1.3. Diagnostic devices.
8.2. Procedure:
8.2.1. Patient monitoring equipment
a) Acute care physiologic monitoring system like monitoring the electrical activity of the
heart via ECG, respiration rate, blood pressure, body temperature, cardiac output and
amount of oxygen and CO2 in the blood. Each patient bed in the CCUhas a
physiologic monitor that measures these body activities. All monitors are networked
to the central nurses station.
b) Pulse oximeter
c) Apnea monitor
8.2.2. Life support and Emergency resuscitative equipment
a) Ventilator
b) Infusion pump
c) Crash cart
d) Intra aortic balloon pump
8.2.3. Diagnostic equipment
a) Mobile x-ray equipment
b) Mobile sonography equipment

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8.2.4. Other CCU equipment

a. Disposable CCU equipment like urinary (foley’s) catheters.
b. Catheters used for arterial and central venous lines swan gauze catheters, chest and
endotracheal tubes.
c. Gastrointestinal and nasogastric feeding tubes
d. Monitoring electrodes.
8.2.5. Maintenance
a. The equipment should be properly maintained, particularly devices that are used for
life support and resuscitation.
b. CCU staffs should perform daily checks on equipment and inform b
c. iomedical engineering staff when equipment needs maintenance repair or
replacement.
d. When each patient is shifted from the CCU to the wards, the monitors equipment and
like pulse oxymeter, infusion pump should be cleaned thoroughly with spirit/sterilium
and dried.
e. When the equipments are not being used, it should be tied and kept safely to prevent
mishandling.
f. In every shift, all the CCU staffs should check the inventory for its proper
management.
8.2.6. Conclusion
Maintenance of equiement for its accountability and long life.
8.2.7. Clinical Alarms
In hospital settings alarms plays an important roll in all emergencies related with
patients and machines. Usually we are using different monitors and ventilators for
knowing and assessing the condition of the patient and to give adequate treatment by
recording vital signs, saturation etc. if there is any abnormalities in patient reading or
with machines its alarms, which help us to be alert and do the necessary requirements.
8.2.8. Different alarms in our hospital
a. Code blue announcement:
Code blue can be announced in any emergency where patient requires resuscitation.
b. Bed side bells:

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This is used by the patients or attenders to get any help from nurse if any emergency.
c. Monitors and Ventilator alarms:
This alarm will ring when the patient’s readings goes above or below the normal
range and if there is any problem with machines or power supply.
d. Infusion pump alarms:
This is using for administering the accurate dosage of medicine in a particular
period of time. If there is any block or the medicine gets over these alarms.

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9. LINEN MANAGEMENT
9.1. Linen is one of the most important item in the ward.
9.2. It provides neat appearance of patient and ward.
9.3. Clean linen is used always.
9.4. Every day linen is changed for all patients.
9.5. Every day each shift linen inventory is taken.
9.6. There is a linen sheet kept in each patient chart it is explained to relative or patient during
admission and discharge provided they sign.
9.7. Dirty linen is kept in the laundry box.
9.8. Solid linen are kept separately washed and then sent to laundry.
9.9. The charge nurse or senior staff takes count of linen before and after sending to laundry.
9.10. Linen are brought back after shifting each patient to other wards or hospital.
9.11. Mending linen is sent and received back.
9.12. Missing linen is replaced.
9.13. Linen is kept under lock and key.

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10. QUALITY ASSURANCE PROGRAMME: CCU
Quality assurance is an assessment tool used by health care practitioners to measure the quality of
care provision; it can involve observation interview and review of written care plans and nursing
orders.
The following quality indicators shall be monitored in the CCU on regular basis. The data obtained
shall be analyzed and the trend shall be reported to the medical audit committee. The following
indicators shall be monitored by the responsible personnel and communicated to the CCU in charge.
Quality indicators
10.1. Infection control related indicators (Responsibility-HIC team)
10.1.1. Urinary tract infection rate.
10.1.2. Respiratory Infection rate.
10.1.3. Intra-Vascular Device infection rate.
10.1.4. Surgical site Infection Rate.
10.2. Nursing care related indicators (Responsibility-Nursing)
10.2.1. Time for initial assessment
10.2.2. Urinary tract infection rate.
10.2.3. Respiratory Infection rate.
10.2.4. Intra-Vascular Device infection rate.
10.2.5. Surgical site Infection Rate.
10.2.6. Percentage of cases wherein care plan
10.2.7. Percentage of cases wherein the pre-defined initial nursing assessment is completed
within 30 min
10.2.8. Incidence of bed sores/worsening of existing bedsore/admissions with existing
bedsore
10.2.9. Nurse patient Ratio
10.2.10. Number of sentinel events
10.2.11. Percentage of near misses analyzed
10.2.12. Incidence of needle stick injuries
10.2.13. Percentage of medication errors
10.2.14. Incidence of adverse drug event

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10.2.15. Percentage of Medication Charts with illegible writing over a given period
10.2.16. Percentage of accidental removal of tubes and catheters
10.2.17. Incidence of haematoma at puncture site
10.2.18. Incidence of falls
10.2.19. Percentage of patients with adverse drug reaction
10.2.20. No. of dependants patients for activities of daily leaving (ADL)
10.2.21. No of IV cannula established
10.2.22. Incidence of thrombophlebitis
10.2.23. Incidence of transfusion reaction
10.3. Medical care related indicators (Responsibility-Medical audit team)
10.3.1. Hand washing
10.3.2. Incidence of late onset sepsis
10.3.3. Incidence of Deep vein thrombosis
10.3.4. Mortality rate

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11. GUIDELINES FOR INTERPRETATION OF ARTERIAL BLOOD GAS
11.1. Purpose
To correctly interpret the results of an ABG sample.
11.2. Scope
All CCU patients
11.3. Responsibility
Intensivist /Registrars
11.4. Definitions and Abbreviations
11.4.1. ABG Arterial Blood Gas
11.4.2. PCO2 Partial Pressure of Carbon Dioxide in arterial blood
11.4.3. HCO3 Bicarbonate
11.4.4. H+ Hydrogen ion
11.4.5. Na+ Sodium ion
11.4.6. K+ Potassium
11.5. Procedure
The interpretation of an ABG sample should follow these guidelines.
11.6. Checking the validity of ABG:
11.6.1. Find the PCO2. and HCO3.
11.6.2. PCO2. should be approximately = 2 meq/L > HCO3.
11.6.3. Calculate the H+ concentration which should match with the standard H+
concentration at that pH.
11.6.4. Actual H+ = (24* PCO2/ HCO3)
11.6.5. .A change of pH by 0.3 towards the alkaline side would decrease the H+ conc. By ½
and change in pH towards the acidic side would double the H+ conc.
11.6.6. H+ estimation from pH.
a. Approx. H+ conc. Can be calculated by multiplying 40 by 0.8 in case of alkalosis
and by 1.25 in case of acidosis.
pH 6.8 6.85 6.9 6.95 7.0 7.05 7.1 7.2 7.3 7.4 7.45 7.5 7.55 7.6 7.65 7.7 7.8
H+ 158 141 126 112 100 89 79 60 50 40 35 32 28 25 22 20 16

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11.6.7. Achieve a minimal diagnosis:
DISORDER Metab. Metab. Resp. Acidosis Resp. Alkalosis

Acidosis Alkalosis
Primary event Acid Retention of Lung unable to get Increased excretion
production/ Loss bases/ loss of rid of CO2 of CO2
of bases acids
Secondary Hyperventilation Hypoventilation Kidney regulation Kidney
event Decreased PCO2 Increased PCO2 of HCO3 excretes HCO3
H+ Increased Decreased Increased Decreased
pH Decreased Increased Decreased Increased

PCO2 Decreased Increased Increased Decreased
HCO3 Decreased Increased Increased Decreased
11.6.8. Simple or mixed disturbance:

a. APPLY COMPENSATION FORMULA: Predicted PCO2 = HCO3 * 1.5 + (8 +/-
2)
b. FIND PCO2 VALUE FROM ABG: e.g. if PCO2 > predicted value  retention of
PCO2  Respiratory Acidosis.
11.6.9. Calculation of anion gap:
Anion gap is calculated by the formula as follows,
ANION GAP = (Na+ + K+) – (HCO3 + Cl-).
NORMAL ANION GAP IS BETWEEN 10 –14.
11.6.10. Calculation of delta anion gap:
Delta anion gap is necessary for the diagnosis of triple metabolic disorders.
It is calculated as follows,
DELTA ANION GAP = CALCULATED ANION GAP – NORMAL ANION GAP.
11.6.11. CALCULATION OF STARTING BICARBONATE LEVELS:

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This is calculated by adding the delta anion gap to the bicarbonate levels on the ABG. If the
starting bicarbonate levels is higher than normal it means that there is a component of
metabolic alkalosis also involved.
12. PROTOCOL FOR THROMBOLYSIS IN ACUTE MYOCARDIAL INFARCTION
12.1. Purpose
To guide use of at thrombolytic agents in an Acute MI patient.
12.2. Scope
All Acute MI patients admitted in CCU
Intensivist/ Registrar
STK Steptokinese
PTCA percutaneous Transluminal Coronary Angioplasty
CPR Cardio pulmonary resuscitation
12.5. Procedure
12.5.1. Thrombolysis should be initiated if there are no contraindications to thrombolysis. It
is best effective if given within the first 1 hours after MI, but can be given up to 24
hours after the onset of chest pain esp. if the pain persists. Do not delay thrombolysis.
Thrombolysis to be delayed only in case of suspected dissection of the aorta or an
aneurysm, where an X- ray chest is a priority.
12.5.2. History probing for possible contraindications for thrombolysis to be obtained from
the patient, or the patient’s relatives.
12.5.3. Indications for Thrombolysis:
a. Presentation < 12 hours after onset of chest pain with
i. ST elevation > 2 mm in > 2 chest leads.
ii. ST elevation > 1 mm in > 2 limb leads.
iii. Recent onset left bundle branch block.
iv. Posterior infarction (Dominant R waves & ST depression from V1 to V3
v. Presentation within 12 to 24 hours if continuous chest pain and/or ST elevation
present.
12.5.4. Contraindication for Thrombolysis:

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ABSOLUTE RELATIVE
Internal bleed History of severe hypertension
Recent hemorrhagic stroke <2 Weeks Peptic ulcer
Heavy vaginal bleed H/o CVA
Acute Pancreatitis Bleeding diathesis
Recent trauma or surgery < 2 weeks Anticoagulants
Cerebral neoplasm Prolonged or traumatic CPR
Suspected aortic dissection Severe liver Disease
Previous allergic reaction
Pregnancy or < 18 weeks postnatal
Oesophageal varices
Recent head trauma
a. The patient and or his relatives must be given a choice between thrombolysis and PTCA,
explaining to them the pros and cons of each form of therapy.
b. It is the duty of the consultant or the intensivists on duty to explain the nature of the therapy
and the possible outcome of the therapy to the patient or his relatives or both including possible
adverse reactions.
c. Prior to initiation of thrombolysis a written, informed, expressed, free and valid consent to be
obtained from the patient or the relatives of the patient.
d. Inj. Perinorm 1 amp. IV stat followed by Inj. Hydro-cortisone (100mg) IV stat to be given prior
to thrombolysis.
e. The crash cart to be kept ready, including intubation trolley with the defibrillator on standby.
f. Thrombolysis to be carried out only with the attending physician at the patient’s bedside.
g. Immediately after thrombolysis and 1 hour after thrombolysis 12-lead ECG to be repeated and
the ST elevation to be measured.
h. If there is evidence of failed thrombolysis, which is shown by persistent ST elevation, a 2D-Echo
to rule out aneurysm is to be done and if the consultant decides, patient may need to be taken for
rescue PTCA.

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13. RECEIVING MYOCARDIAL INFARCTION PATIENTS

13.1. Purpose
To receive the patient and start the treatment within safe window period in order to decrease
the in-hospital rate of complications and overall mortality associated with acute myocardial
infarction.
13.2. Scope
All patients admitted to CCU with Acute MI
Doctors/ Nurses
13.4.2. HGT Blood Sugar level
13.4.3. PTCA Percutanous TransluminalCoronary Angioplasty
13.4.4. LMWH Low molecular weight Heparin
13.5. Diagnosis
It is based on the presence of 2 out of 3 of the following;
13.5.1. History of typical chest pain.
13.5.2. ECG changes
13.5.3. Increase of cardiac enzymes.
13.6. Procedure
13.6.1. Connect the patient to the cardiac monitor stat.
13.6.2. Take patients vital stats such as pulse, BP, Respiratory rate.
13.6.3. The paramedical staff should always be near the patient.
13.6.4. Start the patient on Oxygen 8-10 lit/min. with facemask.
13.6.5. Take a 12 lead ECG to facilitate the diagnosis.
13.6.6. The paramedical staff should be well conversant with the ECG and notify the doctor
on duty whether a ST elevation is seen and in which leads.
13.6.7. If the doctor is unavailable due to the fact that he is attending other patient to give the
following medications
a. Tab. Aspirin (325mg) crushed sublingually.
b. Tab. Sorbitrate (5mg) crushed sublingually.

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c. Tab. Metoprolol (12.5mg) 1 stat.

d. Inj. Norphine (0.3mg) IV or Morphine 5 – 10mg IV.
e. Anti – emetic.
f. Inj. NTG (50mg/50ccNS) to be started @ 0.3ml/hour  5 µg/min.
g. If patient is in left ventricular failure then Inj. Frusemide (40mg) IV stat to be
repeated SOS.
h. ACE inhibitors short acting such as Tab. Captopril (25mg) QDS if there are no
contraindications for use.
i. If necessary IABP in patients with refractory failure not responding to ionotropic
supports. (Current evidence suggest against use of ionotropic agents such as
Dobutamine alone as they are shown to increase mortality).
13.6.8. To collect blood and sent for the following investigations after securing a wide bore
IV access
a. CBC.
b. S. Creatinine, BUN.
c. S. Electrolytes.
d. Baseline PT, PTT.
e. S. Amylase, LDH, CPK, CPK MB.
f. Trop-T/Trop- I.
g. If intervention is planned then viral markers after taking the patients consent or
consent from a responsible relative if patient unable to give consent.
h. HGT.
i. Urine for routine, microscopy.
j. Rapid urine test for sugars and ketones with keto-diastix.
13.6.9. Lead ECG, repeat in one hour if first ECG normal.
13.6.10. Right lead ECG is a MUST in cases of inferior wall myocardial infarction to rule
out right ventricular infarction.
13.6.11. X –ray chest.
13.6.12. ABG
13.6.13. Inj. Perinorm 1 amp. IV stat followed by Inj. Hydro-cortisone (100mg) IV stat to be
given prior to thrombolysis.

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13.6.14. The crash cart to be kept ready, including the intubation trolley with the DC
defibrillator on standby. Check Defib.is working.
13.6.15. Thrombolysis is to be carried out only with the attending physician at the patients
bedside.
13.6.16. Thrombolysis should be initiated if there are no contraindications to thrombolysis. It
is best effective if given within the first 1 hours after MI, but can be given up to 24
hours after the onset of chest pain esp. if the pain persists. Do not delay
thrombolysis. Thrombolysis to be delayed only in case of suspected dissection of
the aorta or an aneurysm, where an X- ray chest is a priority.
13.6.17. Prior to initiation of thrombolysis a written, informed, expressed, free and valid
consent to be obtained from the patient or the relatives of the patient with at least 2
witnesses witnessing the consent.
13.6.18. It is the duty of the consultant or the intensivists on duty to explain the nature of the
therapy and the possible outcome of the therapy to the patient or his relatives or
both including the likely adverse reactions.
13.6.19. The patient and or his relatives must be given a choice between thrombolysis and
PTCA, explaining them the pros and cons of each form of therapy.
13.6.20. If there are any contra-indications to thrombolysis then an urgent PTCA to be
planned for, the consultant informed, the Interventional Cardiologists of the
consultants choice to be informed by the intensivists on duty.
13.6.21. If the PTCA is to be done beyond normal duty hours the concerned paramedical
staff has to inform the concerned supervisor and the Cath lab staff and other
concerned staff to be intimated regarding the procedure.
13.6.22. The patients relatives should be clearly told regarding the patients criticality, and the
possible complications that may be expected to occur, and the possible outcome
after any form of therapy, in any pateint with myocardial infarction by the doctor on
duty.
13.6.23. Immediately after thrombolysis and 1 hour after thrombolysis 12-lead ECG to be
repeated and the ST elevation to be measured.

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13.6.24. If there is evidence of failed thrombolysis which is shown by persistent ST elevation

a 2D-Echo to rule out aneurysm to be done and if the consultant decides patient may
need to be taken for rescue PTCA.
13.6.25. Patient to be kept under strict bed rest for at least 48 hours.
13.6.26. Following 6 hours after thrombolysis, therapy with Inj. Heparin (25000U/50ccNS)
@ 1000 U/hr, with monitoring of PTTK at interval of 6 hours and then adjusting the
dose to maintain PTTK between 2-3 times the normal value to be carried out for the
next 24 hours.
13.6.27. Following IV Heparin patient to be started on low molecular weight heparin.
Alternatively LMWH can be initiated 6 hrs following thrombolysis.
13.6.28. Treat the complications as and when they present. In case of reperfusion
arrhythmias no treatment is recommended unless there is hemodynamic
compromise.
13.6.29. S. K+ to be monitored very closely at an interval of 8 hours and corrected as and
when required.
13.6.30. Correct the hyperglycaemia with intra-venous insulin for 48 hours, then patient to
be started on sub-cutaneous Insulin. Oral hypo-glycaemic agents should be started
after 5 days of MI and after an adequate glycaemic control is obtained with sub-
cutaneous insulin.
13.6.31. HGT to be monitored for the first 2 days on 1 to 2 hourly (in diabetics)
13.6.32. Patient to be monitored closely with B.P. and Pulse recorded initially at interval of
15 min. followed by 30 min from day 2.
13.6.33. If necessary a CVP line to be inserted by a doctor privileged to do so and CVP to be
monitored esp. patients with left ventricular failure or those required Inotropes.
13.6.34. Hypotension in patients with Right ventricular infarcts best treated with fluids even
though the CVP or JVP may be raised.
13.6.35. In case of patients with inferior wall MI who develop a CHB a temporary pacing
wire can be inserted via a femoral catheter and patient put on temporary pacemaker.
Dual chamber pacing is advisable according to some experts. Alternatively patient
can be put on trans-cutaneous pacemaker. Correction of the underlying electrolyte
imbalance if present takes the priority.

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13.6.36. Reperfusion arrhythmias best treated with Lignocaine IV given bolus of no more
than 100mg at one shot. If they persist then IV Amiodarone to be given 300mg IV
stat followed by an infusion of 900 mg dissolved in 50 cc NS @ 2-4 ml/hr.
13.6.37. If there is no contraindications patient to be transferred to the wards after 3 days
POST OP

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14. PROTOCOL TO BE FOLLOWED IN CASE OF MASSIVE PULMONARY EMBOLISM

14.1. Purpose
To prevent occurrences of PE with the help of Clinical Pathway
14.2. Scope
All CCU admitted patients at high risk of PE.
Doctors and Nurses
14.4. Definitions and abbreviations
14.4.1. INR International Normalised ratio
14.4.2. APTT Activated partial Thromboplasty tent
14.4.3. STK Streptokinase.
14.4.4. RMO Resident Medical Officer
14.5. Procedure
14.5.1. Causes:
a. Venous thrombo-embolism due to deep venous thrombosis in leg veins.
b. Immobility, post surgery esp. pelvic surgery, prolonged bed rest.
c. Hypercoagulability due to pregnancy (post partum), hormone replacement therapy,
oral contraceptive pills, disseminated malignancy, thrombophilia, Anti-phospholipid
syndrome.
d. Right ventricular thrombus (post MI), air, fat, amniotic fluid embolism, septic,
parasitic embolism.
e. Previous thrombo-embolism.
14.5.2. Prevention:
a. Early post-op mobilization.
b. Anti-thromboembolic stockings.
c. Heparin prophylaxis.
d. Avoid OC pills prior to major or orthopedic surgeries
e. Recurrent episodes to be prevented by vena-caval filters with anticoagulation.
14.5.3. Signs & symptoms:
a. Acute dyspnoea.
b. Pleuritic chest pain.

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c. Hemoptysis.
d. Syncope.
e. Hypotension, Tachycardia, gallop rhythm, JVP raised, loud P2, right ventricular
heave, pleural rub, tachypnea, cyanosis, Atrial fibrillation.
f. Cardiac arrest, cardiogenic shock.
14.5.4. Investigations:
a. ABG  hyperventilation + decreased gas exchange  decrease PO2 and PCO2, pH
often is increased.
b. ECG  RBBB, AF, right ventricular strain pattern (V1-V3), right axis deviation,
deep S waves in I, Q in III, T inverted in III. But most common presentation is with a
normal ECG or with sinus tachycardia.
c. X- Ray chest  often normal, wedge shaped area of infarction, small pleural
effusion, decreased vascular markings.
d. D-dimer  increased if thrombosis present. May help in exclusion of PE.
e. CT pulmonary angiography is sensitive and specific in diagnosing of emboli in
pulmonary artery.
f. V/Q Scan can aid in the diagnosis.
g. If V/Q scan is equivocal then pulmonary angiography or bilateral venograms.
h. Location of the source of embolism  venous Doppler of the legs.
i. S. Electrolytes.
j. Baseline APTT and PT (INR).
14.5.5. Management:
In view of history highly suggestive of PE and signs in favor of PE, with the initial
investigations in favor of PE, initiate treatment promptly as majority of the deaths occur
within the first hour.
14.5.6. Aim of therapy in acute set up is to prevent further episodes of pulmonary embolism
from occuring and maintain systolic BP > 90 mm of Hg.
a. Oxygen 100%.
b. If pain then Inj. Morphine (10mg) or Norphine (0.3mg) IV.
c. Establish IV access.
d. Loading dose of Inj. Heparin 5000 U bolus IV.

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e. Infusion of heparin @ 1000 – 2000 U/ hr IV, as guided by the APTT**. APTT to be

monitored every 6 hourly. Heparin to be given for a total of 5 days.
f. Instead of heparin low molecular weight heparin can be used.
g. If the systolic blood pressure is > 90 mm of Hg then Tab. Warfarin 10mg can be
given. Warfarin 1st dose to be given at 8pm on day 1 with the INR done after 16 hrs.
If INR is up to 2 then another 10mg of Warfarin to be given next day at 5 pm and INR
to be repeated the next day morning. PT (INR)** to be monitored daily and kept in the
range of 2-3.
h. If the systolic BP is < 90 mm Hg then start rapid infusion of colloids  if BP still low
even after infusion of 500 ml colloids start Dobutamine @ 5 – 10 microgm/kg/min
(for a 60 kg man  3 – 4 ml/hr). If still the BP is low then to consider Noradrenaline.
i. In case of the patient’s BP < 90 mmHg even after 30-60 min, and a definite evidence
of PE exists,  to consider thrombolysis with streptokinase (STK).of no
contraindication.
j. STK to be given in the following dose  Loading 250000U IV over 30 min. followed
by 100000U/hr IV for 12 – 72 hours according to the response.
**
APTT in case of Heparin and INR in case of Warfarin to be monitored every 6 hourly and
every 12 hourly respectively. The dose of IV Heparin and Warfarin 1st is to be changed according
to the scale. This scale to be incorporated in the nurses’ observation notes used for monitoring
APTT and INR. The concerned paramedical staff attending the patient should adjust the dose of
IV heparin and Warfarin according to the chart in consultation with the doctor on duty.
*  If INR > 4.1 mg then that dose of Warfarin to be missed and the next day 1-2 mg to be
given, if INR > 4.5 then the next 2 doses of Warfarin to be missed. INR to be done daily for first
5 days and then on alternate days until a stable dose is obtained then to be done weekly.

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15. PROTOCOL TO BE FOLLOWED IN MANAGEMENT OF DIABETIC KETOSIS/

KETOACIDOSIS
15.1. Purpose
To manage a case of Diabetic Ketoacidosis.
15.2. Scope
All Diabetic patients admitted with Ketoacidosis.
Intensivist /Registrar
Hyperglycemic ketoacidotic coma only occurs in type I DM, but may be a mode of
presentation in a patient with type II DM esp. in patients with MI, infection, and post- op.,
non-compliance or due to the use of wrong doses of insulin.
15.4.1. RBS Random Blood Sugar.
15.4.2. ABG Arterial Blood Gas.
15.4.3. CBC Complete Blood count.
15.4.4. CPK Creatinine Phosphokinase.
15.4.5. HONK Hyperosmolar Non Ketotic.
15.4.6. LMWH Low Molecular weight Heparin.
15.5. Procedure
15.5.1. Components:
a. Hyperglycaemia.
b. Ketosis
c. \Acidosis (pH < 7.3 usually)
d. Dehydration.
15.5.2. Signs & symptoms:
a. Polyuria
b. Polydipsia
c. Lethargy
d. Anorexia
e. Hyperventilation
f. Ketotic breath

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g. Dehydration
h. Vomiting
i. Abdominal pain
j. Coma
15.5.3. Management guidelines (Emergency):
a. As soon as a patient with unexplained coma comes to the emergency department
the Emergency officer should take a detailed history regarding history of fall or
trauma to the head, history suggestive of infection, history of the patient being
diabetic, consumption of poisons or other intoxicants or any medications in excess,
etc.
b. The Emergency staff should secure a IV access immediately, send the blood for
the following investigations urgently;
i. RBS or CHECK GLUCOSE LEVELS stat.
ii. BUN/ S.Creat.
iii. Urine for sugars and ketones by keto-diastix.
iv. Urine for routine and microscopy.
v. ABG
vi. CBC
vii. S. Electrolytes
viii. S. Osmolality & Urine Osmolality.
ix. If HGT > 400 mg% then ask for S. Ketones.
x. S. Amylase.
xi. Blood culture
xii. Urine culture & Sensitivity
xiii. Blood culture
xiv. ECG
xv. X-ray chest
xvi. CPK, CPK-MB, Trop- T if ECG changes s/o MI / Unstable angina
xvii. If the HGT shows values > 400 mg% then 10 U of Human Actrapid Insulin
(HAI) should be given stat to the patient IV.

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xviii. Naso- gastric tube to be inserted immediately and aspiration done to rule out
gastrointestinal bleeding, make the NGT aspiration continuous.
xix. Foleys catheter to be inserted to measure the urinary output every hourly.
xx. Start correction of dehydration with ½ strength NS IV fast through the wide
bore IV access @ 2000ml / hour.
xxi. Intubate the patient if necessary.
xxii. Transfer the patient to the CCU.
15.5.4. Management Guidelines (CCU):
a. Relevant and detailed history to be obtained by the attending physician in the CCU.
b. The attending paramedical staff should attach the monitors to the patient and be
prepared with a emergency cart and ventilator on standby
c. As soon as the patient is brought into the CCU, HGT and Urine must be checked for
glucose levels and for presence of ketones, making a note of the same in the chart * for
monitoring patients with DKA.
d. The investigations from the emergency to be traced immediately.
e. Take the consent from the relatives for insertion of CVP line in order to monitor the
CVP and to correct the dehydration according to the CVP, so as to maintain the CVP
between 8 to10 cm of water.
f. Dehydration to be corrected as follows: 1 litre of ½ strength NS stat over a period of
30 minutes, followed by 1 litre over next 1 hour followed by 1 litre over next 2 hours
followed by 1 litre of 4 hours followed by 1 liter over 6 hours or according to the
CVP. Maintain blood sugar between 120 to 180 mg% till ketones are negative and
then aim for sugars between 110-140 mg %. CAUTION TO BE USED IN
PATIENTS WITH CRF OR WITH DIABETIC NEPHROPATHY.
g. The same glucometer to be used every time to minimize the error in measuring HGT.
h. Other than ½ strength NS or DNS only NS or DNS can be used. Do not use ringer’s
lactate solution otherwise it may compound lactic acidosis which may be
accompanying either because of infection or the use of OHA’s such as metformin in
patients with compromised renal function. ½ strength NS or DNS is preferred as
giving NS to patients of HONK may lead to central pontine myelinolysis as well as
the hyponatremia assocaited with DKA gets corrected as the water enters the cells.

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16. PROTOCOL TO BE FOLLOWED IN A CASE OF ACUTE INGESTION OF POISON
All patients presenting with the alleged history of acute poisoning to be considered as “high risk”
patients and universal safety precautions to be followed strictly by all the staff concerned in order to
prevent any unintended exposure to blood as well as other secretions of the patient.
16.1. Remove the patient’s clothes and change them to prevent absorption of certain poisons such
as OPC’s.
16.2. Assess the conscious level of the patient and intubate the patient with the relevant sized
cuffed endotracheal tube to prevent aspiration and to protect the airway.
16.3. A relevant history as to the name, nature of the poison, and the amount consumed is to be
obtained from the patient and confirmed from the relative in case of a conscious patient. If
the patient is unconscious then the relevant details to be obtained from the relatives of the
patient.
16.4. It is the duty of the Emergency medical officer or the Emergency staff to inform regarding
the arrival of the patient to the concerned police station, for medicolegal registration.
16.5. If the patient is conscious then take the patient’s consent for insertion of a Naso-gastric tube.
If the patient is comatose then the patient’s relatives consent to be obtained.
16.6. One of the relatives of the patient should be sent to get the container of the allegedly
consumed poison, to verify the details of the poison, the amount that is consumed as well as
the recommended antidote to that particular poison as stated by the manufacturer.
16.7. Never induce emesis.
16.8. A naso-gastric tube is contraindicated in case of acute poisoning with acids, alkalis,
petroleum and petroleum products and kerosene.
16.9. After a no. 14 naso-gastric tube is placed in position it is to be confirmed by auscultating on
the right hypochondriac region while air is pushed through the tube.
16.10. The first aspirate is aspirated and sent to the lab for chemical analysis.
16.11. Naso-gastric wash is given with 300 cc tepid water. The naso-gastric lavage to continue till
the returning fluid is either clear or it does not contain any tablets as in case of patient with
overdose of tablets. In case of acute overdose with paracetamol a single lavage may suffice,
but in case of barbiturates and OPC’s multiple lavages at an interval of 4 hours are
necessary.

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16.12. The amount of fluid siphoned in via the naso-gastric tube should be less than or equal to the
fluid siphoned out hence if the amount is less the patient is to be put in the left lateral
position and pressure is to be applied over the right hypochondriac region, to facilitate the
outflow of the lavage fluid.
16.13. After the lavage a solution of activated characoal (50 g in 200cc tepid water) is kept in the
stomach for patients with tablet overdose. In patients with paracetamol overdose a single
dose of activated charcoal would suffice, but in cases of overdose by benzodiazepines it has
to be given very 4 hourly.
16.14. Specific antidote treatment is then instituted.
16.15. The following investigations are to be done
16.15.1. CBC
16.15.2. S.Creat/BUN.
16.15.3. S. Electrolytes.
16.15.4. Prothrombin time with Liver function tests.
16.15.5. Activated PTT.
16.15.6. Urine for benzodiazepines levels.
16.15.7. Urine for Toxicology A and B screen.
16.15.8. Blood for benzodiazepines.
16.15.9. Blood for Cholinesterase levels.
16.15.10. ABG
16.15.11. ECG
16.15.12. X- ray chest.
16.15.13. Blood for digoxin levels, paracetamol levels if indicated.
16.15.14. Random blood sugars.
16.15.15. Chemical analysis in case of ingested poison

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17. MANAGEMENT OF CHRONIC RENAL FAILURE

17.1. Purpose
Long term management of Chronic Renal failure
17.2. Scope
All Patients Chronic renal failure
Intensivist
17.4. Procedure
17.4.1. Dietary Modification
a. Protein Restriction
b. 0.6-0.8 g/kg/day
c. Phosphate Restriction
d. Potassium- 25-50
e. mEq/day
f. Magnesium Restriction - Avoid magnesium-containing antacids.
g. Sodium Restrictions
h. Not absolute & depends on individual case- 2-4 gm/day
i. Water Restrictions -1000ml plus urine output.
17.4.2. Medical therapy
a. Calcium Replacement
b. Toms-os-cal
c. Calcium ca
d. rbonate tablets
e. 250 mg TDS to 650 mg TDS
f. Aluminum Containing Antacids
g. Starting dose 15-30 ml orally TDS
h. Vitamin D analogue
i. Rocalcitro l(calcijen) at 6am 0.125 µg-0.250 µg
j. Diuretics Frusemide Lasix 80-400 mg orally
k. Ethacrynic acid Edecin 25-200mg orally
l. Bumetanide Bumen 0.5mg-2.0mg orally

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m. Metolazone Metozar 2.5mg-10 mg orally

17.4.3. Anti-hypertensive therapy
a. Angiotensin converting enzyme inhibitor if S.creatinine <3
b. Beta-blockers
c. Ca++channel blockers
d. α blockers
e. α2 agonist
17.4.4. Treatment of Anemia in CRF
Iron  Oral / IV Supplementation

Folic Acid  5mg – 20mg Oral
Recombinant Erythropoeitin  Epox Sc 50U/kg/Trice a week if Hb < 6 gm %
 Maintenance Dose  75 U/kg
After dialysis
Fluid Overload, deranged renal parameters, refractory metabolic acidosis Hemodialysis

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18. CARE OF PATIENT WHO HAD PTCA

18.1. Purpose
It is a technique used for the treatment of CAD.
18.2. Scope
All patients undergoing PTCA
18.3. Responsibilities and Authorities
Registered nurse, Intensivist, Registrar
18.4. Definitions & Abbreviations
A balloon tipped catheter is introduced through a guide wire via Rt. femoral artery in to the
coronary vessel .The balloon catheter is then inflated causing disruption of the intima and
changes in the lesion .The result is an increase in the diameter of the lumen of the coronary
vessels. An improvement in the blood flow below the lesion. Balloon inflation and deflation
may be repeated until satisfactory results are achieved.
18.5. Procedure
18.5.1. Indications
a. Stable angina less than 1 year Unstable angina less than 6 months, despite optimal
medical therapy
b. Single vessel or multivessel disease
c. Evolving MI
d. High risk surgical candidates
18.5.2. Contra Indications

a. Patients with left main coronary artery disease
b. Patient with severe left ventricular function
18.5.3. Recent Advances
a. Laser –assisted balloon angioplasty
A laser light is directed by a percutaneously inserted flexible fiber optic catheter and is able
to vaporize atheromatous lesions in the coronary vessels
b. AtherectomyA burr-tipped high-speed rotating catheter is inserted percutaneously in
to a coronary vessel and drills through the atheromatous lesion, changing it to
microscopic debris

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c. Intracoronary stenting
A tiny coil or diamond mesh tubular device (stent) is placed in to the coronary artery
immediately after successful balloon angioplasty. The stent remains in the vessel to
prevent restenosis.
d. Assessment and Management
ACTION RATIONAL
i. Explain the procedure to the patient and Teaching provides information and may help
relatives decrease anxiety and fear
ii. Obtain informed consent To ensure that the patient and family is ready
for the procedure
Because it is legal document
iii. Evaluate laboratory tests such as cardiac Low serum potassium level results in
enzymes, electrolytes, PT, PTT, increased sensitivity and excitability of the
creatinine, Bun, HIV, HBSAg & HCV myocardium.
Creatinine & BUN to know the function of
kidneys.
Good function of kidneys are important to
filter and excrete the radio opaque dye which
is injected during procedure
iv. Document the height and weight of the To decide the amount of dye can be injected
patient
v. NBM for 4 hrs prior to surgery
vi. Check for any allergy
vii. Insert an IV cannula on left side Procedure is performed on the right side of
the patient
viii. Complete angioplasty check list
ix. Transfer the patient to cath lab on call
with all the reports and files

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e. Nursing Assessment and Management Post-PTCA

i. Transfer the patient to CCU For observing and assessing the patient
closely for signs and symptoms of myocardial
ischemia
ii. Attach the patient to monitor For quick internal cardiac assessment
iii. Check vital signs every ½ hourly
iv. Check peripheral skin color & To evaluate the peripheral circulation
temperature
v. Check dorsalis pedis and posterior To evaluate peripheral circulation
tibialis pulse in the limbs every ½ hrly
vi. Instruct the patient to keep the involved To prevent bleeding from the punctured site
leg in a straight position
To avoid upright position and to avoid
vigorous use of the abdominal muscle,
as in coughing, sneezing or moving the
bowel
vii. Patient can be on liquid diet if no To prevent fluid and electrolyte imbalance
vomiting
viii. Administer analgesics if advised To relive pain
ix. Check hydration and urine output of the To ensure the good function of kidneys to
patient filter and excrete the injected dye during
procedure
x. Send investigations To know electrolyte imbalance
Electrolyte To know the coagulation report of patient
PT, PTT
xi. Watch for hematoma and bleeding from To prevent excessive bleeding and to aid
the punctured site hemostasis, sand bag can be placed over the
puncture site as per physician order
xii. Send PTT after 6 Hours To remove sheath

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f. Assessment and preparation for sheath removal

i. Assess the medical history of bleeding May increase the risk of bleeding or vascular
disorders complications
ii. Assess complete coagulation report To prevent complications (bleeding)
iii. Assess vital signs and record Establishes base line data
iv. Assess Dorsalis Pedis.posterior tibial Establish baseline assessment before sheath
pulse, strength of the pulse. Color, removed
temperature, sensation and movement of
the limb
v. Assess patency of I.V access To administrate emergency medication and
fluids if necessary
vi. Ensure the patient about the procedure
vii. Administrate analgesia before sheath Facilitate pain management
removal
viii. Place the patient with head flat at less Improve ability to avoid hemostasis
than 15 0
ix. Mark distal pulse with marker Facilitate ability to locate pulses after
procedure
x. Keep inj atropine ready Patient can go in to vasovagal attack during
sheath removal
xi. Perform the procedure in an aseptic To prevent infection
technique
xii. Instruct the patient to keep leg straight To prevent bleeding
for 3 more hours and put sand bag on
the dressing
18.5.4. Patient’s Education /Health Maintenance
a. Modification cardiac risk factors as means of controlling progression of coronary
artery disease
b. Name of medications, action, dosage and side effects.
c. Symptoms for which patient should seek medical attention –side effects of
medications, chest pain or weight increases
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d. Dietary control
e. To avoid smoking and alcohol consumption
f. Dates and importance of follow up –tests and exercises
18.5.5. Complications
a. Coronary occlusion
b. Coronary dissection
c. MI
d. Restenosis
e. Coronary artery spas

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19. EXPLORATORY ABDOMINAL SURGERY

19.1. Purpose
Management of Post abdominal surgery patients
19.2. Scope
All CCU patients undergone abdominal surgery
Intensivist
19.4. Definitions ad Abbreviations
19.4.1. CVP Central Venous pressure
19.4.3. DIC Disseminated Intravascular Coagulopathy
19.5. Procedure
19.5.1. After receiving the patient from OT check Hb, K+ or Complete CBC, Na+, K+,
creatinine depending on the surgeries.
19.5.2. If major surgeries more that 3 hrs repeat complete CBC, Na+, K+, creatinine.
19.5.3. IV fluids – 150 ml/hr to maintain good hydration with CVP 8-10 mmHg, and urine
output ≥ 60-70 cc/ hr.
19.5.4. If SBP ≤ 100 mm Hg and CVP is 12 – 15 mmHg, start the patient on dopamine drip.
If the patient is febrile, hypotensive, with low urine output on inotropes, the patient
could be in septicemia.
19.5.5. Repeat ABG, DIC profile.
19.5.6. Confirm with primary consultant about change of antibiotics.
19.5.7. Explain to the relatives the clinical condition of the patient.

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20. POST NEURO SURGERY PATIENTS

20.1. Purpose
To mange a post neuro surgical case
20.2. Scope
All patients undergone neuro surgery
Intensivist / Registrar.
20.4.1. PCO2 Partial Pressure of Carbon Dioxide in arterial Blood.
20.5. Procedure
20.5.1. Ventilate the patient of required post surgeries and clinical decision of extubation
after discussion with intensivists after considering the clinical status of the patient.
20.5.2. Maintain head high 30°.
20.5.3. Maintain PCO2 25-30 for first 48 –72 hrs.
20.5.4. Monitor Heart Rate. If Bradycardia develops as a fresh event and patient is found to
be neuro vitally unstable. Immediately inform the neurosurgeon
20.5.5. Maintain good hydration with CVP 8-10 mm
20.5.6. Neurovitals to be monitored hourly
20.5.7. Repeat post-op – CBC, Na+, K+, Creatinine, ABG

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21. PROTOCOL TO BE FOLLOWED IN CARDIAC ARREST

21.1. Purpose
To learn to correctly diagnose and treat the patient with cardiac arrest
21.2. Scope
All CCU Staff.
Intensivist / Registrar
21.4.2. CPR Cardio Pulmonary Resuscitation
+
21.4.3. S K Serum Potassium
21.4.4. J Joules
21.4.5. VF/VT Ventricular Fibrillation /Tachycardia.
21.4.6. RBS Random Blood Sugar
21.4.7. CPK Creatinine Phosphokinase enzyme
21.5. Causes
21.5.1. Acute myocardial infarction.
21.5.2. Pulmonary embolism.
21.5.3. Trauma.
21.5.4. Electrocution.
21.5.5. Tension pneumothorax.
21.5.6. Shock.
21.5.7. Hypoxia.
21.5.8. Electrolyte imbalance.
21.5.9. Hypercapnia.
21.5.10. Hypothermia.
21.5.11. Drugs- e.g. Digoxin.

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21.6. Procedure
21.6.1. Confirm Diagnosis
21.6.2. Carotid pulse not felt.
21.6.3. Apnoeic
21.6.4. Unconscious.
21.6.5. Flat line or Ventricular fibrillation/ Tachycardia on scope – ECG monitor or
Defibrillator monitor.

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22. CARE OF PATIENT ON VENTILATOR AND WEANING

22.1. Purpose
22.1.1. To maintain adequate ventilation.
22.1.2. To deliver precise concentration of O2
22.1.3. To lessen the work of breathing in those clients who cannot sustain adequate
ventilation on there own
22.1.4. To maintain adequate PaO2; PaCO2&PH
22.2. Scope
Mechanically ventilated patients
22.3. Responsibilities and Authorities
Registered Nurse, Intensivist, Registrar, Anesthetists
22.4. Definitions & Abbreviations
The initiation and maintenance of positive pressure ventilation by insetting a long slender
hollow tube into the trachea via the nose /mouth to maintain & improve oxygenation in
clients having deficiency in marinating a normal breathing pattern.
22.5. Equipment
22.5.1. ECG and pulse oxymeter
22.5.2. AMBU Bag with mask
22.5.3. O2 supply
22.5.4. Suction equipment
22.5.5. Suction catheter
22.5.6. Sterile H2O
22.5.7. Syringe
22.5.8. Sterile gloves
22.5.9. E.T. Tie
22.5.10. E.T. CO2 monitoring device
22.5.11. Ventilator

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22.6. Procedure
S.No ACTION RATIONALE
22.6.1. Explain to the patient and family the Communication and explanation for therapy are
reason for intubation and the need cited as important need of patients & knowledge
for mechanical ventilation of anticipated sensory experience reduces anxiety
& distress
22.6.2. Encourage patient to relax Promotes general relaxation oxygenation &
ventilation
22.6.3. Assess the saturation level, arterial Acute Ventilatory failure is confirmed by an
pH, PaO2 and PaCO2 levels uncompensated respiratory acidosis also helps in
early correction
22.6.4. Check ventilator settings To achieve initial data
FiO2, alarms, connections
22.6.5. Auscultate the lung Reveals the amount of fluid and secretion;
validates that ET tube is in place & equal air
entry to both lungs
22.6.6. Check the E T tube placement, teeth Prevent tube dislodgment & inadvertent
mark; and cuff inflection extubation
22.6.7. Use an oral air way or bite block Prevents client from chewing the tube and from
ET tube compression
22.6.8. Administer sedatives and muscle Administration of sedations/ muscle relaxants
relaxants as ordered may be necessary to provide adequate
oxygenation and ventilation in some patients
22.6.9. Provide adequate humidity via the Replace the function of upper airway to warm
ventilator and humidify the inspired air, liquefy the
secretion and to facilitate their removal
22.6.10. Turn and reposition the client every Helps proper ventilation of both lungs and
two hours mobilizing secretions
Prevent pressure sore
22.6.11. Airway suctioning is to be done on To prevent unnecessary trauma to the airway and

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“as needed” basis with appropriate the nausea

size a suction catheter
22.6.12. Maintain aseptic technique Prevents respiratory tract infection.
throughout the procedure
22.6.13. Hyper oxygenate before and after Extra oxygen prevents desaturation from
each suctioning suctioning
22.6.14. Monitor for any drop in BP; Cardiovascular depression occurs due to
tachycardia (early sign), Bradycardia increased tidal volume; peep. CPAP as it
(late sign)’ arrhythmias and weak decreases venous return and cardiac output
peripheral pulses because of an increased pressure
22.6.15. Change the catheter mount and Prevent occurrence of respiratory tract infection
thermo vent hepa every 72 hours
22.6.16. Provide mouth care every 4 hourly Prevents drying of the oral mucous membrane
and developing stomatitis
22.6.17. Perform cuff care every 8 hours To prevent necrosis and to prevent tube
dislodgement
22.6.18. Ensure activation of all alarms each Ensures patients safety
shift
22.6.19. Ensure availability of manual self Provides capability for immediately delivering
inflating resuscitation bag with ventilation and oxygenation to relive acute
supplemental oxygen respiratory distress caused by hypoxemia or
acidosis
22.6.20. Maintain accurate and up to date
documentation of the events and the
changes made in the Ventilatory
settings
22.6.21. Document the ABG values Helps promote accurate ventilator settings and
accurately adequate mechanical ventilation as per patients
needs.

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23. CARDIO-PULMONARY RESUSCITATION:

23.1. Basic Life Support:
To be initiated by the paramedical staff attending the patient even before the doctor on duty
can reach the patient.
23.1.1. Shout for help or ask some other staff to initiate CODE BLUE (in case the arrest is
detected in the ward). Don’t leave the bedside of the patient.
23.1.2. Note the time.
23.1.3. In case of witnessed arrest give a precordial thump. Recheck carotid pulse.
23.1.4. Verify position of the chest leads, verify position of endotracheal tube.
23.1.5. Start Cardio-pulmonary Resuscitation.
23.1.6. Ask the other paramedical members to get ventilator ready as well as to get the crash
cart to the patient’s bedside.
23.1.7. Ask the other paramedical staff to attach the defibrillator.
23.1.8. The concerned staff to continue CPR as elaborated.
23.1.9. Print screen for documentation.
23.1.10.Blood to be collected immediately and sent without delay for ABG, S. K+, informing
the laboratory to do the investigations urgently.
23.1.11.Try to secure an IV access.
23.1.12.A staff trained at conversing and comforting the relatives should talk to the relatives
and try to calm them and keep away from the patient- preferably out of the CCU.
23.2. Components of Basic Life Support:
23.2.1. AIRWAY: Head tilt (if no head or spinal injury) with the chin to be lifted and jaw
thrust. Open mouth of the patient.
23.2.2. BREATHING: Use AMBU bag with mask and start the patient on artificial
respiration @ 2 breaths for every 15 chest compressions in case of 2 persons. This
should be continued till the doctor reaches the patient and starts resuscitation.
23.2.3. CHEST COMPRESSIONS: CPR should not be interrupted except for intubation- by
appropriate endotracheal tube. For chest compressions to be adequate heel of the hand
should be used with the elbows kept straight. Centre over the lower third of the sternum.
Aim of the chest compression should be compressing the chest by approximate 5 cm @
100 compressions per min.

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23.3. Advanced Life Support:

23.3.1. Attach the defibrillator leads. If there is any delay in the attachment of the leads the
pedals should be placed on the chest of the patient and the monitor should be set to read
from the pedals.
23.3.2. The rhythm should be assessed.
23.4. VT/VF:
23.4.1. Defibrillation should be commenced immediately with the defrillator set to deliver
shock in an asynchronised manner.
23.4.2. Before defibrillating the person who will be defibrillating should see that no one is
touching the patient or the bed of the patient to avoid injury to the doctors and
paramedical staff near the patient. The person should make himself heard by shouting
CLEAR before commencing defibrillation.
23.4.3. Defibrillation should be carried out in the following sequence  150J  no response
 200 J  Biphasic Defib.
23.4.4. Continue CPR continuously irrespective of response for another 1 min.
23.4.5. Assess rhythm.
23.4.6. If still VF/VT shock the patient with 200 J (all shocks).
23.4.7. If IV access is not possible then Lignocaine (Xylocard) can be given through the
endotracheal tube. Since absorption is unpredictable hence 2-3 times the dose diluted in
>10cc of 0.9% NS should be given through the ET followed by 5 ventilations to aid
absorption.
23.4.8. Correct the correctable causes such as hypo/hyperkalemia, acidosis.
23.4.9. While correcting acidosis, not more than 50 cc 8.4% sodium bicarbonate to be used as
it may worsen intracellular acidosis and itself precipitate arrhythmias and hence should
be used only in prolonged CPR. Acidosis should be corrected mainly by ventilation.

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23.4.10. Drug Management in case of refractory VF/VT:

Amiodarone (Cordarone): 300mg I.V. diluted in 10cc NS slow over 15 min, followed
by 300 mg over 1 hour preferably through a central line.
Lignocaine (Xylocard): 100mg I.V. stat,  no response  repeat once  no
response 2 – 4 mg/min I.V. Bolus dose can be given via ET if no I.V access
available.
Procainamide: 100 mg I.V. over 2 min. is an option.
Seek a cardiologists opinion.
23.5. Asystole / Electromechanical Dissociation:
23.5.1. Look for treatable cause and correct it as correcting these may be life saving.
23.5.2. In case of asystole with P waves while waiting for external or internal temporary
pacemaker to be inserted Inj. Atropine 0.6 mg to be given immediately intravenously or
through the endotracheal tube.
23.5.3. External pacing leads to be attached and external pacing to be initiated immediately
with the help of percutaneous paddles.
23.5.4. Use endocardial pacing if experienced pacer is available.
23.6. Decision to stop CPR: No general rule as the survival and outcome of CPR is influenced by
the cause of arrest and the rhythm.
23.6.1. Who can decide: The Intensivist on duty.
23.6.2. When to stop: In patients without myocardial disease do not stop till core temperature
is maintained > 330C and the pH and S.K+ are normal. Consider stopping resuscitation
in cases with myocardial disease or abnormal ABG in the above case after 20 min. if
there refractory asystole or electromechanical dissociation.
23.7. Valid decision regarding do not resuscitate:
23.7.1. Who can decide
a. Intensivist on duty – If the patient’s condition is such that resuscitation is unlikely to
succeed.
b. If a mentally competent patient has consistently stated or recorded the fact that he or
she does not want to be resuscitated
c. If the patient has signed a advanced directive forbidding resuscitation

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d. If the resuscitation is not in the patient’s interest as it would lead to a poor quality of
life.
e. Ideally the patients relatives to be involved prior to an emergency and their written
informed valid free expressed consent for not resuscitating the patient to be
documented and should be witnessed and signed by a minimum of 3 or the available
adult first degree relatives of the patient.
f. When in doubt resuscitate the patient.
g. After successful resuscitation:
i. 12 lead ECG, X-ray Chest, Electrolytes, ABG, RBS, CPK, CPK MB.
ii. Monitor vital signs.
iii. Whatever the outcome the relatives should be informed regarding the patients
Management and the expected future outcome

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24. TRANS ESOPHAGEAL ECHOCARDIOGRAM(TEE)

24.1. Definition:-
TEE is placing of 2-d transducer at the end of a flexible endoscope , to obtain high quality
2-D images via esophagus in multiple planes.
24.2. Purposes:-
24.2.1. Obtain precise information in guiding surgical intervention e.g., myocardial
revascularization, repair of congenital heart defects etc.
24.2.2. Obtain clearer images than regular echo cardio gram because ultrasound waves pass
24.2.3. Obtain clearer visibility of heart and its structure in a patient with obesity and chronic
obstructive pulmonary disease.
24.2.4. Aid diagnosis of cardiac masses, presence of clots in cardiac chambers, prosthetic
valve function , aneurysm, and posterior effusions.
24.2.5. Assess cardiac status of a patient with known cardiac disease undergoing non-cardiac
procedures and during cardiac surgery.
24.2.6. Identify prosthetic valves, vegetations, aortic disease and intra cardiac masses.
24.2.7. Monitor cardiac left ventricular function throughout the surgical procedure space and
through post-operative state.
24.2.8. Assess cardiac morphology and function before, during and after surgical repair of
valvular or congenital cardiac conditions.
24.3. Equipment:-
24.3.1. ECG Machine
24.3.2. Echo Machine
24.3.3. Skin Electrodes
24.3.4. Lead Wires
24.3.5. B.P Apparatus
24.3.6. Electronic Monitoring Machine
24.3.7. Oxygen prongs
24.3.8. Endoscope
24.3.9. Emergency Equipment
24.3.10. Local anesthesia jelly (LOX Jelly)
24.3.11. Local anesthesia spray

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24.3.12. Sterile gloves

24.3.13. IV Fliud with IV Set
24.4. Procedure:-
24.4.1. Pre-TEE Care:
a. Explain about procedure and obtain informed consent.
b. Assess timer of last ingested food or fliud . Patient should be instructed to withhold
food / fluidsfor 6-8 hours prior to procedure .
c. Start IV access.
d. Prepare skin if chest is hairy.
e. Ensure baseline investigations such as blood count, electrolyte levels , ECG and
regular echocardiogram done
f. Remove dentures / any oral prosthesis.
g. Administer stat dose of IV anitibiotics as ordered for patients on artificial heart valve ,
congenital heart disease or previous history of infective endocarditis
h. Assimilator local anaesthetic threat spray
24.4.2. Post TEE Care:
a. Monitor vital signs hourly until stable
b. Position patient in upright / side lying position
c. Advise nil per oral until gag reflex is fully restored for at least 2 hours
d. Explain that mild throat discomfort will be present for a day or two
e. Instruct patient to report immediately if any significant throat discomforts,
hemoptysis, dyspnea, chest pain, etc, present.
f. Advise to take throat lozenges or saline gargles

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25. SOP FOR PRE-OPERATIVE PREPARATION OF CABG-CORAONARY ARTEY

BYPASS GRAFTING
25.1. Purpose
25.1.1. To provide comprehensive care before surgery
25.1.2. To prevent infection
25.1.3. To impacts knowledge about the surgery
25.2. Scope
25.2.1. Patient who are undergoing CABG
25.3.1. Doctors
25.3.2. Nurses
25.3.3. Anaesthetist
25.4. Procedure
25.4.1. Pre-Operative Investigation Includes
a. Chest X-Ray –New PA film
b. ECG
c. Respiratory function test:-PFT, ABG
d. Blood tests:Full blood count (abnormality corrected )renal, function test, Liver
function test , Electrolytes, Glucose , Coagulation test, Hepatitis B& C Screening (If
not done during Angiogram ) HIV, Urine Routine , Cross Matching Blood grouping
(3-6 print) urine Mg & CL
e. Ultrasound for Bilateral Carotid Doppler
f. Bacteriology:- Sputum if necessary
g. Chest Physiotherapy: Before operation in patient with known chest disease or LRTI
25.4.2. Transthoracic Echocardiogarphy :- Left ventricular assessment and valves assessment
a. Coronary Angiography report (to define the extent and location of coronary artery
disease)
b. Consent for operation (including documents of the major risk)
c. Height (cm) and Weight (Kg) to calculate surface area and body mass index
d. All peripheral pulses to be felt for suitability specially for LIMA/RIMA grafts
25.4.3. Pre-Operative Modification of Treatment

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a. Anti Coagulants:-These are stopped off over a few days prior to operation . Patient
need to have a coagulation screen measured on the pre-operative day to confirm a
virtually normal clotting status on the day of operation .If coagulation has not
normalised then consider the use of FFP. If operation is postponed then anti
coagulants should be temporarily restarted.
b. Asprin and clopidogrel :- Ideally it should be stopped 01-05 days before surgery if not
it should be stopped on the day of admission of the patient unless there is unstable
angina.
c. Digoxin:- Continued until the day before operation.
d. Diuretics and Potassium Supplements:- Continued until the day before operation
e. Beta Blockers , Calcium Antagonists , Long Acting Nitrates :- Continue them the
day before operation
f. Antihypertensive :- Maintain until operation
g. Monoamine Oxidose Inhibillator:- Must be discontinued at least three weeks pre-
operatively
h. Anti – Diabetic – Steriods :- Discuss with anaesthetist whether sliding scale insulin is
required
25.4.4. Skin Preparation:-
a. Full body preparation with clippers
b. Betadine scrub before the day of surgery and on the day of surgery .
c. Sterile gown should be worn
d. Linen should be sterilized to use pre- post operative
e. Blood 4-6 pint to be arranged and cross matched (for simple cases ) or 6 units of
blood, fresh frozen plasma and platelets (for complicated cases)
25.4.5. Arrangements for Operation:-
a. The definitive operating list must be submitted to the theatre the day before surgery
b. Blood bank should be informed

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26. PERMANENT PACEMAKER IMPLANTATION

26.1. Purpose:-
To ensure a safe outcome following permanent pacemaker implantation
26.2. Scope:-
All patient undergoing permanent pacemaker implantation
26.3. Pre-Procedure Care:-
26.3.1. Do pre operative teaching and preparations
26.3.2. Vital signs (B.P , Temperature ,Pulse , Respiratory Rate etc)
26.3.3. ECG (12 Lead)
26.3.4. Obtain informed consent
26.3.5. IV access prepare in both hands
26.3.6. Investigations – CBC , Na + , K + , Creatinine , PT / APIT/INR, HIV, Hbsag, HCV
26.3.7. Height and Weight and skin preparation
26.3.8. PAC to be done
26.3.9. Betadine BATH
26.3.10. 4-6 hours NPO( before procedure)
26.3.11. Administer pre-operative medicines as advised by the doctor
26.3.12. Provide good psychological support to the patient and the relatives
26.3.13. Notify the doctor if any abnormalities and any allergies\
26.3.14. Complete Cathlab check list
26.3.15. Transfer the patient to cathlab on call with all the reports and files inform to the
relatives before starting the procedure.
26.4. Post – Operative Care:-
26.4.1. Transfer the patient to ICU or ICCU
26.4.2. Provide comfortable bed and position.
26.4.3. Connect the oxygen if required
26.4.4. Connect the cardiac monitor
26.4.5. Take 12 lead ECG,X-Ray chest AP View and inform to the doctor
26.4.6. Check the vital signs .
26.4.7. Educate the patient not to move the operated side shoulder or hand to prevent
bleeding and dislocation of the implants or device

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26.4.8. IV fluids as per doctors order

26.4.9. Administer analgesics as per doctors order
26.4.10. Follow aseptic techniques for all procedures to prevent infection and administer
antibiotics as per doctors order
26.5. Patient Discharge Instructions:-
26.5.1. How should you take care of any incision?
26.5.2. Keep your incision clean and dry for 5 days after your procedure take sponge bath
working around the incision during this time
26.5.3. Do not submerge incision in tub , pool, Hot tub or take bath for 4 weeks
26.5.4. Unless your incision is bleeding or draining keep incision open to air if there is
bleeding or drainage immediately notify the physician
26.5.5. Avoid using deodorants , powders, lotions etc on your incision for 4 weeks
26.5.6. Your incision should be look better each day
26.5.7. If you notice unusual swelling, redness, drainage or have more pain at the site or have
a fewer greater than 100 degree fahrenheit contact physician immediately
26.6. Education About:-
26.6.1. Activity restriction
26.6.2. Follow up care
26.6.3. Avoid MRI, Testing .If it is not MRI compactable device.
26.6.4. Diet
26.6.5. Pacemaker ID Card
26.6.6. Travelling Instruction
26.6.7. Exercise etc

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27. PREPARATION OF PATIENT FOR CARDIAC CATHETERIZATION AND

MONITORING PATIENT POST CARDIAC CATHETERIZATION
27.1. Purpose: To ensure a safe outcome following cardiac catheterization
27.2. Scope: All patients undergoing cardiac catheterization
27.3. Responsibilities: Cardiologist , Registered nurse , Intensivist , Registrar
27.4. Pre-Procedure:
27.4.1. Do pre-procedure teaching and preparation
27.4.2. Obtain base line vital signs and physical assessment including pulse quality of limbs
27.4.3. Obtain informed consent
27.4.4. Ensure the patient has patient IV access preferably 20 G in the left arm
27.4.5. Ensure base line blood work CBC , Creatinine , Electrolytes , PT, PTT, HIV ,
HBSAG , 12 Lead ECG , Height , Weight have been obtained to the procedure . The
cathlab must be notified of any abnormal blood work
27.4.6. Normal saline infusion to be started for renal protection before and after the pressure
for 12 hours -24 hours
27.4.7. Clip the hairs at this anticipated access site (right radial , right femoral ) with clippers
(do not share the risk)
27.4.8. Remove all of patients jewellery and contact lenses eye glasses , dentures
27.4.9. Medication like warfarin , heparin , LMWH as directed by Cardiologist
27.4.10. Nil per oral as advised by the cardiologist
27.4.11. Check for any allergy
27.4.12. Complete cardiac catheterization check list
27.4.13. Transfer the patient to cathlab on call with all the reports and files
27.5. Post-Procedure:
27.5.1. Transfer the patient to ICCU
27.5.2. Attach the patient to monitor and take ECG if patient underwent angioplasty
27.5.3. Check vital signs every ½ hourly for 2 hours
27.5.4. Check dorsalis pedis and posterior tibialis pulse in the limbs every ½ hourly
27.5.5. Instruct the patient to keep the involved leg in a straight position
27.5.6. To avoid upright position and to avoid vigorous use of the abdominal muscle as in
coughing sneezing or moving the bowel

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27.5.7. Ensure vascular clamp is in the correct position and adequate pressure applied
27.5.8. Patient can be on liquid diet if no vomiting
27.5.9. Check hydration and urine output of the patient
27.5.10. Watch for hematoma and bleeding from the puncture site
27.6. Preparation for Sheath Removal:
27.6.1. Assess the medical history of bleeding disorders, check CT/APTT before the
procedure
27.6.2. Assess vital signs and record
27.6.3. Record dorsalis pedis , temperature, sensation and movement of the limb
27.6.4. Assess patency of IV access
27.6.5. Explain the patient about the procedure
27.6.6. Administer analgesis before sheath removal
27.6.7. Place the patient with head flat at less than 15 degree
27.6.8. Keep Inj. Atropine ready
27.6.9. Perform the procedure in an aseptic technique
27.6.10. Instruct the patient to keep leg straight for 6 more hours and sand bag if necessary

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28. SOP FOR CARE OF POST-OP CABG PATIENTS

28.1. Purpose: To guide the uniformity of care for patients undergoing CABG (Post OP Care)
28.2. Scope: All post op CABG patients
28.3.1. Doctors
28.3.2. Staff Nurse
28.3.3. Paramedicals
28.4. Post – OP Care Procedures
28.4.1. Post – Operative notes shall be prepared by the surgeon which includes procedure
performed post operative diagnosis, plan of care and status of the patient and
documented prior to transfer out of patient from recovery area
28.4.2. Post – operative care plan shall be performed by the operating surgeon in
collaboration with the anaesthesiologist and include advice on
a. IV Fluids
b. Medication
c. Vitals
d. Drain Care
e. Nursing Care
f. Observation Of Complication
28.4.3. Monitor For
a. Central line CS Catheter PA Pressure and Femoral line (arterial line) flushing QIH
b. Chest tube drainage includes mid sternum /left pleural
c. Monitor Q1H drain and dressing for soakage
d. Monitor the Graft site
e. Monitor for edema in both lower and upper extremities
28.4.4. Ambulation
a. Improve muscle strength
b. Decease emotional distress
c. Decrease risk of clot formation and atelectasis and pneumonia

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28.4.5. Diet
a. High protein meals
b. Consider protein supplemental drinks
c. Add fruits and vegetables
28.4.6. Monitor intake and output chart
28.4.7. Weight Monitoring (OD)
28.4.8. Incentive Spirometry
28.4.9. Squeeze pillow tight for added reinforcement of sternum during and with cough
28.4.10. Pain Management
28.4.11. Blood Sugar
28.4.12. Monitor GRBS and treat appropriately monitor for signs & symptoms of infection in
the incision site
28.5. Patient and Family Education
28.5.1. Wound Care
28.5.2. Daily dressing
28.5.3. Monitor for Soakage
28.5.4. Watch for signs of infection
28.5.5. Family and patient teaching about care of wound
28.6. When to report doctor:-
28.6.1. Cardiac
a. HR more than 100 or less than 40
b. BP lower
c. Edema increased in both upper and lower extremities
d. SPO 2 less than 90%
e. ECG changes
f. Output is less
28.6.2. Lungs
a. Ineffective cough , low spo2
b. Fever , Dyspnea
c. Coughing up blood
d. Sharp pain with deep breaths

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e. Crackles or absent lung sounds

28.6.3. Incision
a. Redness at incision site
b. Drainage – brown / pus
c. Odor from incision site
d. Increased pain
e. Gaping incision
28.6.4. Emotion
a. Monitor for
i. Sadness
ii. Not interest in most of the activities
iii. Insomnia
iv. Guilt
b. Encourage the patient with activities
c. Psychological Support

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29. TEMPORARY PACEMAKER

29.1. Introduction: The electrical impulse includes depolarization and subsequently cardiac
contribution. The electrical impulse is initiated by the SA Node the pacemaker of the heart
29.2. Pacemaker: The artificial cardiac pacemaker is an electronic device used to pace the heart
when the normal connection path way is damaged or destroyed
29.3. Purpose: It is used to provide adequate HR and rhythm to patient in an emergency
situation
29.4. Components:
29.4.1. Electrodes
29.4.2. Power Source
29.4.3. Pulse Generator
a. Timing Control
b. Output Dosing
c. Sensing Clamp
29.4.4. Pacemaker Setting
a. Rate
b. Output
c. Sensitivity
29.4.5. Responsibility
a. Doctor
b. Technician
c. Staff Nurse
29.4.6. Before the procedure to be checked
a. Doctor Order
b. Consent Form
c. Angio checklist
d. Preparation to be done
e. Prepare the patient for procedure
29.4.7. Settings Rate:
a. The number of impulse that can be delivered to the heart per minute
b. Acute Anterior MI with 2nd and 3 rd AV Block Acute Inferior MI with heart blocks.

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c. Patient with brady arrythmias and Tachy arrhythmias

29.4.8. Cardiac Indication
Asymptomatic patient who has on a unstable rhythm
29.4.9. After procedure patient monitoring
a. ECG monitoring evaluate the status of the pacemaker
b. IV antibiotic therapy –Before and after procedure
c. Post insertion chest x-ray to chest lead placement and to rule out the presence of a
pnemothorax careful observation of insertion site
d. Continous ECG monitoring of patients rhythm
e. Check regular function of pacemaker
f. The rate setting depend on the physiological needs of the patient but it is generally
maintained between 60-80 b/min
29.4.10. Output: It is the amount of electrical current measured in milliamera (mn) and is
delivered to the heart to inhaler depotricts
29.4.11. Sensitivity:
a. The sensitivity control regulates the ability of the pacemaker to the heart . Intrinsic
electrical activity
b. Sensitivity is measured in millsu and determine the size of intra cardiac signal that
generate will recognize
29.4.12. Indicate:-
a. Maintainance of adequate HR rhythm during special circumstance such as surgery and
post operative reversal
b. Cardiac Catherization
c. Coronary Angioplasty
d. Any block or bundle branch block
e. After the pacemaker insertion the patient arm and shoulder activity is limited to
prevent dislodgement of the newly implanted pacing
29.4.13. Complication
a. Infection
b. Haemothorax
c. Pneumothorax

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d. Perforation of the arterial or ventricular septum by the pacing leads

e. Failure the sense or capture with possible symptomatic bradycardia

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30. LIST OF ASSOCIATED RECORDS

30.1.1. Admission &Discharge Register R/NS/CCU/02
30.1.2. Ward Drug Register R/NS/CCU/03
30.1.3. Ward Teaching Register R/NS/CCU/04
30.1.4. HICC Register R/NS/CCU/05
30.1.5. Emergency Trolley Register R/NS/CCU/06
30.1.6. Narcotic Register R/NS/CCU/07
30.1.7. Continuous Quality Improvement Register R/NS/CCU/09
30.1.8. CSSD register R/NS/CCU/10
30.1.9. Meeting minutes file R/NS/CCU/11
30.1.10. Inventory & Condemned Register R/NS/CCU/12
30.1.11. Linen Inventory & Mending Register R/NS/CCU/13
30.1.12. Preventive Maintenance Register R/NS/CCU/14
30.1.13. Repair Register R/NS/CCU/15
Signature: Signature:

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Annexure I
Job Role
A. Role of consultant
1. To co-ordinate the activities of the CCU
2. To provide medical care for the patients in CCU. Attend to their medical needs.
3. To advise the patients and their family members about the various treatment options for patients
with cardiac failure
4. To disseminate knowledge to the patients and family on prevention of cardiac problem and also
measures to slow progression of disease.
5. To ensure that appropriate consumable used in CCU are made available for care.
6. To provide inservice training in the theory and practice of CCU staffs of the CCU unit.
7. To provide cardiac advice for patients admitted to the Hospital under other services.
8. To examine and provide treatment for out patients who need cardiac services.
9. To conduct classes theory and clinical for the under graduates students as well as the DNB
trainers.
B. Role of CCU resident.
1. Standard medical care of all CCU patient admitted
2. Working up of all cases and documentation of history & examination
3. Working a diagnosis & plan of treatment (investigation & management) along with the
consultant in charge.
4. Procedure done promptly on need basis, including intubation, central line insertion, bone
marrow, LP etc.
5. Informing the relatives about the patient condition, progress, consent prior to procedure.

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C. Role of charge nurse

1. Upholds the standard of nursing practice for critical ill patients.
2. Maintains life saving equipments – ventilators, defibrillators.
3. Evaluates performance of the staff under her supervision and nursing care as a whole. Suggests
modifications.
4. Upholds the standard of nursing practice in relation to safety, quality and quantity. Inspects unit
areas to verify that patient needs are met.
5. Assigns duties to professional and ancillary nursing personnel based on needs for the efficient
functioning of her department.
6. Supports, interprets and promotes the philosophy and objectives of the hospital and of the
nursing service division. Interprets needs and interests of nursing personnel to the CNO/ACNO
on specific problems and interpretations of hospital policies.
7. Responsible for the maintenance of safe and sterile environment in the unit.
8. Formulates the schedule for staffing the unit. Adjusts the weekly schedule as needed to provide
optimum coverage for the unit. Is available to the institution in emergency situations which
create excessive demands on hospital personnel.
9. Orient new staffs to the unit. Participates in guidance and educational programs.
10. Engages in investigations related to improving nursing care.
11. Assists in interviewing applicants and makes recommendations for employing or terminating
personnel.
12. Assists physicians and ensures that nursing care is carried out as directed and treatment is
administered in accordance with physician’s instructions.
13. Directs preparation and maintenance of patient’s clinical record.
14. Investigates complaints of staff, patients and relatives and refers them to supervisor.
15. Instructs patients and members of their families in techniques and methods of home care after
discharge.
16. Ensures establishes inventory standards for medicine solutions, supplies and equipments
accounts for narcotics.
17. Presides over unit personnel meetings to discuss patient care needs. Attends meetings of the
nursing service division to discuss unit operation and staff training needs and to formulate
programmes to improve nursing care.

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18. Assists in the development and revision of nursing policies, regulations and procedures.
19. Rotates to evening and night duty to fill the position of evening and night supervisor.
20. Encourage the staff to participate in regular in-service education.
21. Ensure all staff and educate them about pollution control.
22. Develops, Justify and maintains the fiscal plans (Budget) for Ward. Monitors Operating and
other expenses (salaries, capital expenses) and provides appropriate reports to CNO.
23. To perform any other duties assigned by the CNO/ACNO.
D. Role of Staff Nurse
1. To uphold the standards of nursing practice for critical ill patients.

2. To maintain life saving equipments – ventilators, defibrillators and care of patients on
ventilator and monitors
3. To check inventory of all equipment, crash cart and instruments as per the inventory register and
inform the senior nurse /head nurse in case of any discrepancies noted.
4. To check the communication book for any new instructions during every shift.
5. To check the census of the department.
6. To Enquire and know about the following:
a. New admissions.
b. Transfers.
c. Surgery and investigation list.
d. Discharges.
7. To take over of all patients as the shift changes.
8. To send patients for surgeries / investigations as per the schedule.
9. To document the initial assessment findings in the nurse’s notes.
10. To monitor vital signs routine / as per the orders and document it.
11. To ensure that water and diet is provided for all patients as per the diet orders.
12. To accompany the doctors for clinical rounds and carry out their written orders.
13. To ensure replacement of medicines, if not endorse to the next shift.
14. To complete all relevant documents.
15. To check the patient’s records for any changes, special orders etc.

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16. To endorse the patients to the next shift staff.

17. To inform any special events during the shift to the CNO/ACNO.
18. To ensure that the hygienic needs of patients are met and the unit is tidy at all times.
19. To check medicines for the entire day.
20. To ensure that all admissions, transfers and discharges are entered in the admission
discharge register.
21. To prepare the patients for surgeries / procedures.
22. To check and receive all investigation reports done during the day.
23. To send intimation to the concerned departments.
24. To administer quality care which meets the best standards for nursing practice of the hospital.
25. To know the purpose, expected result and the safety factors involved in the nursing care.
26. Not to divulge confidential information concerning the patient or hospital affairs except to
authorized personnel.
27. To participate in studies related to nursing practice.
28. To participate in the in-service education programs of the institution.
29. To evaluate patients care and make recommendations for the improvement of care.
30. To identify the nursing needs of the patients.
31. To determine observable spiritual, emotional and social factors which might influence a plan of
therapy.
32. To make care plan in the light of nursing needs and the program of therapy as prescribed by the
physician.
33. To maintain a professional level of conduct.
34. To accept direction, supervision, and evaluation of performance.
35. To ensure economical use of time, effort and material.
36. To keep abreast of literature in nursing.
37. To perform any other duties assigned by the charge nurse/ACNO/CNO.

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E. Role of Nursing Aid

1. To give the quality of service which meets the standards for practice of the hospital.
2. To adhere to hospital policies and procedures.
3. Not to divulge confidential information regarding patients and hospital affairs except to
authorized personnel.
4. To conduct himself in a courteous, friendly manner and treat the patient as a guest in the hospital.
5. To assist the Staff Nurses in the care of patients as directed.
6. To report all observations concerning patients to a Staff nurse.
7. To assist in admission procedure for patients admitted through the emergency and outpatient
department.
8. To assist patients in preparing for examination by the doctor.
9. To collect specimen as directed (urine, stool, sputum).
10. To transport patients to the various locations as needed. .
11. To obtain, clean and return equipments and supplies handled in the ward.
12. To take responsibility for seeing that the working area kept clean and equipment is kept in its
place.
13. Runs errand to other departments; pharmacy, central supply, lab, cashier, medical record, other
nursing units.
14. To be accountable for her/his assigned patients hospital linen.
15. To perform any other duties as directed by the Charge Nurse or unit supervisor

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Annexure II
Organogram
Director
Chief Medical Officer
CCU Consultant
Incharge Nurse
Team leader
Staff Nurse Technician Nursing Aid Clerk Housekeeping

CCU

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Page: 1 of 82

BANGALORE BAPTIST HOSPITAL

12. Protocol for thrombolysis in acute myocardial infarction 29

13. Receiving myocardial infarction patients 31

15. Protocol to be followed in management of diabetic ketosis/ 39

Reviewed & issued by: Division Head Approved by: Director(CEO)

22. Care of patient on ventilator and weaning 55

25. SOP for pre-operative preparation of CABG-coraonary 64

27. preparation of patient for cardiac catheterization and 68

Reviewed & issued by: Division Head Approved by: Director(CEO)

1. SCOPE OF THE DEPARTMENT

Reviewed & issued by: Division Head Approved by: Director(CEO)

2. SOP FOR ADMISSION AND DISCHARGE

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

2.7.4. Elimination of the need for invasive haemodynamic monitoring.

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

4. SOP FOR PATIENT CARE

Reviewed & issued by: Division Head Approved by: Director(CEO)

4.2.5. Progressive patient care

Reviewed & issued by: Division Head Approved by: Director(CEO)

5.3. Endotrachial 1 To protect the airway 1. Poor

Reviewed & issued by: Division Head Approved by: Director(CEO)

anesthesia is required 2. Abdomi

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

skin at the point of headache

5.10. Bone To obtain specimen for 1. Infectious skin at the 1. Bleeding

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

increase in the gastric associated with peptic ulcer,

Reviewed & issued by: Division Head Approved by: Director(CEO)

Inj. Dextrose 50% agent (iv) hypoglycemic attacks.

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

Long angled forceps for use with a laryngoscope in removing

Reviewed & issued by: Division Head Approved by: Director(CEO)

7. SOP FOR PROPER DOCUMENTATION OF ENTRIES IN PATIENT’S CHARTS

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

8. SOP FOR EQUIPMENT MANAGEMENT

Reviewed & issued by: Division Head Approved by: Director(CEO)

8.2.4. Other CCU equipment

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

10. QUALITY ASSURANCE PROGRAMME: CCU

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

11. GUIDELINES FOR INTERPRETATION OF ARTERIAL BLOOD GAS

Reviewed & issued by: Division Head Approved by: Director(CEO)

11.6.7. Achieve a minimal diagnosis:

DISORDER Metab. Metab. Resp. Acidosis Resp. Alkalosis

pH Decreased Increased Decreased Increased

11.6.8. Simple or mixed disturbance:

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

13. RECEIVING MYOCARDIAL INFARCTION PATIENTS

Reviewed & issued by: Division Head Approved by: Director(CEO)

c. Tab. Metoprolol (12.5mg) 1 stat.

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)