THE BASIC NURSING TRAINING MANUAL
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Nursing Training Manual
Nursing Training Manual
INTRODUCTION The Basic Nursing Training Manual was designed to guide nurses of Vaatsalya Healthcare Solutions Private Limited (VHS) to refine their knowledge and skills to deliver comprehensive nursing care to our valued customers. The focus of this basic nursing kit is on how to plan, execute and reflect documentation of nursing care delivered that is need based and mandatory. It includes information on all the basic nursing procedures and how to store, assemble, use and after care of equipments, emphasizing the importance of accountability towards organizational assets. This kit can be used as a reference source for all the basic nursing procedures that are carried out on a day-to-day basis in each shift, such as: patient care and their safety, safety of Healthcare team members and visitors, safe use of equipments and its care, practical dos and don’ts etc. While preparing this manual, all nursing supervisors of VHS came to a common conclusion of what procedures were to be prepared and taught. Books, manuals, web surfing, taking photographs at present units, guidance and feedback from friends and doctors, was pooled from all the units to generate content. Once the content was finalized, it was made concise to suit VHS’s work demands by focusing on present Healthcare trends. Many a topics were rewritten. The entire manual has been arranged into 28 modules and each module is organized into various sub-modules as per the requirement. Constructive feedback, if any, is to be given to unit nursing supervisors, who in turn will convey to the Head, Nursing Services, VHS.
Nursing Training Manual
Nursing Training Manual
“Nurses are the hospitality of the hospital.� - Carrie Latet
"The most important practical lesson that can be given to nurses is to teach them what to observe." - Florence Nightingale
Nursing Training Manual
Nursing Training Manual
“When you're a nurse you know that every day you will touch a life or a life will touch yours.” - Author Unknown
"To do what nobody else will do, a way that nobody else can do, in spite of all we go through; is to be a nurse." - Rawsi Williams
“Nursing is an art: and if it is to be made an art, it requires an exclusive devotion as hard a preparation, as any painter's or sculptor's work; for what is the having to do with dead canvas or dead marble, compared with having to do with the living body, the temple of God's spirit? It is one of the Fine Arts: I had almost said the finest of Fine Arts.” - Florence Nightingale
“Nursing encompasses an art, a humanistic orientation, a feeling for the value of the individual, and an intuitive sense of ethics, and of the appropriateness of action taken." - Myrtle Aydelotte
Nursing Training Manual
Training Module for Basic Clinical Nursing Procedures Vaatsalya Hospitals UNITS 1 TO 9
Nursing Training Manual
Nursing Training Manual
PREFACE Nursing is core part in health service delivery system in which health promotion, disease prevention; curative and rehabilitative health strategies are applied. The clinical nursing skills for the Nurses are of paramount importance not only to provide comprehensive care but also enhance the clinical competence. Nurses play a very crucial role in the patient care. Keeping this in mind the Training Program for nurses is a very important activity .There is a lot of information in the practice of Nursing Care, but there is always the need to upgrade the knowledge of Nurses in secondary hospitals through “In-Service Training Program� In order to fulfill such an objective a Module of Clinical Nursing Procedures has been formulated for the Nurses of Vaatsalya Hospitals, which will enable our nurses to perform their duties as well as develop uniformity among our hospitals in caring for our patients.
Brig. D Arujah VSM Head of Nursing Service HO Bangalore.
Nursing Training Manual
Nursing Training Table of Contents Topics 1) Unit One : Introduction to Nursing ...........................................................................................1-4 zz Definition of nursing .............................................................................................................1 zz Historical background of nursing .............................................................................................1 zz Nursing process and Critical thinking ....................................................................................2-4 2) Unit Two : Safety in Health Care facilities .............................................................................5-16
i) Infection control/ universal precaution ......................................................................5-16 zz Nursing process application ...................................................................................................5 zz Normal body defense ...........................................................................................................5 zz Chain of infection ...........................................................................................................5-6 zz Basic medical asepsis ...........................................................................................................6 zz Hand washing.............................. .......................................................................................6-9 zz Standard precaution ........................................................................................................9-10 zz Surgical asepsis ............................................................................................................10-11 zz Isolation ......................................................................................................................11-14
ii) Care of patient unit ....................................................................................................15-17 zz The patient unit ............................................................................................................15-16 zz Care of hospital and health care unit equipment ..................................................................16-17
3) Unit Three : Basic Client Care ..............................................................................................18-61 i) Admission, Transfer, and Discharge of Patient .........................................................18-20 zz Admission .......................................................................................................................18 zz Transfer .....................................................................................................................18-19 zz Discharge ....................................................................................................................19-20
ii) Vital Signs .Definition ..................................................................................................21-27 zz Temperature, Pulse, Respiration & Blood pressure
iii) Specimen collection .................................................................................................28-33 zz General consideration for specimen collection .........................................................................28 zz Collecting stool specimen ..............................................................................................28-29 zz Collecting urine specimen ..............................................................................................29-30 zz Collecting sputum .........................................................................................................30-31 .......................................................................................31-33 zz Collecting blood specimen
iv) Bed making ................................................................................................................34-40 zz Closed bed & Occupied bed ...........................................................................................35-40 zz Post operative bed ........................................................................................................35-40 v) Personal hygiene and skin care .................................................................................41-51 zz Mouth care ..................................................................................................................41-42 zz Bathing .......................................................................................................................42-43 zz Bed bath .....................................................................................................................43-44 zz Therapeutic bath ...........................................................................................................44-45 zz Back care and Decubitis ulcers ........................................................................................45-46 zz Giving and receiving bedpan and urinals ...........................................................................46-47 zz Perineal care ...............................................................................................................47-48 zz Hair cares ...................................................................................................................49-50 zz Pediculosis treatment .....................................................................................................50-51
Nursing Training Manual
vi) Cold & heat application ..............................................................................................51-54 zz Care of a patient with fever ...................................................................................................52 zz Heat application ................................................................................................................52 zz Cold application .................................................................................................................52 zz Tepid sponge ................................................................................................................52-53 zz Local application of cold and heat ..........................................................................................53 zz Application of cold ..............................................................................................................53 zz Application of heat ..............................................................................................................53 zz Sitz bath ........................................................................................................................53-54 vii) Body mechanics and mobility ...................................................................................55-57 zz Basic principles of body mechanics .........................................................................................55 zz Turning the patient to a side lying position .................................................................................56 zz Joint mobility and range of motion .....................................................................................56-57 viii) Body positioning .........................................................................................................58-61 zz Guideline for positioning the client ..........................................................................................58 zz Client positioning for examination & treatment ..........................................................................58 zz Recumbent Position and Dorsal Recumbent Position ....................................................................58 zz Prone Position and Semi Prone Position ....................................................................................59 zz Fowler’s and Knee chest position ........................................................................................59-60 zz Dorsal Lithotomy Position ......................................................................................................60 zz Helping the client into wheel chair ......................................................................................60-61
4. Unit Four : Nutrition and Metabolism ..................................................................................62-70 zz Fluid and electrolyte balance ..................................................................................................63 zz Acid base balance ...........................................................................................................63-67 zz Nutrition ............................................................................................................................67 zz Gastrostomy / Jejunostomy Feeding ...................................................................................67-68 zz Inserting a gastric tube .......................................................................................................68 zz Nasogastric feeding ...................................................................................................... 68-69 zz Total parentral nutrition ...................................................................................................69-70 5. Unit Five : Elimination of Gastro Intenstinal & Urinary Tract outputs .................................71-80 zz Gastric Lavage ................................................................................................................71-72 zz Gastric Aspiration ...........................................................................................................72-73 zz Enema ..............................................................................................................................73 zz Cleansing Enema ............................................................................................................73-74 zz Retention Enema .............................................................................................................74-75 zz Rectal Washout ..................................................................................................................75 zz Passing flatus tube ...............................................................................................................76 zz Urinary catheterization ....................................................................................................76 zz Catheterization using straight catheter ..................................................................................76-78 zz Inserting indwelling catheter .............................................................................................78-80 6. Unit Six : Medication Administration ....................................................................................80-97 i ) Medication Administration zz Definition of pharmacology ....................................................................................................80 zz Drug metabolism .................................................................................................................80 zz Factors affecting drug metabolism ...........................................................................................80 zz Drug Administration .............................................................................................................80 zz Application of nursing process ...............................................................................................81 zz Oral drug administration ..................................................................................................81-82 zz Suppository ...................................................................................................................82-83
Nursing Training Manual
ii ) Parenteral Routes of Drug Administration ..............................................................84-92 zz Subcutaneous injection ...................................................................................................84-85 zz Intramuscular injection ...................................................................................................85-86 zz Intravenous injection ......................................................................................................86-87 zz Intravenous therapy .......................................................................................................87-89 zz Blood transfusion .........................................................................................................89-91 zz Cut down ..................................................................................................................91-92 iii ) Administration of Vaginal Medications .................................................................. 93-94 zz Administration of vaginal medications ....................................................................................93 zz Administration of ophthalmic Medication ................................................................................93 zz Administration of otic medications .....................................................................................93-94 iv) Inhalation ....................................................................................................................95-97 zz Definition of inhalation ........................................................................................................95 zz Oxygen Administration ........................................................................................................95 zz Giving Oxygen by Mask ......................................................................................................95 zz Giving Oxygen by Nasal Catheter .....................................................................................95-96 zz Giving Oxygen by Tent ...................................................................................................96zz Steam Inhalation ..............................................................................................................96 zz Nelson’s Inhaler ..........................................................................................................96-97
7) Unit Seven : Wound Cares...................................................................................................98-104 zz Definition ......................................................................................................................98 zz Wound Healing process ................................................................................................98-99 zz Dressing a Clean wound ...................................................................................................99 zz Dressing of Septic Wound ............................................................................................99-100 zz Dressing with a Drainage Tube .....................................................................................100-101 zz Wound Irrigation ......................................................................................................101-102 zz Suturing ..................................................................................................................102-103 zz Removal of Stitch .......................................................................................................103-104 zz Clip Application and Removal ...........................................................................................104 8) Unit Eight : Perioperative nursing Cares .........................................................................105-109 zz Preoperative Care ............................................................................................................105 zz Care the day before Surgery ...............................................................................................105 zz Care at the day of Surgery .................................................................................................105 zz Care just before Surgery .............................................................................................106-107 zz Intraoperative Care .........................................................................................................107 .......................................................................................107-109 zz Postoperative Care 9) Unit Nine : Care of the dying & Post-mortem care ........................................................110-113 zz Definition .......................................................................................................................110 zz Stages of Dying ........................................................................................................110-111 zz Spirituality of Dying ............................................................................................................... zz Assisting the Dying ............................................................................................................... zz Care after Death .....................................................................................................111-113
Nursing Training Manual
Chapter 1 : Introduction
Nursing Training Manual
UNIT ONE INTRODUCTION Nursing Definition : “It is the diagnosis and treatment of human responses to actual or potential health problems� Nursing is assisting the individual, sick or well in carrying out those activities contributing to health or its recovery (to peaceful death) that he will do without any help, if he had the necessary strength, will or knowledge and to do this in such a way as to help him to be able to help himself. Nursing is an art and science that involves working with individual, families, and communities to promote wellness of body, mind, and spirit. It is a dynamic, therapeutic and educational process that serves to meet the health needs of the society, including its most vulnerable members.
Historical Background of Nursing: Nursing has a history as long as that of human kind. Human beings have always faced the challenge of caring for the sick and dependent members. The mother is the first nurse. In the 19th century, one woman changed the course of nursing: Florence Nightingale. She was born in to a wealthy family, she had the strong belief that nursing was a call to look after the sick and she recognized that optimum care of the sick required education. In 1860 she created a school of Nursing which was the model of nursing education she was the founder of modern nursing.
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Chapter : Introduction
Nursing Training Manual
Nursing Process and Critical thinking Nursing Process 1. Assessment Collects Client Health Data
2. Nursing Diagnosis Analyzes Assessment Data to Determine Diagnoses
3. Outcome Identification Indentifies Expected Outcomes of Client for Nursing Diagnoses
4. Planning Develops Plan of Care and Prescribes Interventions to Attain Expected Outcomes
5. Implementation Implements the Interventions (AAction Types) in the Plan of Care
6. Evaluation Evaluates Client’s Attainment of Outcomes
ANA, Standards of Clinical Nursing Practice. (1988)
Nursing Process Definition: It is a tool or method for organizing and delivering care or a deliberate intellectual activity whereby the practice of nursing is approached in an orderly systematic manner. It is a series of planned steps and actions directed towards meeting the need and solving of problems of the clients.
Purpose of nursing process: yy To identify client’s health care needs. yy To establish nursing care plans so as to meet those needs. yy To complete the nursing intervention designed to meet the needs. yy To provide individualized care. yy Linda Hall first introduced the term Nursing Process in 1965.
Steps of the Nursing Process: The nursing process has five steps: 1. Assessment : The systematic collection of data to determine the patient’s health status and to identify any actual or potential health problems. The best sources of information about the client are the client and the family. Health professionals, previous client records act as information sources.
Data collection falls into two categories: a. Objective Data include all the measurable and observable pieces of information about the client and his/her overall state of health. The term objective means that only precise and accurate information or clear descriptions are used. b. Subjective Data consists of the client’s opinions, feelings about what is happening. Only the client can tell you that he she is having pain. Sometimes the client can communicate through body language: gestures, facial expressions and body posture. To get subjective data you need sharp interviewing, listening, and observation skills.
Method of Data collection: a. Observation is an assessment tool that relies on the use of the five senses (sight, touch, hearing, smell and taste) to discover information about client. b. Health interview – the health interview may also be called a history taking.
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Nursing Training Manual
Chapter : Introduction
2. Diagnosis : Identification of the following two types of patient problems. yy Nursing diagnosis – actual or potential health problems that can be managed by independent nursing interventions.Purposes of t he Nursing Diagnosis – the nursing diagnosis serves the following purposes: yy Identifies Nursing Priorities. yy Directs nursing interventions to meet the client’s high priority needs. yy Provides a common language and forms a basis for communication and understanding between nursing professionals and health care team. yy Guides the formulation of expected outcomes for quality assurance requirements of third party payer. yy Provides a basis for evaluation to determine if nursing care was beneficial to the client and cost effective. yy Is of help in making staff assignment.
Diagnostic Statement. The client may present with more than one problem. Therefore, the nursing diagnosis may be made up of multiple diagnostic statements. Each diagnostic statement has two or three parts depending on the healthcare facility. The three-part statement consists of the following components: yy Problem yy Etiology Signs and symptoms, a two-part diagnostic statement consists of the problem, and signs and symptoms.
Problem The problem portion of a statement describes- clearly and concisely- a health problem a client is having.
Etiology The etiology part of the diagnostic statement is the cause of the problem. Etiology may be physiologic, psychological, sociologic, spiritual, or environmental.
Signs and symptoms The third part of the diagnostic statement summarizes data. You may need to include several signs and symptoms. For instance, the client with Pneumonia had cough with thick sputum, Abnormal breath sounds, increased respiration, and difficulty in breathing.
Writing the Diagnostic Statement The Diagnostic Statement connects problem, etiology, signs and symptoms. a) E.G. Ineffective Airway Clearance related to physiologic effects of pneumonia as evidenced by increased sputum, b) Collaborative problems – certain physiologic complications that nurse monitor to detect onset or change in status. Nurses manage collaborative problems using physician prescribed and nursing prescribed interventions to minimize the complications of the events.
3. Planning – development of goals and a plan of care designed to assist the patient in resolving the diagnosed problems. Setting priorities, establishing expected outcomes, and selecting nursing interventions result in plan of nursing care. Setting priorities Nursing diagnosis is ranked in order of importance. Survival needs or imminent life threatening situations takes the highest priority. For e.g. the need for air, water and food are survival needs. Nursing diagnostic categories that reflect these high priorities needs include Ineffective Airway Clearance and deficient fluid volume. Establishing Expected Outcomes An expected outcome is a measurable client behavior that indicates whether the person has achieved the expected benefit of nursing care. It may also be called a goal or objective. An expected outcome has the following characteristics: yy Client oriented yy Specific Page : 3
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Chapter : Introduction
yy Reasonable yy Measurable.
Selecting Nursing Intervention Nursing intervention is also called Nursing Orders or nursing actions, they are activities that will most likely produce the desired outcomes (short term or long term). To achieve this outcome, one should select nursing interventions such as the following examples: yy Offering fluids frequently yy Positioning frequently yy Teaching deep breathing exercises yy Monitoring vital signs yy Administering Oxygen, etc. accordingly.
3.Implementation – actualization of the plan of care through nursing interventions. 5. Evaluation – determination of the patient’s responses to , the nursing intervention and the extent to which the goals have been achieved. Critical Thinking It is defined as an intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing synthesizing, and or evaluating information gathered from, or generated by observation experience, reflection, reasoning or communication, as a guide to belief and action. The nurse process is considered to be the specific critical thinking competency in nursing. Critical thinking skill helps the nurse To look at all aspects of a situation and then at the conclusion.
Questions for weekly test. 1. Define nursing using modern definition. 2. Who is the first nurse? , and who is the founder of modern nursing. 3. What is nursing process; mention the steps in nursing process. 4. State two common ways of collecting data about client. 5. Describe Critical thinking.
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Nursing Training Manual
Chapter : Saftey In Health Facilities
UNIT TWO SAFETY IN HEALTH CARE FACILITIES i) INFECTION CONTROL / UNIVERSAL PRECAUTIONS Nurses are involved in providing a biologically safe environment and promoting health. Microorganisms exist everywhere in the environment; in water, soil and body surfaces such as skin, intestinal tract, and other areas open to the outside.
Normal Body Defense Individuals normally have defenses that protect the body from infection. These defenses can be categorized as specific and nonspecific. Specific Defenses (immune): are directed against identifiable bacteria, viruses, fungi, or other infectious agents. Specific defenses of the body involve he immune system, which responds to foreign protein in the body (E.g. bacteria or transplanted tissues) or, in some cases even the body’s own proteins. Immunity is the specific resistance of the body to infection (pathogens or their toxins), There are two major types of immunity: active and passive. Through active immunity, the host produces its own antibodies in response to natural antigens (e.g. infection) or artificial antigens (e.g. Vaccines) with passive immunity; the host receives natural (e.g. from a nursing mother) or artificial (e.g. from an injection of immune serum) antibodies produced by another source. Non - Specific Defenses protect the person against all microorganisms, regardless of prior exposure. Non-specific defenses include anatomic and physiologic barriers. In fact skin and mucus membranes are body’s first line of defense against microorganisms. Inflammation is a local and non-specific defense response of the tissues to injury or infection. It is an adaptive mechanism that destroys or dilutes the injurious agent, prevents further spread of injury, and promotes the repair of damage tissue. Inflammation is characterized by the following classic signs and symptoms: (a) Pain, (b) Swelling, ( c ) Redness, (d) Heat and (e) Impaired function of the part. This is called inflammatory process An infection is an invasion of the body tissue by microorganisms and their proliferation there. Such a micro organism is called infectious agent. Pathogen is a microorganism that causes disease. A “true” pathogen causes disease or infection in a healthy individual.
Chain of Infection Infectious Agent (Pathogenic)
Susceptible host
Reservoir Chain of Infection
Portal of exit (from)
Portal(s) of entry Vehicle (Means of)
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Chapter : Saftey In Health Facilities
Etiology is the study of causes; the etiology of an infectious process is the identification of the invading microorganisms. Infectious diseases are the major causes of illness and death. There are six links in the chain of infection: 1. The etiologic agent, or microorganism: 2. The Reservoir. 3. Portal of exit from reservoir. 4. Means of transmission. 5. Portal of entry into the host. 6. Susceptibility of the host.
Conditions Predisposing to Infection Certain conditions and invasive techniques predispose clients to infection because the integrity of the skin is broken or the illness itself establishes a climate favorable for the infectious process to occur. Among the most common are surgical wounds; changes in the antibacterial immune system, or alterations in the body. Nosocomial Infection: They are infections that are acquired while the client is in hospital, infections that were not present or incubating at the time of admission. Standard Precautions: Also called universal precautions. These were instituted as a result of the human immunodeficiency virus (HIV) epidemic. Blood and body fluid precautions were practiced on all clients regardless of their potential infectious state. In 1987, body substance isolation (BSI) was proposed. The idea of this isolation system was to isolate all moist and potentially infectious body substances (blood, feces, urine, sputum, saliva, wound drainage and other body fluids) from all clients, regardless of their infectious status, primarily through the use of gloves. Standard precaution blends the major features of universal precautions (blood and body fluids precautions) and body substance into a single set of precautions to be used for the care of all clients in hospitals, regardless of their diagnosis or presumed infection status. The new standard precautions apply to blood, all body fluids, secretions, and excretions, whether or not they contain visible blood; non-intact skin; and mucous membrane. Fundamental Principles: Certain fundamental principles should be applied to all clients. These include hand washing, use of gloves, and proper placement of clients in hospital to prevent spread of microorganisms to others or to the client, and appropriate use of isolation equipment to prevent the spread of microorganisms to health care workers and other clients.
Basic Medical Asepsis Hand Washing (Medical Asepsis)
Purpose yy To prevent the spread of infection. yy To increase psychological comfort.
Hand Washing ÁÁ Keeping hands clean through improved hand hygiene is one of the most Importatnt steps we can take to avoid getting sick and spreading germs to others. ÁÁ Many diseases and conditions are spread by not washing hands with soap and clean, running, water. ÁÁ If clean, running water is not accessible, as is common in many parts of the world, use soap and available water. ÁÁ If Soap and water are unavailable, use an alcohol-based hand sanitizer that contains at least 60% alcohol to clean hands.
Wash Your Hands : The Right Way ÁÁ What is the right way to wash your hands? ÁÁ Wet your hands with clean, running water (warm or cold) and apply soap. ÁÁ Rub your hands together to make a lather and scrub them well; be sure to scrub the backs of your hands, between your fingers, and under you nails. ÁÁ Continue rubbing your hands for at least 20 seconds. ÁÁ Rinse your hands well under running water. ÁÁ Dry your hands using a clean towel or air dry them. ÁÁ When should you wash your hands? Page : 6
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Chapter : Saftey In Health Facilities
ÁÁ Before, during, and after preparing food ÁÁ Before eating food ÁÁ Before and after preparing food ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ
Before eating food Before and after caring for someone who is sick Before and after treating a cut or wound After using the toilet After changing diapers or cleaning up a child who has used the toilet
Wash Your Hands : The Right Way ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ
After blowing your nose, coughing, or sneezing After touching an animal or animal waste After touching garbage What if i don’t have soap and clean, running water? Washing hands with soap and water is the best way to reduce the number of germs on them. If soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60% alcohol. Alcohol-based hand sanitizers can quickly reduce the number of germs on hands in some situations, but sanitizers do not eliminate all types of germs. Hand sanitizers are not effective when hands are visibly dirty. How do you use hand sanitizers? Apply the product to the plam of one hand. Rub your hands together. Rub the product over all surfaces of your hands and fingers untill your hands are dry
Steps of Hand washing Techniques ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ
Duration of entire procedure : 40-60 seconds Wet hands with water, Apply enough soap to cover the hand surface; Right palm over left dorsum with interlaced fingers and vice versa palm to palm with ficners interlaced Back of fingers to opposing palms with fingers interlocked Rotational rubbing of left thumb clasped in right palm and vice versa Rotational rubbing backwards and forwards with clasped fingers of right hand in left palm and vice versa Rinse hands with water and remove all the soapy solution Dry hands throughly with a single use towel Use towel to turn off the faucet or tap Your hands are now safe. A word of caution – If you wash your hands before a Medical procedure, do not touch any unclean surface before touching the patient, clean instruments, items or wearing gloves.
Hand washing Tips and educational activities 1. Supervisors and administrators should develop strategies to make water, soap and antiseptics available at all times. 2. All staff must be aware of the importance of good hand washing practices 3. All health care providers should Hold regular in-service training programs to create awareness of the importance of good hand washing practices. Donning and removing gloves Equipment Gloves (both clean and sterile) yy Receptacle for used gloves. Procedure 1. Wash your hands to remove microorganisms and avoid contamination. 2. Remove glove from glove receptacles 3. Hold glove at wrist edge and slip finger into opening. Pull Glove up to wrist. Page : 7
Training Manual
Hand washing Techniques
Chapter : Saftey In Health Facilities Nursing Training Manual
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Chapter : Saftey In Health Facilities
4. Place gloved hand under wrist edge of second glove and slip fingers into opening 5. Remove glove by pulling off, touching only outside of glove at cuff, so that glove turns inside out. 6. Place rolled-up glove in palm of second hand. 7. Remove second glove by slipping one finger under glove edge and pulling down and off so that glove turns inside out Both gloves are removed as a unit. 8. Dispose of gloves in proper container, not at bedside. 9. Wash your hands.
Standard precautions Nursing Process
Assessment yy Assess for skin integrity yy Assess for presence of drainage from lesions or body cavity. yy Assess for ability to deal with oral secretions. yy Assess for compliance to hygiene measure (i.e., covering mouth when coughing, ability to control body fluid). yy Assess ability to carry out activities of daily living. yy Assess extent of barrier techniques needed (i.e., gloves, gown, mask, protective eye wear). yy Assess need for special equipment (i.e., hazardous waste bags, plastic bags for specimens).
Planning yy To prevent clients from acquiring nosocomial infections. yy To prevent the spread of microorganisms to health professionals. yy To reduce potential for transmission of microorganisms. yy To protect hospital personnel and others from contamination. yy To provide appropriate equipment and techniques for preventive measures.
Implementation/Procedures yy Donning protective gear utilizing standard precautions. yy Leaving a clients room using standard precautions.
Evaluation/Expected Outcomes. yy Clients remain infection free yy Transmission of microorganisms is controlled. yy Health Care Workers are protected from micro organisms. yy Appropriate nursing interventions are carried out for the client. yy Donning Protective Gear Utilizing Standard Precautions.
Equipment yy Disposable gloves, Gown, Mask. yy Apron yy Cap yy Protective eye wear (goggles)
Procedure 1. Wash hands using soap and dry. 2. Put on gown by placing one arm at a time through sleeves wrap gown around body so as to cover clothing completely. 3. Bring waist ties from back to front of gown or turn back according to hospital policy. This ensures that entire clothing is covered by the gown, while caring for clients. 4. Done disposable gloves.
Standard precaution Guidelines 1. Wash hands thoroughly after removing gloves and before and after patient contact. 2. Wear gloved when there is direct contact with blood, body fluids, secretions, excretions, and contaminated items. This include neonate before first bath, wash as soon as possible if an anticipated contact with this body substances occurs. Page : 9
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Chapter : Saftey In Health Facilities
3. Protect clothing with gowns or plastic aprons if there is a possibility of being splashed or direct contact with contaminated material. 4. Wear mask, goggles, or face shield to avoid being splashed including during suctioning, irrigations, and deliveries. 5. Do not break or recap needles, discard them intact in bathroom facilities to puncture resistant containers except for ABG (Arterial blood gas). 6. Place all contaminated articles and trash in leak : Proof bags, check hospital policy regarding double bagging. 7. Clean spills quickly with a 1:10 solution of bleach or according to facility policy. 8. Place clients at risk of contaminating the environment in a private room with separate bathroom facilities. 9. Transport infected clients using appropriate barriers,
Surgical Asepsis (Sterile Technique) Definition: Practices, which will maintain area free from microorganisms, as by surgical scrub, or sterile technique. Surgical Asepsis is used to maintain sterility. Use of effective sterile technique means that no organisms are carried to the client . Microorganisms are destroyed before they can enter the body. Sterile technique is used when changing dressings, administering parental (other than the digestive tract) medications, and performing surgical and other procedures such as urinary catheterization. With surgical asepsis, first articles are sterilized, and then theircontact with any unsterile article is prevented. When a sterile article touches an unsterile article, it becomes contaminated. It is no longer sterile.
Disinfection and Sterilization Disinfection: is a process that results in the destruction of most pathogens, but not necessarily their spots. Common methods of disinfection include the use of alcohol wipes, a hexachlorophene or chlorohexidine gluconate soap scrub, or povidon-iodine scrub to kill microorganisms on the skin. Stronger disinfectants include phenol and mercury bichoride, which are too strong to be used on living tissues. Boiling can be used to disinfect in animate objects. However it does not destroy all microorganisms and spores.
Sterilization: It is a process of exposing articles to steam heat under pressure or the chemical disinfectants long enough to kill all microorganisms and spores. Exposure to steam at 18 pounds of pressure at a temperature of 1250c for 15 minutes will kill even the toughest organism. A pressure steam sterilizer is called an autoclave. Some chemicals also can be used to sterilize an object. However chemical disinfectants powerful enough to destroy germs or extreme temperature cannot be used on certain articles, such as plastics. Sharp cutting instruments are usually sterilized by dry heat, or chemicals. Today, however, most sharps such as scalpels, and suture removal scissors are disposable. Needles used for injections are always discarded.
Other methods of sterilization include radiation and gas sterilization with ethylene oxide. Items to be used to maintain sterility technique
Hair covering: In sterile environments a cap or hood is worn to cover the hair, Remember that no hair can show. If hair is long, a special type of hood will be worn. Surgical Mask: In strict sterile situations such as in Operation Theatre / Labour Room or with protective isolation, the mask covers the mouth and nose. The purpose of mask is to form a barrier to stop the transmission of pathogens. The mask prevents harmful microorganisms in your respiratory tract from spreading to the client. When the client has an infection, the mask protects you from his/her pathogens. Sterile Gown: Sterile Gown is normally worn in the Operation Theatre /Labour Room complex with protective isolation and sometimes in the delivery room, the hands touch only the part of sterile gown that will touch the body after the gown is in place. Thus, touch only the inside of the gown. Someone else ties the strings. The back of the gown is considered contaminated, even though it was sterile when put on. Be careful when wearing a sterile gown not to touch anything that is unsterile.
Sterile Gloves: For some procedures sterile gloves are worn. Remember that once gloves are put on, touching anything unsterile contaminates them. Therefore, make all preparation before putting on gloves. Page : 10
Nursing Training Manual
Chapter : Saftey In Health Facilities
Procedure for putting on sterile gloves: Steps: 1. Wash the hands to limit the spread of microorganisms. 2. Open the outer glove package, on a clean, dry, flat, surface at waist level or higher. 3. If there is an inner package, open it in the same way, keeping the sterile gloves on the inside surface with cuffs towards you. 4. Use one hand to grasp the inner upper surface of the glove’s cuff for the opposite hand. Lift the glove up and clear it of the wrapper. 5. Insert the opposite hand in to the glove, placing the thumb and finger in to the proper openings. Pull the gloves into place, touching only the inside of the glove at cuff. Leave the cuff in place. 6. Slip the fingers of the sterile gloved hand under (inside) the cuff of the remaining glove while keeping the thumb pointed outward. 7. a) Insert the ungloved hand into the glove. b) Pull the second glove on; touching only the outside of the sterile glove with the other sterile gloved hand and keeping the fingers inside the cuff. c) Adjust gloves and snap cuffs into place. Avoid touching the inside glove and wrist area. 8. Keep the sterile gloved hands above waist level. Make sure not to touch the cloth. Keep hands folded when not performing a procedure. Both actions help to prevent accidental contamination.
Isolation Isolation is defined as separation from others, separation of people with infectious disease or susceptible to acquire disease from others. Isolation technique is a practice that is designed to prevent the spread or transmission of communicable diseases. Types of isolation Two primary types of isolation systems are used in health care: 1. Category – specific isolation 2. Disease – specific isolation Currently these isolation classifications are mostly replaced by standard precaution and transmission based precaution. 1. Category – specific isolation, specific categories of isolation (eg. Respiratory, contact, enteric, or wound) are identified, using colour coded cards. This form of isolation is based on the client’s diagnosis. 2. Disease specific isolation, uses a single all –purpose sign. Nurse selects the unit appropriate for the specific disease causing isolation.
Preparing for Isolation Purpose a. To prevent spread of microorganisms. b. To control infectious diseases Equipment Specific equipment depends on isolation precaution system used. yy Soap and running water. yy Isolation cart containing masks, gowns, gloves, plastic bags, isolation tape. yy Linen hamper and trash can, when needed. yy Paper /Towel. Procedure 1. Check orders for isolation 2. Ensure isolation cart is available 3. Check that all necessary equipment to carry out the isolation order is available 4. Ensure that the linen hamper is and trash cans are available, if needed. 5. Explain the purpose of isolation to the client and family. 6. Instruct family in procedures required. 7. Wash hands with anti microbial soap before and after entering isolation room.
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Nursing Training Manual
Chapter : Saftey In Health Facilities
Donning and Removing Isolation Attire Equipment yy Gown yy Clean gloves For donning attire 1. Wash and dry hands you enter a room 2. Take gown from isolation cart, put on a fresh gown each time you enter an isolation room. 3. Hold gown so that opening is in back when you are wearing the gown. 4. Put gown on by placing one arm at a time through sleeves, put gown – up and over your shoulder. 5. Wrap gown around your back, tying strings at your neck. 6. Wrap gown around your waist, making sure your back is completely covered. Tie string around your waist. 7. Done eye shield and /mask, if indicated. Mask is required if there is a risk of splashing fluids. 8. Don clean gloves and pull gloves over gown wristlets. For Removing Attire 1. Untie gown waist strings 2. Remove gloves and dispose of them in garbage bag. 3. Next, untie neck strings, bringing them around your shoulders, so that gown is partially off your shoulders. 4. Using your dominant hand and grasping clean part of wristlet, put sleeve wristlet over your non dominant hand. Use your non-dominant hand to pull sleeve wristlet over your dominant hand. 5. Grasp outside of gown through sleeves at shoulders. Pull gown down over your arms. 6. Hold both gown shoulders in one hand, carefully draw your other hand out of the gown, turning arm of gown inside out. Repeat this procedure with your other arm. 7. Hold gown away from your body, fold gown up inside out. 8. Discard gown in appropriate place. 9. Remove mask, place in a receptacle and wash your hands. Using a mask -- Equipment - Clean mask Procedure 1. Take a clean mask from the container 2. Position mask over the nose and mouth 3. Bend nose bar so that it conforms over bridges of your nose 4. If you are using a mask with string ties, tie top strings on top of your head to prevent slipping. If you are using a con shaped mask, tie top strings over your ears. 5. Tie bottom strings around your neck to secure mask over your mouth. There should not be any gaps between the mask and your face. 6. Important; change mask every 30 minutes or sooner if it becomes damp as effectiveness is greatly reduced after 30 minutes or if the mask is moist. 7. Wash your hands before removing mask. 8. To remove mask, untie lower strings first, or slip elastic band off without touching mask. 9. Discard mask in a soiled bin or container and wash your hands. Removing Items from Isolation Room Equipment yy Large red isolation bags yy Specimen container yy Plastic bag with biohazard label yy Laundry bag yy Red plastic container in room yy Cleaning articles Procedure 1. Dispose of all sharps in appropriate red plastic container in room 2. Place all linen in linen bag 3. Place reusable equipment such as procedure trays in plastic bags 4. Dispose of all garbage in plastic bags Page : 12
Nursing Training Manual
Chapter : Saftey In Health Facilities
5. Double bag all material used from isolation room, follow procedure for utilizing double bagging for isolation. All material removed from an isolation room is potentially contaminated; this will prevent spread of microorganisms. 6. Replace all bags, such as linen bag and garbage bag, in appropriate container in room. 7. Make client’s room as clean as necessary using germicidal solution. Using double bagging for isolation Equipments – a) 2 isolation bags
b) Items to be removed from room
c) Gloves Procedure 1. Follow dress protocol for entering isolation room, or if you are already in the isolation room, continue with step 2. 2. Close isolation bag when it is one-half to three fourths full. Close bag inside the isolation room. 3. Double bag for safety if outside of the bag is contaminated, if the bag could be easily penetrated, or if contaminated material in the bag is heavy and could break the bag. 4. Set -up a new bag for continued use inside room. Bag is usually red with the word “Bio hazard” written on the outside of bag. 5. Place bag from inside room into a bag held open by a second health care worker outside room, if double bagging is required. Second health worker care worker, makes a cuff with the top of the bag and places hands under cuff. This prevents hands from becoming contaminated. 6. Place bag in to second bag without contaminating outside of bag. Secure top of bag by tying a knot on top of the bag. 7. Take bag to designated area where biohazard material is collected; usually “dirty” utility room. 8. Remove gloves and wash hands. Transporting Isolated Client outside the Room Equipment -Transport Vehicle -Bath Blanket -Mask if needed. Procedure 1. Explain procedure to the patient 2. If client is being transported from a respiratory isolation room, instruct him or her to wear a mask for the entire time out of the isolation room. 3. Cover the Transport vehicle with a bath blanket if there is a chance of soiling when transporting a client who has a draining wound or diarrhea. 4. Help client to transport vehicle. Cover client with a bath blanket. 5. Tell receiving department what type of isolation client needs and what type of precautions hospital personnel should follow. 6. Remove bath blanket, and handle as contaminated linen when client returns to room. 7. Instruct all hospital personnel to wash their hands before they leave the area. 8. Wipe down transportation vehicle with antimicrobial solution if soiled. Protocol for leaving Isolation Room yy Untie gown at wrist, yy Take off gloves, yy Untie gown at neck, yy Pull gown off and place in laundry hamper yy Take off mask yy Wash hands
Guide lines for Disposing of Contaminated Equipment yy Disposable Gloves: place in isolation bag separate from burnable trash and direct to appropriate hospital area for disposal yy Glass equipment: Bag separately from metal equipment and return to CSR (Central Sterilization Room). yy Metal equipment: Bag all equipment together, label and return to CSR. yy Rubber and plastic items: Bag it separately and return to CSR for gas sterilization.
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Chapter : Saftey In Health Facilities
yy Dishes: require no special precautions unless contaminated with infected material; then bag, label and return to kitchen. yy Plastic or paper dishes: Dispose of these items in burnable trash. yy Soiled linen: place in laundry bag, and send to separate area of laundry room for special care. yy Needles and Syringes: Do not recap needles; place in puncture proof (resistant) containers. yy Sphygmomanometer and Stethoscope: require no special precaution unless they are contaminated. If contaminated disinfect using the appropriate cleaning protocol based on the infective agent. yy Thermometers: Clean with appropriate, disinfectant and disinfect with appropriate solution.
Study questions for weekly test 1. Describe infection prevention in health care set ups 2. List chain of infection 3. Identify between medical asepsis and surgical asepsis. 4. Discuss the purpose use and components of standard precautions., 5. Maintain both Medical and Surgical asepsis. 6. Describe how to setup a client’s room for isolation including appropriate barrier techniques. 7. Identify how to follow specific airborne, droplet and contact precautions.
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Nursing Training Manual
Chapter : Care Of Patient Unit
ii) Care of patient unit PATIENT UNIT Definition: Patient: is a person who is waiting for or undergoing medical/nursing treatment and care. Patient care unit: is the space where the patient is accommodated in hospital where he receives care. The patients unit in a hospital is of the three types: 1. Private Room – is a room in which only one patient can be accommodated. 2. Semi – Private rooms – is a patient which can accommodate two patients. 3.Ward – is a room, which can receive three or more patients. Consists of hospital bed, I.V. Stand, bedside locker chair or stool overhead light , suction and oxygen, electrical outlets, sphygmomanometer, call bell and waste container .
Hospital bed: yy A manual bed which requires the use of hand racks or foot pedals to manipulate the bed into desired positions i.e. to elevate the head end or the foot end of the bed. Handles should be positioned under the bed when not in use. Side Rails: It should be attached to both sides of the bed. Full rails – run the entire length of the bed Half rails –run only half way and are commonly attached to paediatric beds.
Bedside cabinet: yy It is a small cabinet that generally consists of a drawer and a small cupboard area with shelves yy It is used for storing the patient’s personal belongings that are desired nearby or that will be frequently used. yy It is used to store the utensils needed for patient care e.g. soap, toilet articles cafeteria tray tumbler etc.
Bed side table: yy The height should be adjustable yy Can be used over the bed or beside it. yy It can be used for holding the tray during meals, or care items near the bedside when completing personal hygiene.
Chair: yy Most basic care units have at least one chair or stool located near the bedside. yy For the use of the client, visitor, or a care provider.
Bedside Light: yy It is usually attached to the wall or ceiling. yy Important for the nurse during assessment. yy Useful for the client for reading or doing close work
Suction and Oxygen Outlets: yy Suction is a vacuum created in a tube that is used to pull (evacuate) fluids from the body E.g. to clear respiratory mucous or fluids. yy Oxygen is one of the gases frequently used for health care. Oxygen is derived through a tube connected to an oxygen the bed. cylinder or central supply.
Electrical Outlets: yy Almost always available in the wall at the head end of the bed.
Sphygmomanometer: yy Blood pressure apparatus used for recording Blood Pressure of the patient.
Call bell: yy It is used for the client to maintain constant contact with the care providers.
Care of Patient Unit: yy Nursing Staff are not responsible for actual cleaning of dust and other dirty materials from hospital. However, it is the staff nurse’s duty to supervise the ground staffs who perform this job.
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Chapter : Care Of Patient Unit
General Rules for Cleaning: yy Dry dusting of the room is not advisable. yy Dusting should be done by sweeping only. yy Use a damp duster for collecting dust. yy Dust with clean duster. yy Collect dust at one place to avoid flying from place to place. yy Dusting should be done without disturbing or removing the patients from bed and disturbing them. yy Dusting should be done from top to bottom i.e. from upward to downward direction. yy While dusting take care not to spoil the beds or walls or other fixtures in the room or hospital ward. yy While dusting, wounds or dressings should not be opened by other staff.
B. Care of Hospital and Health Care Unit Equipments 1. General Instructions for Care of Hospital equipments yy Use articles only for the purpose for which they are meant for yy Keep articles clean and in good condition. Use the proper cleaning method. yy Protect mattresses with rubber sheets. yy Use protective pillowcases on pillows. yy Do not boil articles, especially rubber articles and instruments longer than the correct time. yy Do not sterilize rubber goods and glass articles together – wrap glass in gauze when sterilizing it by boiling. yy Protect table tops when using hot utensils or any solution that may leave stain or destroy the table top. yy Report promptly any damaged or missing equipment
2. Care of equipment in general yy Rinse used equipment in cold water. Soak materials in recommended antiseptic solutions. Remove any sticky materials. Hot water coagulates the protein of organic material and tends to make it adhere. yy Wash well in hot soapy water. Use an abrasive, such as a stiff – bristled brush, to clean equipment. yy Rinse well under running water. yy Dry the article. yy Clean the gloves brush and clean the sink.
3. Care of linen and Removal of Stains: yy Clean linen should be folded properly and be kept neatly in the linen cupboard. yy Dirty linen should be put in the dirty linen bag (Hamper) and never be placed on the floor. yy Torn linen should be mended or sent to the sewing room. yy Linen with blood stains should be soaked in cold water to which a small amount of hydrogen peroxide is added if available. yy Linen stained with urine and feces is first rinsed in cold water and then washed with soap. yy Iodine stained linen – apply ammonia, rinse and then wash with cold water. yy Ink stained linen – first soak in cold water or milk for at least 24 hours then rub a paste of salt and lemon juice on the stain and allow the article to lie in the sunlight. yy Tea or coffee stains – wash in cold water and then pour boiling water on the stain. yy To remove vitamin B Complex stains dissolve in water or spirit. yy Mucus stains –soak in salty water. yy Rust – soak in salt and lemon juice and then bleach in sun.
4. Care of Cheatle Forceps and Jars:
1. Cheatle Forceps: or pick up forceps is an instrument that allows one to pick up sterile equipment. 2. Sterile equipment: material, which is free from all forms of microorganisms.
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Chapter : Care Of Patient Unit
Forceps should be kept inside the jar in which 2/3 of the jar should be filled with antiseptic solution. yy Wash the forceps and jars and sterilize daily yy Fill the jar with disinfectant solution daily such as dettol or 1%Hypochlorite solution. yy Care should be taken to always hold the forceps tip downwards yy Care should be taken not to contaminate the tip of the forceps. yy If the tip of the forceps is contaminated accidentally, it should be sterilized before placing it back in the jar to avoid contamination.
5. Rubber Bags: yy Hot water bottles, ice caps should be drained and dried. yy They should be inflated with air and closed to prevent the sides from sticking together
6. Rubber Tubing: yy They should be washed with warm soapy water. yy The inside of the tube must be flushed and rinsed well.
Study questions for weekly test 1. Define Patient and patient unit. 2. State some of the important general instructions for nursing procedures. 3. List items commonly found in the patient’s unit.
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Nursing Training Manual
Chapter : Basic Client Care
Nursing Training Manual
unit three BASIC CLIENT CARE i) ADMISSION, TRANSFER AND DISCHARGE OF PATIENTS A. Admission : is a process of receiving a new patient to an individual unit (ward) of the hospital. (Hospitalized individuals have many needs and concerns that must be identified then prioritized and for which action must be taken). Purpose To help to a new patient to adjust to hospital environment and routines. To alleviate the patient’s fear and worry about the hospitalization. To facilitate recovery of the patient from his/her problems.
Nurse’s responsibilities during Admission of a patient to hospital. 1. Check for orders of admission. 2. Check about financial issues, payment scheme (free or paying). 3. Assess the patient’s immediate need and take action to meet them. These needs can be physical (e.g. acute pain) or emotional distress, (upset) 4. Make an introduction and orient the patient Greet the patient ÔÔ Introduce self to the patient and the family ÔÔ Explain what will occur during the admission process (admission routines) such as admission bath, put on hospital gowns etc. ÔÔ Orient patient to individual unit: Bed, bathroom, call light, supplies and belongings; and how these items ÔÔ work for patient use. ÔÔ Orient patient to the entire unit: location of nurses office, lounge etc. ÔÔ Explain anything you expect a patient to do in detail. (This helps the patient’s participation in their care). ÔÔ Introduce other staff and roommates. 5. Perform baseline assessment General assessment a. Observation and physical examination such as: ÔÔ Vital signs; temperature, pulse respiration and blood pressure. ÔÔ Fluid balance chart (intake / output chart) ÔÔ Weight record of the patient. b. Interview patient and take nursing history to determine the patient’s condition. 6. Take care of the patient’s personal property. ÔÔ Items that are not needed can be sent home with family members. ÔÔ Other important items can be kept at bedside or should be put in safe Place by writing the patients name on the package. 6. Documentation ÔÔ Record all parts of the admission process. ÔÔ Other recording include ÔÔ Medical case notes, Nurses notes, medication records, ÔÔ Additional measures can be carried out according to the patient’s problems. (Diagnosis).
B. Transfer of the Patient to another unit Transfer of the patient to another unit is done for several reasons. Procedure Explain the transfer to the client and the family. ÔÔ Assemble the entire client’s personal belongings, charts, medical records, x-ray and lab reports. Double check for all other linen and materials. ÔÔ Determine how the patient is to be moved.
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Chapter : Basic Client Care
ÔÔ Provide for client safety. Take measures to accommodate IV bottles, drains and catheters. Protect the client from draft, and cover the client with a blanket for warmth and privacy. ÔÔ Collect all the client’s medications; IV Bags, tube feedings and so forth. Medication cards or records for accuracy. ÔÔ Review the patient’s health records and check for completeness. ÔÔ Record the transfer in a transfer note. Give the time, the unit to which the transfer occurs, types 0f transportation (wheelchair, stretcher), and the client’s physical and psychological condition. ÔÔ Make sure that the receiving unit is ready. Usually a short verbal report is given to the receiving department nurse.
C. Discharging the patient Indications for discharge yy Progress in the patient’s condition. yy No change in the patient’s condition (Referral). yy Against Medical Advice yy Death. Nurse’s responsibility during discharging the patient 1. Check for orders that a patient need to be discharged. 2. Plan for continuing care of the patient. ÔÔ Referral as necessary. ÔÔ Give information for a person involved in the patient care. ÔÔ Contact family or relatives if needed. ÔÔ Facilitate transportation with responsible unit. 3. Teaching the patient about ÔÔ What to expect about disease outcome. ÔÔ Medication (Treatment) to be continued at home. ÔÔ Activity. ÔÔ Diet. ÔÔ Need for continued health supervision, and others as needed. 4. Do final assessment of physical and emotional status of the patient and the ability to continue own care. 5. Check and return all patients’ personal property (Toilet and bath items) in the patient’s unit and those items kept in safe area. 6. Keep records ÔÔ Write discharge note ÔÔ Keep special forms for facility Discharge summaries usually include: yy Description of patient’s condition at discharge yy Treatment (e.g. wound care, Current medication) yy Diet yy Activity level yy Restrictions Referral is a condition in which a client/patient is sent to a higher health care system for better diagnostic and therapeutic actions. yy Any active health problems. yy Current medication yy Current treatments that are to be continued yy Eating and sleeping habits. yy Self- care abilities yy Support networks yy Life-style patterns yy Religious preferences. Discharging a patient against medical advice (AMA) 1. When the patient wants to leave an agency without the permission of the physician/nurse in charge 2. Ascertain why the patient wants to leave the agency Page : 19
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Chapter : Basic Client Care
3. Notify the physician/nurse in charge of the client’s decision. 4. Offer the patient the appropriate form to complete 5. If the client refuses to sign the form, document the fact on the form and have another health professional witness this. 6. Provide the patient with the original of the signed form and place a copy in the record. 7. When the patient leaves the agency, notify the physician, nurse in-charge, and agency administration as appropriate. 8. Assist the patient to leave as if this were a usual discharge from the agency (the agency is still responsible while the patient is on premises) for clients belongings on admission.
Study Questions: 1. Mention concepts related to caring for clients belongings on admission. 2. State some of the nursing consideration related to admission of a client. 3. Exercise how to transfer a client from one unit to another safely and effectively. 4. Identify nursing considerations related to discharge of a client from health care facility 5. Explain teaching that should occur at time of a client discharge.
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Chapter : Basic Client Care
ii) VITAL SIGNS Vital signs reflect the body’s physiologic status and provide information critical to evaluating homeostatic balance. The term “Vital” is used because the information received is the clearest indication of overall health status. Vital signs includes: T (temperature), PR (pulse rate), RR (respiratory rate), and BP (blood pressure). Purpose: yy To obtain base line data about the patient’s condition. yy To aid in diagnosing patient condition (diagnostic purpose) yy For therapeutic purpose so that to intervene accordingly. Equipment yy Vital sign tray or TPR Tray yy Stethoscope yy BP Apparatus or Sphygmomanometer yy Thermometer yy Second hand watch yy Pen and paper or TPR book yy Cotton swabs in a bowl yy Disposable gloves if available yy Container to receive dirty swabs yy Time to assess the Vital Signs 1. On admission – to obtain baseline data 2. When a client has a change in health status or reports symptoms such as chest pain or fainting 3. According to a Nursing or Medical order. 4. Before and after the administration of certain drugs that could affect RR or BP. (respiratory and cardio-vascular system). 5. Before and after surgery or an invasive diagnostic procedure. 6. Before and after any surgical intervention that could affect the vital signs. E.g. Ambulation. 7. According to the hospital or health institution policy.
Temperature : Body temperature is the measurement of heat inside a person’s body (core temperature); it is the balance between the heat produced and heat lost. Normal body temperature using oral route is 370c or 98.60f
There are two kinds of body temperature 1. Core Temperature ÔÔ It is the temperature of the deep tissues of the body, such as the cranium, thorax, abdominal cavity, and pelvic ÔÔ Remains relatively constant ÔÔ It is the temperature that we measure with a thermometer. 2. Surface Temperature ÔÔ The temperature of the skin, the subcutaneous tissue and fat.
Alterations in Body Temperature yy Normal body temperature is 370 C or 98.60 F (Average) the range is 36-380C (96-980F). yy Pyrexia: a body temperature above the normal ranges 380c-410c (100.4 – 105.80F). yy Hyperpyrexia: a very high fever, such as 410 C >420 C leads to death. yy A client who has fever is referred as febrile and one who has not is referred to as a febrile. yy Hypothermia: - body temperature between 340c - 350c, < 340c is death.
Common types of Fevers 1. Intermittent fever: the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperature. 2. Remittent fever: a wide range of temperature fluctuation (more than 20 C) occurs over the 24 hr period, all of which are above normal.
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Chapter : Basic Client Care
3. Relapsing fever: short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature. 4. Constant fever: the body temperature fluctuates minimally but always remains above normal.
Factors Affecting Body Temperature. 1. Age of adults until puberty ÔÔ Children’s temperature continues to be more labile than those of adults until puberty. ÔÔ Elderly people, particularly those > 75 yrs are at risk of hypothermia. ÔÔ Normal body temperature of a new born if taken orally is 370c
2. Diurnal variations ÔÔ Body temperature varies throughout the day. ÔÔ The point of highest temperature is usually reached between 8PM and midnight and lowest point is reached during sleep between 4 and 6 AM.
3. Exercise ÔÔ Hard or strenuous exercise can increase body temperature to as high as 38.3 - 400 c – measured rectally.
4. Hormones ÔÔ In women progesterone secretion at the time ovulation raises the body temperature by about 0.3 – 0.60 c above basal temperature.
5. Stress. ÔÔ Stimulation of the skin can increase the production of epinephrine and nor epinephrine – which increases metabolic activity and heat production.
6. Environment Extremes in temperature can affect a person’s temperature regulatory systems. yy Measuring Body Temperature yy Sites to Measure Temperature yy Most common sites are: ÔÔ Oral ÔÔ Rectal ÔÔ Axillary ÔÔ Tympanic Thermometer: is an instrument used to measure body temperature. Types of thermometers 1. Oral Thermometer • Has a long slender tip. 2. Rectal Thermometer • Has a short rounded tip 3. Axillary • Long slender tip 4. Tympanic
1. Rectal Thermometer: Readings are considered to be more accurate, most reliable, is > 0.650c (10f) higher than the oral temperature. Procedure yy Explain the procedure to the patient yy Wash hands and assemble necessary equipment and bring to the patient’s bedside. yy Position the patient in a lateral position yy Apply the lubricant 2.5 cm above the bulb; yy Insert the thermometer 1.5 – 4 cm into the anus. For an infant 2.5 cm, for a child 3.7 cm – for an adult 4 cm. yy Measure temperature for 2 – 3 min yy Remove the thermometer and read the finding yy Clean the thermometer with tissue paper. yy A rectal thermometer record does not respond to changes in arterial temperature as quickly as an oral thermometer.
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Chapter : Basic Client Care
Contra-indications yy Rectal or perineal surgery; yy Fecal impaction – the depth of the thermometer insertion may be insufficient ;Rectal infection yy Neonates – it can cause rectal perforation and ulceration;
2. Oral Procedure yy Explain the procedure to the patient yy Wash hands and assemble necessary equipment and bring to patient’s bedside tell the patient to open his mouth yy Position the patient comfortably and tell the patient to open his mouth yy Take the thermometer from the lotion bottle, wipe it with a clean cotton swab, from the bulb to the stem yy Hold the thermometer firmly with the thumb and fore finger; shake it with strong wrist movements until the mercury line falls to at least 350c yy Place the bulb of the thermometer well under the client’s tongue, where it will be in contact with the blood vessels close to the surface. yy Remove the thermometer after 3-5 min, yy Wipe it using a firm twisting motion from the finger tip i.e. stem to the bulb yy Hold the thermometer at eye level, read the finding yy Dispose the tissue, wash the thermometer in luke warm soapy water, dry and replace the thermometer in the container having lotion yy Wash your hands yy Record the in the chart or TPR Book, yy Report any abnormal finding to the senior nurse present or to the doctor.
Contraindications yy Child below 7 yrs yy If patient is delirious, mentally ill yy Unconscious yy Uncooperative or in severe pain yy Surgery of the mouth yy Nasal Obstruction yy If patient has nasal or gastric tube in position.
Axillary Procedure yy Explain the procedure to the patient yy Wash hands yy Make sure that the client’s axilla is dry yy If it is moist pat it dry gently before inserting the thermometer yy After placing the bulb of the thermometer in the axilla of the patient, yy Bring the client’s arm down against the body as tightly as possible, with the forearm resting across the chest. yy Hold the thermometer in place for 8-10 min or the electronic thermometer in place until the reading registers directly yy Remove and read the thermometer, dispose of the equipment properly yy Wash hands yy Record the reading N.B. The axillary method is the safest and most noninvasive. Pulse It is a wave of blood created by contraction of the left ventricle of the heart. i.e. the pulse reflects the heart beat or is the same as the rate of ventricular contractions of the heart – in a healthy person. In some types of cardiovascular diseases heartbeat and pulse rate differs. E.G. Client’s heart produces very weak or small pulses that are not detectable in a peripheral pulse far from the heart. Page : 23
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Peripheral Pulse: is a pulse located in the periphery of the body e.g. in the foot, and or neck. Apical Pulse (central pulse): it is located at the apex of the heart. The PR is expressed in beats/ minute (BPM). Pulse Deficit – It is a difference that exists between the apical and radial pulse.
Factors Affecting Pulse Rates 1. Age: as age increases the PR gradually decreases. New born to one month – 130 BMP. Adult 80 BPM ranges from -60100 BPM /min. 2. Sex: After puberty the average males PR is slightly lower than females. 3. Exercise: PR increases with exercise. 4. Fever: increases PR in response to the lowered B/P that results from peripheral vasodilatation – increases metabolic rate. 5. Medications: digitalis preparation decreases PR, Epinephrine – increases PR. 6. Heat: increases PR as a compensatory mechanism. 7. Stress: increases the sympathetic nerve stimulation – increases the rate and force of heart beat. 8. Position changes: when a patient assumes a sitting or standing position blood usually pools in the dependant vessels of the venous system. Pooling results in a transient decrease in the venous blood return to heart and subsequent decrease in BP increases heart rate.
ii ) Pulse sites: Temporal: is superior (above) and Lateral to (away from the midline of) the eye. 1. Carotid: at the side of the neck below tube of the ear (where the carotid artery runs between the trachea and the sterno clidio-mastoid muscle). 2. Temporal: the pulse is taken at temporal bone area. 3. Apical: at the apex of the heart: routinely used for infants and children <3 yrs. In adults – left midclavicular line under the 4th ,5th , 6th intercostals space. Children <4 yrs of the Lt Mid Clavicular line. 4. Brachial: at the inner aspect of the biceps muscle of the arm or medially in the antecubital space (elbow crease) 5. wrist – readily available and routinely used. 6. Femoral: along the inguinal ligament. Used for infants and children. 7. Popiliteal: behind the knee. By flexing the knee slightly. 8. Posterior tibial: on the medial surface of the ankle 9. Pedal: (Dorsalis Pedis): palpated by feeling the dorsum (upper surface) of the foot on an imaginary line drawn from the middle of the ankle to the surface between the big and 2nd toe. Method Pulse: is commonly assessed by palpation (feeling) or auscultation (hearing) The middle 3 fingertips are used with moderate pressure for palpation of all pulses except apical; the most distal parts are more sensitive.
Assess the pulse for yy Rate yy Rhythm yy Volume yy Elasticity of the arterial wall Pulse rate: yy Normal rate 60-100 b/min (80) yy Tachycardia – excessively fast heart rate (> 100/min) yy Bradycardia < 60/min
Pulse Rhythm: yy The pattern and interval between the beats, random, irregular beats – dysrythymia
Pulse Volume: the force of blood with each beat yy A normal pulse can be felt with moderate pressure of the fingers and can be obliterated with greater pressure. yy Full or bounding pulse forceful of full blood volume obliterated with difficulty. yy Weak, feeble or thread readily obliterated with pressure from the finger tips.
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Elasticity of arterial wall yy A healthy, normal artery feels, straight, smooth, soft and elastic. yy It reflects the status of the client’s vascular system if the pulse is regular, measure (count) for 30 seconds and multiple by two. If it is irregular count for 1 full minute.
Procedure for measuring radial pulse (the most common) yy Wash hands yy Explain the procedure to the patient yy Position the client’s forearm comfortably with the wrist extended and the palm down. yy Place the tips of your 1st, 2nd and 3rd fingers over the client’s radial artery on the inside of the wrist on the thumb side yy Press gently against the client’s radial artery to the point where pulsation can be felt distinctly. yy Using a watch, count the pulse beats for 30 seconds and multiply by two to get the rate per minute. yy Count the pulse for full minute if it is abnormal in any way or take an apical pulse. yy Record the rate (BPM) on paper or the flow chart. Report any irregular findings to appropriate person. yy Wash your hands.
iii) Respiration: It is the act of breathing (includes intake of O2 removal of CO2) Ventilation is another word, which refer to the movement of air in and out of the lungs. Hyperventilation: very deep, rapid respiration. Hypoventilation: very shallow respiration.
Two types of breathing 1. Costal (thoracic) ÔÔ Involves the external muscles and other accessory muscles (sternoclodio mastoid) ÔÔ Observed by the movement of the chest wall upward and downward. Commonly used for adults.
2. Diaphragmatic (abdominal) ÔÔ Involves the contraction and relaxation of the diaphragm, observed by the movement of abdomen. Commonly used for children.
Assessment yy The client should be at rest yy Assessed by watching the movement of the chest or abdomen. yy Rate, Rhythm, depth and special characteristics of respiration are assessed.
A. Rate: is described as rate per minute (RPM)
Healthy adults RR =15-20/minute, is measured for a full minute, if regular for 30 seconds. As the age decreases the respiratory rate increases. 1. Apnea : temporary cessation of breathing 2. Bradypnea: slow respiration 3. Tachypnea: fast breathing
B. Rhythm: is the regularity of expiration and inspiration normal breathing is automatic and effortless. C. Depth: described as normal, deep or shallow. Deep: a large volume of air inhaled and exhaled, inflates most of the lungs. Shallow: exchange of a small volume of air minimal use of lung tissue.
IV. Blood Pressure: Blood pressure is the pressure exerted by blood against the wall of blood vessels. It includes arterial, venous and capillary pressures. Arterial BP: it is a measure of a pressure exerted by the blood as it flows through the arteries. Arterial blood pressure (BP)=cardiac output (CO) x total peripheral resistance (TPR). There are two types of blood pressure. 1. Systolic pressure: is the pressure of the blood as a result of contraction of the ventricle (is the pressure of the blood at the height of the blood wave);
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2. Diastolic blood pressure: is the pressure when the ventricles are at rest. 3. Pulse pressure: is the difference between the systolic and diastolic pressure. Blood pressure is measured in mmHg and recorded as fraction. A number of conditions are reflected by changes in blood pressure. yy An increase in blood pressure is called hypertension; a decrease is called Hypotension.
Conditions affecting Blood Pressure: Fever
increase
Stress
increase
Arteriosclerosis
Increase
Obesity
Increase
Haemorrhage
Decrease
Low Haemocrit
Decrease
External Heat
Decrease
Exposure to cold
Increase
Sites for measuring Blood Pressure 1. Upper arm
Using brachial artery (commonest).
2. Thigh around
Popliteal Artery
3. Forearm
Using radial artery
4. Leg
Using posterior tibial or dorsal pedis
Methods of Measuring Blood Pressure Blood pressure can be assessed directly or indirectly yy Direct (invasive monitoring) measurement involves the insertion of catheter into the brachial, radial, femoral artery. The physician inserts the catheter and the nurse monitors the pressure reading. With use of correct placement, it is highly accurate. yy Indirect (non-invasive methods)
A. Auscultatory. ----
B. Palpatory.
The commonest method used in health activities.
When taking blood pressure using stethoscope, the nurse identifies five phases in series of sounds called Karotkoffâ&#x20AC;&#x2122;s sound. Phase 1: The pressure level at which the 1st joint clear tapping sound is heard; these sounds gradually become more intense. To ensure that they are not extraneous sounds, the nurse should identify at least two consecutive tapping sounds. Phase 2: The period during deflation when the sound has a swishing quality. Phase 3: The period during which the sounds are crisper and more intense. Phase 4: The time when the sounds become muffled and have a soft blowing quality. Phase 5: The pressure level when the sounds disappear. Procedure Assessing Blood Pressure Purpose o To obtain baseline measure of arterial blood pressure for subsequent evaluation. o To determine the clients homodynamic status o To identify and monitor changes in blood pressure resulting from a disease process and medical therapy. Equipment o Stethoscope. o Blood pressure cuff of the appropriate size. o Sphygmomanometer.
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Procedure 1. Prepare and position the patient appropriately ÔÔ Make sure that the client has not smoked or ingested caffeine, within 30 minutes prior to checking of blood pressure ÔÔ Position the patient in a sitting position, unless otherwise specified. The arm should be slightly flexed with the palm of the hand facing up and the forearm supported at heart level. ÔÔ Expose the upper arm. 2. Wrap the deflated cuff evenly around the upper arm ÔÔ Apply the centre of the bladder directly over the medial aspect of the arm. The bladder inside the cuff must be directly over the artery to be compressed if the reading is to be accurate. ÔÔ For adults, place the lower border of the cuff approximately 2 cm above antecubital space. 3. For initial examination, perform preliminary palipatory determination of systolic pressure. ÔÔ Palpate the brachial artery with the finger tips ÔÔ Close the valve on the pump by turning the knob clockwise ÔÔ Pump up the cuff until you no longer feel the brachial pulse. ÔÔ Note the pressure on sphygmomanometer at which the pulse is no longer felt. ÔÔ Release the pressure completely in the cuff, and wait 1 to 2 minutes before making further measurement. 4. Position the stethoscope appropriately ÔÔ Insert the ear attachments of the stethoscope in your ears so that they tilt slightly forward. ÔÔ Place the diaphragm of the stethoscope over the brachial pulse; hold the diaphragm with the thumb and index finger. e the cuff 5. Auscultate the client’s blood pressure. ÔÔ Inflate the cuff until the sphygmomanometer registers about 30 mmhg above a point where the brachial pulse disappeared. ÔÔ Release the valve on the cuff carefully so that the pressure decreases at the rate 2-3 mmhg per second. ÔÔ As the pressure falls, identify the manometer reading at each of the 5 phases. ÔÔ Deflate the cuff rapidly and completely. ÔÔ Repeat the above step once or twice as necessary to confirm the accuracy of the reading 6. Remove the cuff from the client’s arm. 7. For initial determination, repeat the procedure onthe client’s other arm, there should be a difference of no more than 5 to 10 mmhg between the arms. The arm found to have the higher pressure, should be used for subsequent examinations. 8. Document and report pertinent assessment data, report any significant change in client’s blood pressure to the nurse incharge. Also report these findings: ÔÔ Systolic blood pressure (of adult) above 140mmhg. ÔÔ Diastolic blood pressure (of adult) above 90mmhg ÔÔ Systolic blood pressure (of adult) below 100 mmhg.
Study questions yy Explain vital signs and list what it includes. yy Identify important times to assess vital signs. yy Mention some of the factors affecting body temperature. n the two methods of assessing yy What does pulse deficit mean? yy Define arterial blood pressure. yy Explain the two methods of assessing blood pressure.
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iii) SPECIMEN COLLECTION Specimen collection refers to collecting various specimens (samples), such as stool, urine, blood and other body fluids or tissues, from the patient for diagnostic or therapeutic purposes. Various types of specimen collected from the patient in the clinical settings, either in outpatient department (OPD) or In-patient units for diagnostic and therapeutic purposes. These includes, stool, urine, blood and other body fluid or tissue specimens.
A. General considerations for Specimen Collection. When collecting specimens, wear gloves to protect self from contact with body fluids. 1. Get request for specimen collection and identify the types of specimen being collected and the patient from which the specimen is to be collected. 2. Give adequate explanation to the patient about the purpose, type of specimen being collected and the method used. Assemble and organize all the necessary materials for the specimen collection. 3. Get the appropriate specimen container and it should be clearly labeled have tight cover to seal the content and placed in the plastic bag or racks, so that it protects the laboratory technician from contamination while handling it. ÔÔ The patient’s identification such as, name, age, card number, the ward and bed number (if in-patient). ÔÔ The types of specimen and method used (if needed) ÔÔ The time and date of the specimen collected. 5. Put the collected specimen into its container without contaminating outer parts of the container and its cover. 6. All specimens should be sent promptly to the laboratory, so that the temperature and the time changes do not alter the content.
B. Collecting stool specimen Purpose yy For laboratory diagnosis, such as microscopic examination, culture and sensitivity tests. Equipment required yy Clean bedpan or commode. yy Wooden spatula or applicator yy Specimen container yy Tissue paper yy Laboratory form yy Disposable glove, for patients confined in bed yy Bed protecting materials yy Screen to provide Privacy. Procedure i. For Ambulatory Patients Give adequate instructions to the patient to ÔÔ Defecate in clean bedpan or commode. ÔÔ Avoid contaminating the specimen by urine, menstrual periods or used tissue papers, because these may affect the analysis. ÔÔ Void before collecting the specimen ÔÔ Transfer the sample (specimen) to the container using spatula or applicator ii. For Patients Confined to bed 1) Prepare the patients unit • Provide privacy by drawing screens, closing windows and doors 2) Prepare the patient • Put on gloves. • Position the patient • Place bed protecting materials under the patients hips. • Assist the patient place the bedpan under the patients buttocks (follow the steps under “giving and removing bedpan”). •Ensure privacy by leaving the patient alone but be around to help when required. •Instruct the patient to call you when finished defecation.
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•Remove the bedpan and keep it in a safe place by covering it. •Place the patient in a comfortable position. 3. Obtain stool sample • Take the used bedpan to utility room/toilet • Using a spatula without contaminating the outside of the container, • The amount of stool sample usually depends upon the test , usually • Grams sample from formed stools and • 15 – 30 ml sample from liquid stool. • Visible mucus, pus or blood should be included in the sample stool specimen taken. 4. Care of equipments and the specimen collected. • Handle and label the specimen correctly. • Send the specimen to the laboratory as soon as possible, because the fresh specimen provides the most accurate results. • Dispose the bedpan’s content and give proper care of all equipments used. 5. Documentation and report.
C. Collecting Urine Specimen. Types of Urine Specimen Collection yy Clean voided urine specimen. (Also called clean catch or mid-stream urine specimen) yy Sterile urine specimen yy Timed urine specimen – Short period Long period Purpose
1-2 hrs or 24 hrs
yy For diagnostic Purposes yy Routine laboratory Analysis and culture and sensitivity tests. Equipment required yy Disposable Gloves yy Specimen Container yy Laboratory requisition form (completely filled) yy Water and soap or cotton balls and antiseptic solutions (swabs) yy For patients confined to bed Urine receptacles (i.e. bedpans or urinals).Bed protecting materials and screen to provide privacy. Procedure yy For Ambulatory Patients Give adequate instructions to the patient about ÔÔ The purpose and method of taking the specimen ÔÔ Assist the patient to move to the toilet. yy For patient’s confined to bed ÔÔ Prepare the patient unit providing privacy ÔÔ Prepare the patient ÔÔ Put on gloves ÔÔ Place bed protecting material under patient’s hips ÔÔ Assist the patient to position in bed and in positioning the receptacle. ÔÔ Assist the patient to clean the vulva or penis thoroughly using soap and water or antiseptic swabs (follow the steps of giving and receiving bedpan / urinal and clean the genitalia. ÔÔ Obtain Urine Specimen ÔÔ Ask patient to void ÔÔ Let the initial part of the voiding passed into the receptacle (bedpan or urinal) then pass the next part (mid stream) into the specimen container. ÔÔ Do not allow the container to touch body parts ÔÔ Collect about 30-60 ml of midstream urine. Page : 29
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ÔÔ ÔÔ ÔÔ ÔÔ ÔÔ ÔÔ ÔÔ ÔÔ ÔÔ ÔÔ ÔÔ ÔÔ ÔÔ
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Handle the outside parts of the container and put on the cover tightly on specimen container. Clean the outer parts of the container with cotton if any spillage occurs Remove the gloves Place the patient in a comfortable position Take care of the specimen and the equipment. Handle and label the container correctly. Send the urine specimen to the laboratory immediately together with the completed laboratory requisition form Empty the receptacles content properly Give appropriate care for the used equipments. Document pertinent data and report, such as Specimen collected, amount time and date Consistency of the urine Patient’s experience during voiding (did he have any pain or burning sensation while voiding).
Collecting a Sterile Urine Specimen Sterile urine specimen collected using a catheter in aseptic technique.
Collecting a timed urine specimen Purpose yy For some tests of renal functions and urine compositions, such as: - measuring the level of hormones, such as adrenocortico steroid hormone creatinine clearance or protein quantitation tests. Equipment required yy Urine specimen collecting materials (usually obtained from the laboratory and kept in the patient’s bathroom. yy Format for recording the time, date started and end, and the amount of urine collected on each patient’s voiding during the specified period for collection. Procedure
1. Patient Preparation ÔÔ ÔÔ ÔÔ ÔÔ
Adequate explanation to the patient about the purpose of the test, when it begins and what to do with the urine. Place alert signs about the specimen collection at the patient’s bedside or bathroom. Label the specimen container to include date and time of each voiding as well as patient’s identification data. Containers may be numbered sequentially (e.g. 1st, 2nd, 3rd etc) in case of 24 hrs urine collection.
2. Collecting the urine Usually it begins in the morning. ÔÔ Before you begin the timing, the patient should void and do not use this urine (It is the urine that has been lying in the bladder for some time). ÔÔ Then all urine voided during the specified time (e.g. the next 24 hrs) is collected in the container. ÔÔ At the end of the time(e.g. 24 hrs period) the patient should void the last specimen, which is added to the rest. ÔÔ Ensure that urine is free from feces.
D. Collecting Sputum Specimen Sputum is the mucus secretion from the lungs, bronchi, and trachea, but it is different from saliva. The best time for sputum specimen collection is in the mornings up on the patient’s awaking (that have been accumulated during the night). If the patient fails to cough out, the nurse can obtain sputum specimen by aspirating pharyngeal secretions using suction. Purpose Sputum specimen is usually collected for: yy Culture and sensitivity test (i.e. to identify the microorganisms and sensitive drugs for it) yy Cytological examination yy Acid fast bacillus (AFB) tests yy Assess the effectiveness of the therapy. Equipment required yy Disposable Gloves yy Specimen Container
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yy Laboratory requisition form yy Mouth Care (wash) tray. Procedure 1. Patient Preparation Before collecting the sputum specimen, teach the patient about the difference between sputum and saliva, how to cough deeply to raise sputum ÔÔ Position then patient, usually sitting up position may help. Also postural drainage can be used. ÔÔ Give oral care to avoid sputum contamination with microorganisms of the mouth. Avoid using tooth paste because it alters the result. 2. Obtain Sputum Specimen. ÔÔ Put on gloves, to avoid contact with sputum particularly if haemoptysis (blood is present) in the sputum. ÔÔ Ask the patient to cough out deeply to raise up sputum ÔÔ Take usually 15-30 ml sputum. ÔÔ Ask the patient to spit out the sputum into the specimen container. ÔÔ Make sure it does not contaminate the outer part of the container. If contaminated clean (wash) with disinfectant. ÔÔ Cover the cap tightly on the container. 3. Place the patient in a comfortable position. ÔÔ Give oral care following sputum collection (to remove any unpleasant taste) 4. Care of the specimen and the equipment used ÔÔ Label the specimen container ÔÔ Arrange or send the specimen promptly and immediately to the laboratory. ÔÔ Give proper care of equipments used. 5. Document the amount, color, consistency of sputum, (thick, watery, tenacious) and presence of blood in the sputum.
E. Collecting Blood Specimens The hospital laboratory technicians obtain most routine blood specimens. Venous blood is drawn for most tests, but arterial blood is drawn for blood gas measurements. However, in some setting nurses draw venous blood samples. Purpose Specimen of venous blood are taken for complete blood count, which includes yy Hemoglobin and Hemotocrit measurements. yy Erythrocytes (RBC) count yy Leukocytes (WBC) yy Differential counts Equipment yy Sterile Gloves yy Tourniquet yy Antiseptic swabs yy Dry cotton /(gauze) yy Needle and Syringe yy Specimen container with the required diluting or preservative agents, for example anticoagulant. yy Identification/ labeling: name, age, address, etc. yy Laboratory requisition form. Procedure 1. Patient preparation ÔÔ Instruct the patient what to expect and for fasting (if required ) ÔÔ Position the patient comfortably. 2. Select and prepare the vein sites to be punctured. yy Put on gloves yy Select the vein to be punctured. Usually the large superficial veins are used such as, brachial and median cubital veins yy Place the vein in dependant position.
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yy Apply tourniquet firmly 15-20 cm above the selected site. It must be tight enough to obstruct vein blood flow, but not to occlude arterial blood flow. yy If the vein is not sufficiently dilated massage the vein from the distal towards the site or encourage the patient to clench and unclench his fist repeatedly. yy Clean the puncture site using antiseptic swabs. 3. Take specimens of venous blood ÔÔ Adjust the syringes and needles ÔÔ Clean and disinfect the area with alcohol swab, dry with sterile cotton swab ÔÔ Puncture the vein sites ÔÔ Release the tourniquet when you are sure to be in the vein. ÔÔ Withdraw the required amount of venous blood for the tests. ÔÔ Withdraw the needle and hold the sites with dry cotton (to apply pressure) ÔÔ Put the blood into the specimen container ÔÔ Make sure not to contaminate outer part of the container and not to destroy the blood cells while putting it into the container. 4. Place the patient in a comfortable position 5. Care of the specimens and the equipment ÔÔ Label the container ÔÔ Shake gently (if indicated to mix) ÔÔ Send immediately to laboratory along with the request ÔÔ Take proper care of all used equipments 6. Documentation and reporting. Observation and Recording of Signs and Symptoms of the patient. 1. Objective symptoms (signs) ÔÔ Are symptoms, which could be seen by the health personnel ÔÔ E.G. swelling, redness, rash, body discharges (defecation, diaphoresis, emesis.) 2. Subjective symptoms: ÔÔ Are symptoms, which are felt by the patient? ÔÔ E.g. decrease of appetite, dizziness, deafness, burning sensation, nausea, etc. 3. Chart
Definition: It is a written record of history, examination, tests, diagnosis, and prognosis response to therapy. Purpose of patients chart. a) For diagnosis or treatment of a patient while in the hospital (find after discharge) if patient returns for treatment to the hospital. b) For maintaining accurate data on matters demanded by courts. c) For providing material for Audit and research. d) For serving an information in the education of health personnel (medical students, interns, nurses, dietitians, etc.) e) For securing needed vital statistics. f) For promoting public health.
General Rules for Charting. yy Spelling: make certain you spell correctly. yy Accuracy: Records must be correct in all ways, be honest. yy Completeness: No omission, avoid unnecessary words or statements. yy Exactness: Do not use a word you are not sure off. yy Objective information: Record what you see avoid saying (condition better). yy Legibility: Write plainly and distinctly as possible. yy Neatness: No wrinkles, proper speaking of items, place all abbreviations, and at the end of the statement. yy Composition: / arrangement, chart carefully consult if in doubt avoid using of chemical formulas. yy Sentences: need to be complete and clear, avoid repetition. yy Don’t overwrite or use a whitener. If wrong neatly score it out legibly and write again. yy Record time of charting: specific time and date. Page : 32
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yy Color of ink: Black or blue (red for blood transfusion, days of surgery.) It should be recorded on a graphic sheet. yy All orders should be written and signed. Verbal or Telephonic orders should be taken only in emergency, verbal orders should be written in the order sheet and signed on the next visit.
Orders of Assembling Patient’s Chart a. History sheet b. Personal and social data c. Order sheet d. Doctor’s progress notes e. Nurses notes f. Vital sign sheet (graphic) g. Intake output recording sheet h. Laboratory and other diagnostic reports Patients or relatives and friends of patients are not allowed to read the chart when necessary, but can have access if allowed by the treating doctor. 4. Intake and Output a. Intake: all fluids that are taken into the body through the mouth, Naso- gastric tube or parentrally. b. Output: all fluids that are excreted or put out of the body through the mouth. Naso-gastric tube, urethra, drainage tubes or other routes (Gastro intestinal tract – diarrhea, vomiting). Purpose: To replace fluid losses & to check for retention of body fluid yy Fluid balance sheet yy 24 hrs the intake output should be compared and the balance is recorded. yy Positive balance if intake > output, yy Negative balance if output > intake.
Study questions 1. Explain any three reasons for laboratory examination of urine. 2. Explain one reason for collecting specimens like sputum, blood and stool. 3. Mention purposes for sputum specimen collection. 4. Decsribe the process how to draw venous blood for laboratory investigation. 5. How can you obtain sterile urine specimen? 6. Explain the correct collection of the following urine specimens: midstream, 24 hrs urine sample. 6. Differentiate between signs and symptoms
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IV) BED MAKING Nursing is a profession that requires extensive training in patient care and procedures. One of these tasks is learning how to make a bed properly, especially since beds are such an integral part of the patient’s world while staying in the hospital.
The routine to change an unoccupied bed is efficient and thorough, due to the volume of beds that need changing. Patients need to be nursed in bed to make them comfortable. The nurse will also be comfortable without straining on her back. Hospital beds patients positions can easily be changed with minimal disturbances to him. Some patients may require an absorbent pad near the center of the bed. In that case, a smaller sheet called a draw sheet covers it and gets tucked in place.
MAKING BEDS Nurses need to be able to prepare hospital beds in different ways for specific purposes. The bed is occupied or unoccupied, or the purpose for which the bed is being prepared, certain practice guidelines pertain to all bed-making.
MAKING BEDS
Reasons for bed making ÁÁ ÁÁ ÁÁ ÁÁ
To keep the ward neat and tidy. For patients comfort. To prevent cross infection. For treatment of certain conditions. Page : 34
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Types of Bed Making
General Guidelines for Bed Making ÁÁ Wash hands thoroughly after handling a client’s bed linen. ÁÁ Linens and equipment that have been soiled with secretions and excretions harbor microorganisms that can be transmitted to others directly or by the nurse’s hands or uniform. ÁÁ Hold soiled linen away from uniform. ÁÁ Linen for one client is never (even momentarily) placed on another client’s bed. ÁÁ Place soiled linen directly in a portable linen hamper or tucked into a pillow case at the end of the bed before it is gathered up for disposal. ÁÁ Do not shake soiled linen in the air because shaking can disseminate secretions and excretions and the microorganisms they contain. ÁÁ When stripping and making a bed, conserve time and energy by stripping and making up one side as much as possible before working on the other side. To avoid unnecessary trips to the linen supply area, gather all linen before starting to strip a bed. 1. Closed bed : Is a smooth, comfortable and clean bed, which is prepared for a new patient. In a closed bed: the top sheet, blanket and bed spread are drawn up to the top of the bed and tucked under the pillows. 2. Open bed : Is one which is made for an ambulatory patient are made in the same way but the top covers of an open bed are folded back to make it easier for the patient to get in. 3. Anesthetic bed : Is a bed prepared for a patient recovering from anesthesia. Purpose to facilitate easy transfer of the patient from stretcher to bed. 4. Postoperative (post op) or surgical bed, used when clients have left for the operating room or procedural area, is left with the top sheets fan folded lengthwise and not tucked in to facilitate the client’s return to bed. 5. Occupied bed, is a bed prepared for a weak patient who is unable to get out of bed. It provides comfort and facilitates movement of the patient in bed. 6. Amputation bed, is a regular bed with bed cradles and sand bags. Purpose to lift the weight of the bed clothes off the affected part an Purpose d allow easy observation of the amputated part. 7. Fracture bed, A regular bed with hard board support under the mattress. Purpose: to provide a firm unyielding support to the fractured part. 8. Cardiac bed, a special bed prepared for a heart patient extra items a cardiac table and extra pillows purpose to ease difficulty in breathing. 1- Check the activity orders, and assesses the client’s ability to get out of bed. Rationale: This determines whether an unoccupied or occupied bed should be made. 2-Assess the client’s self-toileting ability; note the presence of any wounds, drainage tubes. Rationale: This determines if placement of waterproof pads should be on the bed.
PLANNING Expected outcomes focus on the client’s safety and comfort. 1-Client has a clean, safe environment throughout hos¬pitalization. 2-Client verbalizes a sense of comfort while in bed. 3-Client’s skin remains free of irritation throughout hospitalization. Equipment yy Linen bag, matters (change only when soiled) , bottom sheet (flat or fitted), draw sheet (optional), top sheet, blanket, bedspread, waterproof pads (optional), pillow¬cases, bedside chair or table, disposable gloves (if linen is soiled),
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washcloth, and antiseptic cleanser.
STEPS: 1. Determine if client has been incontinent or if excess drainage is on linen. Gloves will be necessary. 2. Assess activity orders or restrictions in mobility in planning if client can get out of bed for procedure. Assist to bedside chair or recliner. 3. Lower side rails on both sides of bed, and raise bed to comfortable working position. 4. Remove solid linen, and place in laundry bag. Avoid shaking or fanning linen. 5. Reposition mattress, and wipe off any moisture using a washcloth moistened in antiseptic solution. Dry thoroughly. 6. Apply all bottom linen on one side of bed before moving to opposite side. 7. Be sure fitted sheet is placed smoothly over mattress. To apply a flat unfitted sheet, allow about 25 cm (10 inches) to hang over mattress edge. Lower hem of sheet should lie seam down, even with bottom edge of mattress. 8. Pull remaining top portion of sheet over top edge of mattress. 9. While standing at head of bed, miter top corner of bottom sheet. 10. Tuck remaining portion of unfitted sheet under mattress. 11. Optional: Apply draw sheet, laying center fold along middle of bed lengthwise. Smooth draw sheet over mattress, and tuck excess edge under mattress, keeping palms down. 12. While standing at head of bed, miter top corner of bottom sheet. 13. Move to opposite side of bed, and spread bottom sheet smoothly over edge of mattress from head to foot of bed. 14. Apply fitted sheet smoothly over each mattress corner. 15. For an unfitted sheet, miter top corner of bottom sheet (see Step 8), making sure corner is taunt. 16. Grasp remaining edge of unfitted bottom sheet, and tuck tightly under mattress while moving from head to foot of bed.
17. Smooth folded draw sheet over bottom sheet, and tuck under mattress, first at middle, then at top, and then at bottom. 18. If needed, apply waterproof pad over bottom sheet or draw sheet. If needed, apply waterproof pad over bottom sheet or draw sheet. 19. Place top sheet over bed with vertical center fold length¬wise down middle of bed. Open sheet out from head to foot, being sure top edge of sheet is even with top edge of mattress 20. Make horizontal toe pleat; stand at foot of bed and fan fold in sheet 5 to 10cm (2 to 4 inches) across bed. Pull sheet up from bottom to make fold, approximately 15 cm (6 inches) from bottom edge of mattress. 21. Tuck in remaining portion of sheet under foot of mat¬tress. Then place blanket over bed with top edge paral¬lel to top edge of sheet and 15 to 20 cm (6 to 8 inches) down from edge of sheet. 22. Make cuff by turning edge of top sheet down over top edge of blanket and spread. 23. Standing on one side at foot of bed, lift mattress corner slightly with one hand, and with other hand tuck top sheet, blanket, and spread under mattress. Be sure toe pleats are not pulled out.
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24. Make modified mitered corner with top sheet, blanket, and spread. After triangular fold is made, do not tuck tip of triangle (see illustration). 25. Go to other side of bed. Spread sheet, blanket, and spread over evenly. Make cuff with top sheet and blanket. Make modified corner at foot of bed. 26. Apply clean pillowcase. 27. Place call light within client’s reach on bed rail or pillow, and return bed to height allowing for client transfer. Assist client to bed. 28. Arrange client’s room. Remove and discard supplies. Perform hand hygiene.
Modified Mitered Corner with top Sheet
COMMUNICATION TIP yy Use an organized approach and reassuring tone of voice so the client feels safe and comfortable during bed-making. ÔÔ Encourage the client to report any discomfort or special requests while the bed is being made. ÔÔ When making an occupied bed, ask the client to assist as able and to report any discomfort or the need to rest. ÔÔ Interact throughout the entire procedure, even if client is not responsive.
SURGICAL BED BEDMAKING Steps Postoperative (post op) or surgical bed. Begin with clean unoccupied bed. Rational: Facilitates transfer of postoperative client from stretcher to bed. A-Fold all top linen from foot of bed toward center of mattress. Linen fold should be flush with bottom edge of mattress. B. Fold top linen that is hanging down over sides of bed toward center of mattress. Face one side of bed and fold nearest bottom corner back and over toward opposite side of bed, forming a triangle. Repeat for top corner (see illustration).
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C. Grasp apex of triangle and fanfold top linen over to far side of bed. D. Leave bed in high position with side rails down. E. Bed height matches height of stretcher and facilitates client transfer.
Occupied Bed Making: 1. Raise entire bed to comfortable working height. Lower head of bed, if tolerated by client. Lower side rail on nurseâ&#x20AC;&#x2122;s side; leave far side rail up. 2. It is easier to apply wrinkle-free, tight linen if bed is in the flat position. 3. Loosen all top linen. Remove spread and blanket, leaving client covered with top sheet or bath blanket. 4. Fold spread and blanket in quarters, and place over bottom of bed or on back of chair if they are clean and are to be reused. Note: Gloves are worn to remove linen only if it is soiled with body secretions. 5. Assist client to a side-lying position on far side of bed. Slide pillow over so it remains under clientâ&#x20AC;&#x2122;s head. Check that any tubing is not being pulled. 6. Provide privacy and warmth.
Bed Making
7. Roll bottom sheet, draw sheet, and any pads as far as possible toward client. Clean and dry the mattress if necessary. 8. Place clean bottom sheet on bed with seam side down. (1) Bottom sheets may be fitted. (2) If flat, center sheet on bed and pull bottom hem to foot end of mattress. Open sheet toward client. 9. Unfold flat bottom sheet lengthwise to cover mattress. Tuck top of sheet under head end of mattress. 10. Miter top corner of a flat bottom sheet, and tuck in side of sheet under mattress. Page : 38
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11. Place folded draw sheet and/or waterproof pads on center of bed with seam side down. Fan fold toward client. It provides additional protection to bed linen. 12. Cover unoccupied portion of bed with half the material, tucking draw sheet under mattress. Place remaining materials as close to client as possible. Keep clean linen and soiled linen separate. 13. Place waterproof pads with absorbent side up and plastic side down. Some pads go under cloth draw sheet. Newer, larger absorbent pads go on top of draw sheet or replace it (check agency policy). Waterproof absorbent pads protect bedding and keep moisture away from client’s skin. 14. Assist client with logrolling over all linen and facing you. Keep client covered with top sheet or bath blanket. Raise side rail on the side client is facing. Go to other side of bed, and lower side rail. 15. Remove soiled linens. Hold them away from uniform. Place on chair seat or in disposable bag or hamper if it is close by. Do not leave client alone with side rail down, even for a moment. Remove gloves if worn, and dispose of them properly. 16. Gently slide clean linen toward you, and straighten the clean linen out. Avoid friction of linen being pulled across skin. 17. Miter the top corner of bottom sheet as before. 18. Grasp side of flat bottom sheet tightly. Keeping it taut, tuck it under mattress. Proceed from head to foot. 19. Repeat by tucking draw sheet, proceeding from middle to top to bottom. 20. Straighten out waterproof pads that are on top of draw sheet. 21. Assist client into a supine position 22. Place a clean top sheet, blanket, and spread over client, leaving several inches of sheet at top to be folded down. 23. With client grasping clean top linens, slide out used top sheet or bath blanket. Cuff top sheet over blanket and spread. Prevent exposure of client. Give a neat appearance to bed and keeps client’s face off blanket.
24. Make a modified miter corner with linens at foot of bed. Miter the corner as before, but do not tuck in lower edge of triangle. 25. Loosen linen at client’s feet to client’s comfort 26. Allow for movement of client’s feet, prevents top linen from forcing feet into plantar flexion, and prevents pressure ulcers from developing 27. Supporting client’s head remove pillow and change pillowcase
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EVALUATION ÔÔ Observe client’s linens for cleanliness and tightness. ÔÔ Ask if client is comfortable after bed is made. ÔÔ Observe client’s skin for signs of irritation. Unexpected Outcomes and Related Interventions Client is not comfortable in bed. ÁÁ Check that linens are clean and dry. Tighten them. ÁÁ Assist client with changing position in bed. ÁÁ Client’s skin appears red and irritated. ÁÁ Reposition client frequently. Consider use of pressure-relieving mattress. ÁÁ Keep client’s bedding clean and dry. ÁÁ Bed making is the techniques of making different types of bed. Before bed making the nurse should observe certain rules. Lastly the nurse should know the reasons for making the patient’s bed. ÁÁ Recording and Reporting: Bed making is usually not documented. Some agencies require the nurse to check off this activity on a flow sheet.
Questions for weekly test 1.
How many types of bed making do you know?
2.
What is the function of a bed cradle?
3.
Which types of beds are usually prepared for newly admitted patients?
4.
What is the difference between open and closed bed?
5.
Define occupied bed.
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v) Personal Hygiene and Skin Care A. Mouth Care Purpose yy To remove food particles from around and between the teeth. yy To remove dental plaque to prevent dental caries. yy To improve appetite. yy To enhance the client’s feelings of well being. yy To prevent sores and infections of the oral tissue. yy To prevent bad smell (odor) or halitosis. Equipments yy Toothbrush (use the patient’s private item) if not available use gauze pieces and plain water. yy Tooth paste (use patient’s private item) if not available use soda bi carb and plain water. yy A mug with water yy Kidney tray or emesis basin yy Towel yy A gallipot or bowl to hold dentures if required. yy An Artery forceps, dissecting forceps yy Glycerine or Vaseline if required yy Used swab container. Procedure 1. Prepare the patient: ÔÔ Explain the procedure and gain his confidence ÔÔ Assist the patient to a sitting position in bed (if the health condition permits). If not assist the patient to lie on one side with the head on a pillow. ÔÔ Place the towel under the patient’s chin. ÔÔ Wet the patient’s mouth with a little water. 2. Brush the teeth ÔÔ Moisten the toothbrush with water and spread a small amount of paste on it. ÔÔ Brush the teeth following the appropriate technique of brushing. ÔÔ Hold the brush against the teeth with the bristles at up degree angle. ÔÔ Use a small vibrating circular motion with the bristles at the junction of the teeth and gums use the same action on the front and back of the teeth. ÔÔ Use back and forth motion over the biting surface of the teeth. ÔÔ Brush the tongue last. 1. Give the patient water to rinse the mouth and let him / her to spit the water into the kidney tray or emesis basin. ÔÔ Assist the patient to wipe his / her mouth. 2. Place the patient in a comfortable position. ÔÔ Remove all articles used for mouth wash from the patient’s unit. Document and report abnormal findings.
Mouth wash solutions 1. Normal saline: a solution of common salt with water in proportion of 4gm/500cc of water. 2. Hydrogen per-oxide.5-20 cc (in water) 3. KMNO4 – in crystal form 4. CC or KMNO4 solution in a glass of water (1:700) or one small crystal in a glass of water 4. Soda-bi-carb solution: 4 gm of soda in 1 pint of water. 5. Lemon juice: 2 Tsp full of lemon juice in a cup of water- an improvised method for mouth wash. Note : If the patient has denture, remove them before starting and wash them with the brush.
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Mouth care for unconscious patient Position yy Place the patient in the left or right lateral position with the head turned to one side, the saliva automatically runs out of the mouth by gravity rather than being aspirated by the lungs or it can be sucked out. yy Rinse the patient’s mouth by drawing about 10ml of water or mouthwash solution into the syringe and injecting it gently in to each side of the mouth. yy If injected with force, some of it may flow down the client’s throat and be aspirated into the lungs. yy All the rinse solution should return; if not suction the fluid to prevent aspiration.
Giving and Receiving Bedpans and Urinals yy Bedpan is a vessel used to receive urine and feces in females and feces in male. yy Urinal – is used to receive urine. There are two types of urinals male and female
Types of Bedpans 1. The high back, or regular pan (standard pan) 2. The slipper or low back pan.
Advantage yy Has a thinner rim than a standard Bedpan yy Is designed to be easily placed under a person’s buttocks. yy Are useful for people who are – yy Paralyzed or who cannot be turned safely e.g. Spinal injury. yy Confined to bed with a plaster cast. yy Immobilized by traction in some cases of fractures yy Very thin emaciated patients. yy Disadvantage yy Easier to spill the contents of the slipper pan
3. Pediatrics bedpan yy Are small sized and usually made of plastic.
B. Bath (Bathing and Skin Care) It is a bath or wash given to a patient in the bed, who is unable to care for himself / herself. It should be 43-460c (110-1150f) 1. Cleansing Bath: It is given chiefly for cleansing or hygiene purposes and includes: ÔÔ Complete bed bath: the nurse washes the entire body of a dependent patient in bed. ÔÔ Self help bed bath: client’s confined to bed are able to bathe themselves with help from the nurse for washing the back and areas they are notable to attend to. ÔÔ Tub bath: Used for therapeutic baths ÔÔ Shower bath: Many ambulatory patients are able to use the shower. ÔÔ The water should be comfortably warm for the patient. ÔÔ People vary in their sensitivity to heat generally it should be 43-460c (110-1150f) ÔÔ The water for a bed bath should be changed at least once.
Before bathing the patient determine a) The type of bath the patient needs b) What assistance the patient needs c) Other care the patient is receiving – to prevent fatigue d) The bed linen required, and patient’s fresh linen. Note: when bathing a client with infection, the care giver should wear gloves in the presence of body fluids or open lesions.
Principles yy Explain the procedure to the patient. yy Close doors and windows: air current increases loss of heat from the body by convection. yy Provide privacy: Hygiene is a personal matter and the patient will be more comfortable. Page : 42
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yy Help the patient to void before bathing as he will feel more comfortable. yy Place the bed in a high Position: avoids undue strain on the nurses back. yy Assist the client to move near you – facilitates access which avoids undue reaching and straining. yy Roll the wash cloth or sponge cloth around your fist as this retains water and heat better than a cloth loosely held. yy Clean the eye from the inner canthus to the outer using separate corners of the wash cloth – prevents transmitting microorganisms, prevents secretions from entering the naso lacrmal duct. yy Firm strokes from distal to proximal parts of the extremities increases venous blood return.
Purpose of a bath: yy To remove transient moist, body secretions and excretions, and dead skin cell. yy To stimulate circulation yy To produce a sense of well being. yy To promote relaxation, comfort and cleanliness. yy To prevent or eliminate unpleasant body odors. yy To give an opportunity for the nurse to assess ill clients. yy To prevent pressure sores. Two types of bath given to patients yy Cleansing. yy Therapeutic.
C. Bed bath. Equipment yy A trolley with two basins or two buckets yy Bed protecting material like rubber sheets and towels. yy Bath blanket or use top linen yy Two bath towels yy Wash cloths yy Clean linen for patient to use after bath. yy A fresh set of bed linen. yy A hamper for soiled linen and cloths yy Basin with warm water (43-460c for adults and 38-400c for children). yy Soap on a soap dish yy Hygienic supplies, such as lotion, powder or deodorants (if required) yy Screen yy Disposable gloves yy Lotion thermometer if available. Procedure 1. Prepare the patient unit ÔÔ Close windows and doors, use screen to provide privacy. 2. Prepare the patient and the bed ÔÔ Explain the procedure to the patient. ÔÔ Place the bed in a high position to reduce undue strain on the nurses back ÔÔ Remove patient’s gown and pajamas ÔÔ Assist patient to move towards you so it facilitates access to reach patient without undue straining. Position the patient in supine, semi-fowler or fowler’s position depending on the patient’s condition. ÔÔ Check the temperature of the water using a lotion thermometer or the back of the hand. 3. Make a pad with the wash cloth, so it retains heat and water than a cloth loosely held. 4. Washing body parts unnecessary exposing. ÔÔ Expose only the parts of the patients body being washed avoid unnecessary exposing. ÔÔ Wash, rinse and dry each body parts thoroughly using washing towels and paying particular attention to skin folds. Page : 43
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ÔÔ Suggested order for washing body parts; Face, ear, neck ÔÔ Arms and hands further away from the nurse ÔÔ Chest ÔÔ Arms and hands nearest to the nurse ÔÔ Buttocks and genital areas. ÔÔ Change the water after it gets dirty. ÔÔ If possible assist patient to wash own face, hands, feet, and genital areas by placing the basin on the bed. Assist the patient with grooming ÔÔ Apply powder, lotion or deodorants according to the patients wish. ÔÔ Help patient to care for hair, mouth and nails. 5. Place the patient in a comfortable position ÔÔ Change bed linen if soiled ÔÔ Arrange and tidy the bed ÔÔ Remove the screen ÔÔ Replace all articles used for the bath after proper cleaning to their respective place. ÔÔ Document and report any pertinent data ÔÔ Observation of the skin condition ÔÔ General appearance or reaction of the patient ÔÔ Type of bath given and report abnormal findings to nurse i/c
D. Therapeutic Baths yy Are usually ordered by the Physician or Nurse i/c yy Are given for physical effects, such as to soothe irritated skin or to treat an area (perineum) yy Medications may be placed in the water. yy It is generally taken in a tub1/3 or ½ full. yy The client remains in the tub for a desired time, often 20-30 min yy If the clients back, chest and arms are to be treated, immerse in the solution. yy The bath temperature is generally included in the order, 37.7-460c (100-1150f) for adults and 40-500c (1050f) for infants.
Bath Solutions 1. Saline: 4ml (1Tsp) NaCl to 500 ml of water ÔÔ Has a cooling effect ÔÔ Cleans ÔÔ Decreases skin irritation. 2. Potassium permanganate (Kmno4): available in tablets which are crushed, dissolved in a little water, and added to the bath water. ÔÔ It cleans and disinfects ÔÔ Treats infected skin areas ÔÔ Oatmeal and Cornstarch can also be used.
Tub Bath Typically, bathtubs are low in height to ease the process of getting in and out of the tub. Guide rails are essential. Be sure to assist the client as necessary. Equipment yy Bath blanket yy Bath mat yy Bath towel yy Soap yy Clean linen for the patients use yy Clean bed linen yy Bath thermometer if available yy Disinfectant for cleansing the tub.
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Procedure ÁÁ Check the bath room temperature, which should be warmer than the normal room temperature. ÁÁ Make sure that the tub is clean, Scour it carefully with disinfectant. Wear the gloves when cleansing the tub. ÁÁ Rinse the tub well ÁÁ Place a chair near the tub, with a bath blanket opened over it. ÁÁ Place towel, wash cloth and soap where the client can reach them easily. ÁÁ Fill the tub about halfway (less for children) ÁÁ Check the water with bath thermometer, if available or with the sensitive part of the skin. Water temperature should be warm to very warm but never over 40.60C ÁÁ Place a bathmat in front of the tub. ÁÁ Bring the client to the bathroom. Help the person to remove closing and, if necessary, to get into the tub. Show the client how to use the handrails. ÁÁ Explain to the client how to use the bath room call signals ÁÁ Check frequently, if the client needs assistance ÁÁ Do not leave a child or a client who is unsure, unsteady, or self injurious alone. ÁÁ When the client has finished bathing, help the client out of the tub and help to dry. After dressing assist the client back to the room. ÁÁ Inform the ground staff to carefully clean the tub after the bath. ÁÁ Dispose of the gloves and wash your hands. ÁÁ Document the procedure, describing any unusual client reactions
E. Back care: includes the area from the back and shoulder to the buttocks Purpose yy To relieve muscle tension yy To promote physical and mental relaxation yy To improve muscle and skin functioning yy To relieve insomnia yy To relax the patient yy To provide relief from pain yy To prevent pressure sores (decubitis ulcers) yy To enhance circulation. It allows the nurse to check the patient’s skin and look for red areas that may later develop into pressure sores or decubitis ulcers.
Clinical alert : yy Do not rub over reddened areas of the skin since rubbing skin can cause friction resulting in pressure sores formation. yy The best time to give a patient a back rub is after bath or before the patient goes to sleep. yy A lotion may be used to soften the skin during the massage. Alcohol or spirit is refreshing, but it is not recommended because it evaporates and dries up the skin. yy Talcum powder is used to rub the back and massage the pressure points. Equipment
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yy Basin of warm water yy Wash cloth yy Towel yy Soap & Skin care lotion. Procedure:
1. Prepare the patient and patient’s unit. yy Provide privacy by using screen or closing windows and doors. yy Assist the patient to move close to your working side. yy Explain the procedure to the patient and gain confidence. yy First wash your hands yy Position patient in the prone position ie. (Lying on the abdomen) if possible. If not due to the patient’s condition use side lying position with the patient facing away from you. yy Expose the back of the patient yy Spread the towel close to the patient’s back to prevent the bed from getting wet yy Wash the back with warm water and soap using the sponge cloth or wash cloth. Rinse and dry well.
2. Massaging the back yy Pour a little lotion (oil) onto your palms and rub them together to warm the lotion before massaging.
Technique for Backrub (Massage) yy Rub towards the neck line using long, firm, smooth strokes. yy Pause at the neckline, using your fingers to massage the side of the neck. yy With a kneading motion, rub out along the shoulders continue the kneading motion and move down on each side of the trunk with both hands until you are again at the sacral area. yy Then, placing your hands side by side with the palms down, rub in figure of 8 patterns over the buttocks and sacral area yy Massaging back using appropriate techniques (light pressure to smooth heavy pressure to stimulate. yy Next, again using the kneading motion, move up to the sides through the intrascapular space towards the shoulder. yy Complete the backrub using long, firm strokes up and down the back (shoulder to Sacrum and back to shoulder).
3. Place the patient in a comfortable position Mop extra lotion or oil from the patient’s back using a towel. ÔÔ Change the patient’s bed linen if required and tidy the bed.
4. Clean and replace all equipments used for the patient. 5. Document the procedure, your observations and patient’s reactions. Three types of massage strokes used in back care are 1. Effleurage or stroking the body 2. Light, circular friction and straight, dup,firm strokes 3. Petrissape: Kneading and making large quick pinches of the skin, tissue and muscle. yy Clean the back first yy Warm the massage oil or lotion before use by pouring over your hands: Cold lotion may startle the client and increase discomfort. 1. Effleurage the entire back: has a relaxing sedative effect if slow movement and light pressure are used. 2. Petrissape first up the Vertebral column and then over the entire back: is stimulating if done quickly with firm pressures. Report any abnormal observations on the skin of the patients back (such as signs of pressure sores) to the nurse and physician in charge of the case. Assessment: Signs of relaxation and / or decreased pain (relaxed breathing, decreased muscle tension, drowsiness, and a calm relaxed effect) yy The patient will tell you that his pain is gone and he is relaxed yy Areas of redness, broken skin, bruises, and other signs of skin breakdown.
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Note yy The duration of the massage ranges from 5-20 minutes. yy In the location of bony prominences direct pressure over these areas must be avoided. yy Frequent positioning is preferable to back massage as massaging the back could possibly lead to subcutaneous tissue degeneration especially in elderly clients.
F. Offering and removing Bedpans yy If the individual is weak or helpless, two people are needed to place and remove bedpans. yy If a person needs a bedpan for a longer time periodically replace the pan to ease pressure and prevent tissue damage. yy Metal bedpans should be warmed before use by: yy Running warm water inside the rim of the pan or over the pan. yy Covering with cloth. Semi-fowler’s position relieves strain on the client’s back and permits a more normal position for elimination. Improper placement of the bedpan can cause skin abrasion to the sacral area and spillage. yy Place a regular bedpan under the buttocks with the narrow end towards the foot of the bed and the buttocks resting on the smooth, rounded rim yy Place a slipper pan with the flat low end under the buttocks of the client. yy Covering the bedpan after use reduces offensive adors and the client’s embarrassment. If the client is unable to achieve regular defecation help by attending to: 1. The provision of privacy 2. Timing – do not ignore the urge to defecate ÔÔ A patient should be encouraged to defecate when the urge to defecate is recognized. ÔÔ The patient and the nurse can discuss when mass peristalsis normally occurs and provide time for defecation (the same time each day) 3. Nutrition and fluids ÔÔ For a constipated client: increase daily fluid intake, drink hot liquids and fruit juices etc. ÔÔ For a client with diarrhea - encourage oral intake of foods and fluids. ÔÔ For a client who has flatulence: limit carbonated beverages; avoid gas – forming foods. 4. Exercise ÔÔ sRegular exercise helps clients develop a regular defecation pattern and normal feces. 5. Positioning 6. Sitting position is preferred.
Measures to assist the patient to void include: yy Running water in the sink so that the client can hear it. yy Warming the bedpan before use. yy Pouring warm water over the perineum slowly yy Having the person assume a comfortable position by raising the head end of the bed.(men often prefer to stand) yy Providing sufficient analgesia for pain yy Having the patient blow through a straw into a glass of water – relaxes the urinary sphincter.
G. Perineal care (Genital care) Perineal Area: yy Is located between the thighs and extends from the symphysis pubis of the pelvic bone (anterior) to the anus (posterior). yy Contains sensitive anatomical structures related to sexuality, elimination and reproduction.
Perineal care (Hygiene) yy Is cleaning of the external genitalia and surrounding area. yy Always done in conjunction with general bathing. Patients in special need of perineal care yy Post partum and surgical patients (surgery of the perineal area)
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yy Non surgical patients who are unable to care for themselves yy Patients with catheter (particularly indwelling catheter) Other indications for perineal care are: 1. Genito – Urinary inflammation 2. Incontinence of urine and feces 3. Excessive secretions or concentrated urine, causing skin irritation or excoriation. Purpose yy To remove normal perineal secretions and odors yy To prevent infection (e.g. when an indwelling catheter is in place) yy To promote the patients comfort yy To facilitate wound healing process Equipments yy Bath towel, Gauze pieces or cotton swabs yy Warm water or prescribed solution in a container yy Gloves, Bedpan, Bed protecting material yy Perineal pad or dressing (if needed) Procedure 1. Patient preparation ÔÔ Give adequate explanation ÔÔ Provide privacy ÔÔ Fold the top bedding and take down the pajamas(to expose perineal area and drape using the top linen ÔÔ Position patient lying on back with knees flexed and spread apart ÔÔ Place bed protecting materials under the patient’s hip ÔÔ Place the bedpan under patients buttocks. Cleaning the genital area Put on gloves For female patients ÔÔ Remove dressing or pad used ÔÔ Inspect the perineal area for inflammation, excoriation, swelling or any discharge. In case of postpartum or surgical patients yy Clean by wet cotton swabs, first the labia majora then the skin folds between the majora and minora by retracting the majora using gauze pieces, clean from anterior to posterior direction using separate swab for each stroke. (This directions lessens the possibility of Urinary Tract Contamination) In case of non-surgical patients yy Wash and clean the genital area with wet cotton swabs in the same manner. Female Perineum yy Is made up of vulva (external genetalia), including the mons pubis, prepuce, clitoris, urethral and vaginal orifices, and labia majora and minora yy The skin of the vaginal orifice is normally moist yy The secretion has a slight odor due to the cells and normal vaginal florae yy The clitoris consists of erectile tissues and many nerve fibers. It is very sensitive to touch Care - Gloves to be worn yy Convenient for a woman to be on a bedpan to clean and rinse the vulva and perineum yy Secretion collects on the inner surface of the Labia yy Use hand to gently retract the Labia yy Use a separate cotton swab for each wipe in a downward motion (from urethra to back perineum) yy Then clean the rectal area.
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Note - Following genital and rectal surgery, sterile supplies may be needed for cleaning the operative site, e.g. sterile cotton balls yy The operative site and perineal area may be washed with an antiseptic solution – apply by squirting them on the perineum by squeezing a wet cotton swab. or a squeeze bottle. Male perineum yy The penis contains pathways for urination and ejaculation through the urethral orifice (meatus) yy At the end of the penis is the glans covered by a skin flap (foreskin or prepuce) yy The urethral orifice is located in the centre of the penis and opens at the tip. yy The shaft of the penis consists of erectile tissue bound by the foreskin’s dense fibrous tissue.
Care – Gloves to be worn yy Hold the shaft of the penis firmly with one hand and the gauze piece with the other – to prevent erection – embarrassment. yy Use a circular motion, cleaning from the center to the periphery yy Use a separate gauze piece every time Position Lying in bed with knees flexed to clean the perineal part and let the patient lie on one side to clean the perineal area. N.B The urethral orifice is the cleanest area and the anal orifice is the dirtiest area – always stroke from front to back to wash from clean to dirty parts. Note: Entry of organisms into the urethral orifice can cause UTI
H. Hair care Hair care usually done after the bath and as daily hygienic activities .Hair care includes combing (brushing of hair), washing shampooing of hair and pediculosis treatment. Combing and brushing of hair A patient’s hair should be combed and brushed daily. Most patients do these themselves if the required materials and others may need the nurse’s assistance. Purpose yy Stimulates the blood circulation to the scalp yy It increases the sense of well being. Equipment yy Comb, Hand mirror, Towel, hair oil if required. Procedure 1. Prepare the patient yy Position the patient in either sitting or semi-fowler’s position if the patient is weak or unconscious. yy Place the towel over the patient’s shoulder, if in sitting position or over the pillow if patient is in semi-fowler’s position or lying on one side. yy Remove any pins and ribbons 2. Comb the hair by dividing the hair. ÔÔ Hold a section of hair 2-3 inches from the end and comb the end until it is free from tangles. Move towards the scalp by combing in the same manner to remove tangles. ÔÔ Continue fluffing the hair outward and upward until all the hair is combed. ÔÔ Arrange the hair as neatly and simply as possible according to the patient’s preference of style. ÔÔ Remove the towel and place the patient in a comfortable position 3. Care of equipment 4. Documentation. Shampooing / washing the hair of a patient confined to bed. Purpose yy Stimulates blood circulation to the scalp through massaging yy Clean the patient’s hair so it increases a sense of wellbeing to the patient. yy To treat hair disorders like dandruff.
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Equipments yy Comb and brush, Shampoo / Soap in a soap dish yy Ubber sheet , bucket, two wash towels, two cotton balls yy Water in a bucket, a mug, a receptacle to collect the dirty water. yy Hair oil if required. Procedure 1. Prepare the patient ÔÔ Assist the patient to move to the right side of the bed ÔÔ Remove any hair accessories (e.g. pins, ribbons etc) ÔÔ Brush and comb the hair to remove tangles 2. Arrange the equipment ÔÔ Remove the pillows from under the patient’s head and place it under patient’s shoulder (to hyper extend the neck) ÔÔ Tuck the towel under the patient’s shoulder and neck ÔÔ Place the rubber sheet under the patient’s head and shoulders, make a funnel type fold and extend it to the receptacle which is near the bed. 3. Protect the patient’s eyes and ears ÔÔ Place damp wash cloth over the patient’s eyes to protect from soapy water. ÔÔ Place cotton balls in the patient’s ears to prevent water collecting in the ear canal. 4. Shampooing / washing the hair ÔÔ Apply shampoo (soap) to the scalp ÔÔ Massage all over the scalp symmetrically using your fingertips ÔÔ Rinse the hair with plain water to remove the shampoo / soap ÔÔ Remove damp washcloth from over patient’s eyes and cotton balls from ears. 5. Dry the patient’s hair ÔÔ Squeeze the hair with your hands to remove as much water as possible ÔÔ Rub patients hair with towel 6. Termination of procedure ÔÔ Place the patient in a comfortable position ÔÔ Remove all the equipment used for hair wash from the patients unit and place it in the utility room ÔÔ Assist the patient to comb her hair. 7. After care of the equipment 8. Documentation and reporting
I. Pediculosis Treatment : Definition: Pediculosis is infestation with head lice Purpose yy To prevent transmission of some arthropod born diseases yy To make patient comfortable Equipment yy Lindane yy 1% permethrine cream rinse yy Clean bed linen yy Fine tooth comb yy Disinfectant for comb yy Clean Gloves yy Towel Lice: The head louse is a tiny, wingless parasitic insect that lives among human hairs and feeds on extremely small amounts of blood drawn from the scalp. Although they may sound gross, lice (the plural of louse) are a very common problem, especially for kids ages 3 years to 12 years (girls more often than boys).
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Lice aren’t dangerous and they don’t spread disease, but they are contagious and can just be downright annoying. Their bites may cause a child’s scalp to become itchy and inflamed, and persistent scratching may lead to skin irritation and even infection. It’s wise to treat head lice quickly once the diagnosis is made because they can spread easily from person to person. Pediculosis is an infestation of the hairy parts of the body or clothing with the eggs, larvae or adults of lice. The crawling stages of this insect feed on human blood, which can result in severe itching. Head lice are usually located on the scalp, crab lice in the pubic area and body lice along seams of clothing. Body lice travel to the skin to feed and return back to the clothing. Medicated shampoos or cream rinses containing pyrethrins or permethrin are preferred for treating people with head lice. Products containing pyrethrins, permethrin or malathion are available over-the-counter, but those containing lindane or malathion are available only through a physician’s prescription. Lindane-based shampoos are not recommended for infants, young children, pregnant women, lactating women, the elderly, and persons with HIV or seizure disorders, persons who have very irritated skin or sores where the lidane will be applied and persons who weigh less than 110 pounds. Retreatment after 7 to 10 days is often recommended to ensure that no eggs have survived. Nit combs are available to help remove nits from hair. Dose and duration of shampoo treatment should be followed carefully according to label instructions.
Feeding a helpless patient During illness, trauma or wound healing, the body needs more nutrients than usual. However, many peoples, because of weakness, immobility and/or one or both upper extremities are unable to feed themselves; therefore the nurse must be knowledgeable, sensitive and skillful in carrying out feeding procedures. Purpose yy To be sure that the patient receives adequate nutrition yy To promote the patient wellbeing Procedure 1. Prepare the patients unit ÔÔ Remove all unsightly equipments; remove soiled linen and arrange the bedside locker. ÔÔ Ensure an odor free environment which makes eating more pleasant and aids digestion. 2. Prepare the patient ÔÔ Offer bedpans and urinals, to comfort the patient and avoid interruption by elimination needs. ÔÔ Assist the patient to wash hands, face and oral care. ÔÔ Position the patient comfortably Mid or high fowlers position ÔÔ Protect the bed using suitable protective cover 3. Prepare the food tray Identify the type of diet ordered ÔÔ Assess any special conditions in which the patient’s diet is to be delayed or omitted (e.g. Lab, radiological examination or surgery) 4. Feed the patient Place the food tray in such a way that the patient can see the food. ÔÔ Position yourself at patients eye level, if possible Digestion is better when the patient is not emotionally upset. yy Never hurry a patients eating. This could make the patient feel uncomfortable and fearful of taking up your time. yy Allow the patient to determine when enough has been eaten, as way of providing choices. 5. Place the patient in a comfortable position. Assist the patient to wash his hands and give oral care. ÔÔ Provide a quiet environment so that the patient can relax after his meal, which also promotes good digestion. 6. After care of the equipment 7. Document feeding and any assessment
Study questions: 1. Explain the purposes of bed bath, mouth care, and perineal care. 2. Describe therapeutic bath. 3. State the three types of strokes used in back care 4. Which position is appropriate to give perineal care in both sexes?
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VI) COLD AND HEAT APPLICATION Heat and cold are applied to the body for local and systemic effects. Heat Application Purpose 1. To relieve pain and muscle spasm – by relaxing muscles 2. To increase blood flow to the area 3. To relieve swelling 4. To relieve inflammation and congestion 5. To facilitate wound healing Heat yy Increases the action of phagocytic cells that ingest moisture and other foreign material. yy Increases the removal of waste products or infection metabolic process yy It relieves chilling and gives comfort. Heat can be applied in both dry and moist forms Dry Heat: - is applied locally, for heat conduction ÔÔ By means of a hot water bottle Moist Heat: - can be provided, through conduction ÔÔ By compression or sitz bath
Cold Application Purpose yy To relieve pain: cold decreases prostaglandin’s, which intensify the sensitivity of pain receptors and other substances at the site of injury by inhibiting the inflammatory processes. yy To reduce swelling and inflammation: by decreasing the blood flow to the area (vasoconstriction) yy Reduce raised body temperature due to fever Cold can be applied in moist (cold compress 18-270c) and dry form (ice pack (bag) ,150c) Systemic effects of cold – extensive cold applications can increase blood pressure. Systemic effects of Heat – produce a drop in blood pressure – excessive peripheral vasodilatation.
Tepid sponging Definition: Sponging of the skin with cool water. Purpose: 1. To lower body temperature (fever) 2. Tepid (lukewarm) water + alcohol 3. Parts water and 1 part alcohol The temperature of the water is 320c (below body temperature) 27-370c -alcohol evaporates at a low temperature and therefore removes body heat rapidly. yy Less frequently used because alcohol causes skin drying yy Heat loss is by conduction and vaporization yy Determine the patients temperature, PR and RR frequently every 15 min yy Sponge each area (part) for 2-3 min changing the sponge cloth yy The sponge bath should take about 30 min yy Reassess the vitals at the end yy Discontinue the bath if the client becomes pale, cyanotic or shivers, or if the PR becomes rapid or irregular. Temperature of Hot water bottle (bag) 520c for normal adults, 40.5-460c for children, 2 years; How to fill a hot water bag yy Fill the bag 2/3 full
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yy Expel the remaining air and secure the cap yy Maximum effect occurs in 20-30 min; The application is repeated every 15 min – 3 hrs to relieve swelling compress- moist gauze or cloth immersed in (hot or cold) water and applied over an area.
Local Application of Cold and Heat Application of Cold yy Has a systemic and local effect yy Can be applied to the body in 2 ways 1. Moist 2. Dry Hyperpyrexia or sun stroke yy To reduce body temperature during high fever and yy To relieve local pain yy To reduce subcutaneous bleeding e.g. in sprain and contusion yy To control bleeding e.g. epistaxis yy To relieve headache.
1. Moist Cold. yy Cold compress - A cloth is immersed in cold water and applied in area where we get large superficial vessels
E.g. axilla and groin. Change the cloth when it becomes warm. It should be applied for 15-20 min.
Dry Cold (Ice cap) yy Ice kept in a rubber cap yy Covered with a cloth and kept on an area yy Temperature ,150c
Application of heat Purpose yy To relieve stasis of blood yy To increase absorption of inflammatory products yy To relieve stiffness of muscle and muscle pain yy To relieve pain and swelling of a localized inflammatory boil or carbuncle – sometimes increases edema, increases capillary permeability yy To increase blood circulation yy To promote suppuration yy To relieve distention and congestion yy To provide warmth to the body.
Methods Dry Heat – By using Hot water bottles Temperature of Hot water bottle (bag) 520c for normal adults, 40.5-460c for children <2 years and debilitated or unconscious patient’s How to fill a hot water bag yy 2/3 of the bag should be filled with water. yy Expel the remaining air and secure the cap yy Dry the bag and hold it upside down to test for leakage yy Wrap it in a towel or cover it and place it on the body part yy Maximum effect occurs in 20-30 min; yy Remove after 30-45 minutes.
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Moist heat 1. Hot compress: a sponge cloth immersed in hot water of temperature 40-460c and change the site of the sponge cloth frequently. Complication Burns can occur in patients who are Paralyzed, having numbness, and loss of sensation. Sitz Bath It is used to soak the client’s pelvic area yy A client sits in a special tub or basin having medicated solution yy The area from the mid thighs to the iliac crests or umbilicus – is soaked in warm solution yy This helps to increase the blood circulation to the perineum. (When the legs are also immersed blood circulation to the perineum or pelvic area decreases.) yy The temperature of the water should be 40-430c (105-1100f) – unless the patient is unable to tolerate the temperature. Purpose yy To relieve pain in post operative rectal condition yy Facilitates wound healing (after episiotomy) yy To release the bladder in case of urinary retention Procedure yy Privacy to be maintained. yy If it is to be given in a basin fill 2/3 of it with warm water – add the ordered medication and dilute. yy Medication KMNO4 250 mg IN 500 ml of water yy Duration of the sitz bath is 15-20 min or 25-30 min depending on the client’s health. NB. Great care has to be taken to prevent heat/cold burns when applying heat or cold especially to elderly patients and children.
Study questions 1. Mention the two purposes of heat application 2. Describe the mechanism of action of heat application. 3. What is tepid sponging? 4. What is the common medication used in sitz bath? 5. What is the average duration of time for a sitz bath.
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VII) BODY MECHANICS AND MOBILITY Body Mechanics: is the effort; coordinated, and safe use of the body to produce motion and maintain balance during
activity
Proper body mechanics Use of the safest and most efficient methods of moving and lifting is called body mechanics .This means applying mechanical principles of movements to the human body. Basic Principles of Body Mechanics. The laws of physics govern all movements. From these laws we derive the principles of body mechanics.
Basic Principles 1. It is easier to pull, push, and roll an object than to lift it. The movement should be smooth and continuous, rather than jerky. 2. Often less energy or force is required to keep an object moving than it is to start and stop it. 3. It takes less effort to lift an object if the nurse works as close to it as possible. Use the strong leg and arm muscles as much as possible. Use back muscles, which are not as strong, as little as possible. Avoid reaching. 4. The nurse rocks backward or forward on the feet and with his / her body as a force for pulling or pushing. Principles under lying proper body mechanics involve three major factors: centre of gravity, base of support, and line of gravity.
Centre of gravity The person’s centre of gravity is located in the pelvic area. This means that approximately half the body weight is distributed above this area, half below it, when thinking of the body divided horizontally. In addition, half the body weight is to each side, when thinking the body is divided vertically. When lifting an object, bend at knees and hips, and keep the back straight. By doing so, the centre of gravity remains over the feet, giving extra stability. It is thus easier to maintain balance.
Base of Support A person’s feet provide the base of support. The wider the base of support, the more stable the object is within limits. The feet are spread sidewise when lifting, to give side to side stability. One foot is placed slightly in front of the other for back-to – front stability. The weight is distributed evenly between both feet. The knees are flexed slightly to absorb jolts. The feet are moved to turn the object being moved.
Line of Gravity Draw an imaginary Vertical (up and down) line through the top of the head, the centre of gravity, and the base of support. This becomes the line of gravity or the gravity plan. This is the direction of gravitational pull (from the top of the head to the feet). For highest efficiency, this line should be straight from the top of the head to the base of support, with equal weight on each side. Therefore, if a person stands with the back straight and the head erect, the line of gravity will be approximately through the centre of the body, and proper body mechanics will be in place. Body alignment
Body Alignment When lifting, walking, or performing any activity, proper body alignment is essential to maintain balance. When a person’s body is in correct alignment, all the muscles work together for the safest and most efficient movement, without muscle strain. Stretching the body as tall as possible produces proper alignment. This can be accomplished through proper posture. When standing, the weight is slightly forward and is supported on the outside part of the feet. Again the head is erect; the back is straight, and the abdomen is in (remember that the client in bed should be in approximately the same position as if he/she was standing).
Positioning the Client Encouraging client’s to move in bed, get out of bed, or walk serves several purposes. Prolonged immobility can cause a number of disorders, among which are pressure ulcers, constipation, and muscle weakness, pneumonia and joint deformities. By assisting clients to maintain or regain mobility, you promote self- care practices and help to prevent deformities.
Moving and Positioning Clients Moving and positioning promote comfort, restore body function, prevent deformities relieving pressure, prevent muscle strain, and stimulate proper respiration and circulation. Purpose: yy To increase muscle strength and social mobility yy To prevent potential problems of immobility yy To stimulate circulation
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yy To increase the patient’s sense of independence and self esteem. yy To assist a patient who is unable to move by himself yy To prevent Fatigue and injury yy To maintain good body alignment.
Practice guidelines
-Maintain functional client body alignment. (Alignment is similar whether the client is standing or lying in bed). -Maintain client safety -Reassure the client to promote comfort and cooperation. -Properly handle the client’s body to prevent pain or injury. -Follow proper body mechanics -Obtain assistance, if needed, to move heavy or immobile client’s -Follow specific physician’s orders -Do not use special devices (e.g. splints, traction unless ordered)
Turning the Patient to a Side- Lying Position Supplies and Equipment -Cotton blanket or towels, rolled for support. Procedure/Steps 1. Wash your hands 2. Explain the procedure to the Patient. 3. Adjust the bed to a comfortable height. 4. Lower the patient’s head to as flat a position as he /she can tolerate, and lower the side rail. 5. Move the patient to the far side of the bed. Raise the side rail. 6. Ask the patient to reach for the side rail. 7. Take a deep breath, tensing your abdominal and gluteal muscles, roll the patient towards you. 8. Position the patient’s legs comfortably a) Flex his/her lower knee and hip slightly b) Bring his /her lower upper leg forward and place a pillow between legs. 9. Adjust the patient’s arms a) Shift his/her lower shoulder towards you slightly b) Support his/her upper arm on a pillow 10. Wedge a pillow behind the patient’s back. Use rolled blankets or towels as needed for support 11. Lower the bed, elevate the head end of the bed or raise the head with the help of a pillow as the patient feels comfortable and raise the side rail. 12. Wash your hands.
Joint Mobility and Range of Motion Every joint in the body has a specific but limited opening and closing motion that is called its range of motion (ROM). The Limit of the joint’s range is between the points of resistance at which the joint will neither open nor close any further. Generally all people have a similar ROM for their major joints.
Passive Range of Movements If a client is unable to move, the nurse helps by performing passive range of motion (PROM) exercise. Performing Passive ROM Exercises / steps 1. Wash your hands. 2. Explain the procedure to the patient 3. Adjust the bed to a comfortable height. Select one side of the bed to begin PROM exercises. 4. Uncover only the limb to be exercised 5. Support all joints during exercise activity 6. Use slow, gentle movements when performing exercises. Repeat each exercise three times. Stop if the patient complains of pain or discomfort. 7. Begin exercise with the patient’s neck and work downwards. 8. Flex, extend and rotate the patient’s neck. Support his/her head with your hands. 9. Exercise the patient’s shoulder and elbow.
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a) Support the patient’s elbow with one hand and grasp the patient’s wrist with your other hand b) Raise the patient’s arm from the side to above the head. c) Perform internal rotation by moving the patient’s arm across his/her chest. d) Externally rotate the patient’s shoulder by moving the arm away from the patient.
e) Flex and extend the patient’s elbow. 10. Perform all exercises on the patient’s wrist and fingers. a) Flex and extend the wrist b) Abduct and adduct the wrist c) Rotate and pronate the wrist d) Flex and extend the patient’s fingers e) Abduct and adduct the fingers f) Rotate the thumb 11. Exercise the patient’s Hip and leg. a) Flex and extend the hip and knee while supporting the leg. b) Abduct and adduct the hip by moving the patient ‘s straightened leg toward you and then back to median position c) Perform internal and external rotation of the hip joint by turning the leg inward and then outward. 12. Perform exercises on ankle and foot. a) Dorsiflex and plantar flex the foot b) Abduct and adduct the toes c) Evert and invert the foot 13. Move to the other side of the bed and repeat exercise 14. Position and cover the patient. Return the bed to a low position. 15. Wash your hands 16. Document completion of PROM exercises.
Controlling Postural Hypotension yy Sleep with the head of the bed elevated (18-20 inches). This makes the person’s position change on rising less severe. yy Avoid sudden changes of position. Arise from bed in 3 steps. ÔÔ Sit on the side of the bed with the legs dangling for 1 minute. ÔÔ Stand straight holding onto the edge of the bed or another non mobile object for 1 minute ÔÔ Sit up in the bed for 1 minute. Gradual change in position stimulates rennin, kidney enzyme that has a role in regulating BP and which prevents a dramatic drop in BP. yy Balance is maintained with minimal effort when the base of support is enlarged in the direction in which the movement will occur. yy Contracting muscles before moving an object lessens the energy required to move it. yy The synchronized use of as many large muscles groups as possible during an activity increases overall strength and prevents muscle fatigue and injury. yy The closer the line of gravity to the centre of the base of support, the greater the stability. yy The greater the friction against the surface beneath an object the greater the force required moving the object. (pulling creates less friction than pushing) yy The heavier the object, the greater the force needed to move the object. yy Moving an object along a level surface required less energy than moving an object up an inclined surface or lifting it against gravity. yy Continuous muscle exertion can result in muscle stretching and injury.
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VIII) Body Positioning Placing the patient in various positions is done for diagnostic and therapeutic purposes. Some of the reasons include promoting comfort, restoring body function preventing deformities, relieving pressure, preventing muscle strain, restoring proper respiration and circulation and giving nursing treatment.
Guidelines for Positioning the Patient ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ ÁÁ
Maintain functional patient body alignment. (Alignment is similar whether the patient is standing or in bed). Maintain patient safety Reassure the patient to promote comfort and cooperation. Properly handle the patient’s body to prevent pain or injury. Follow proper body mechanics Obtain assistance, if needed to move heavy or immobile patient’s Follow specific orders Do not use special devices (e.g. Splints, traction) unless ordered for the patient’s positioning for examination and treatment.
Patient positioning for Examination and Treatment Horizontal Recumbent position This position is required for most of the physical examinations. The patient lies on the back with the legs extended. The arms are placed, folded on the chest, or alongside the body. One small pillow may be used. Cover the patient with bath blanket for privacy. Caution: This position may be uncomfortable for a person with a back problem.
Dorsal recumbent position Dorsal recumbent position - used for variety of examinations and procedures. The patient lies on the back, with the knees flexed and the soles of the feet flat on the bed.
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Cover the patient with a sheet or a bath blanket folded once across the chest. The second sheet should be cross wise- Over the patient thighs and legs. Wrap the lower ends of this sheet around the patient’s legs and feet. Fold the sheet so the genital area is easily exposed. Keep the patient covered as much as possible.
Prone position Prone Position: - is used to examine the spine and back. The patient lies on the abdomen with head turned to the side for comfort. The arms are held above the head or alongside the body. Cover the patient with a bath blanket for privacy. Caution: Unconscious patients, pregnant women, patients with abdominal incisions, and patients with breathing difficulties cannot lie in this position.
Sim’s position Sims’ Position: - This position is used for rectal examination. The patient rests on the left side, usually with a small pillow under the head. The right knee is flexed against the abdomen, the left knee is flexed slightly, the left arm is behind the body, and the right arm is in a comfortable position. Cover the patient with a bath blanket. Caution: The patient with leg injuries or arthritis often cannot assume this position.
Fowler’s position Fowler’s Position: - this position is used to promote drainage or to make breathing easier. Adjust the head rest to the desired height, and raise the bed section (Gatch bed) under the patient’s knees. Place a rolled pillow between the patient’s feet and use the foot of the bed as a brace, if desired. Caution: Observe for signs of dizziness or faintness when you raise the head of the bed.
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Knee –Chest position Knee-chest Position: - is used for rectal and vaginal examinations and as treatment to bring the uterus into normal position. The patient is on the knees with the chest resting on the bed and the elbow rested on the bed, or with the arms above the head, the patient’s head is turned to the side. The thighs are straight up and down, and the lower legs are flat on the bed. Caution: The patient may become dizzy or faint and fall. Do not leave the patient alone.
Lithotomy position Dorsal Lithotomy Position: - is used for examination of pelvic organs. It is similar to dorsal recumbent position, except that the patient’s legs are well separated and the knees are a cutely flexed. The nurse will usually place the patient’s feet in stirrups. Keep the client covered as much as possible for privacy. Helping a patient into a wheelchair or chair
Equipment yy Wheelchair yy Slippers or shoes (non-skid) Procedure 1. Wash your hands 2. Explain the procedure to the patient 3. Position the wheelchair next to the bed or at 450angle to the bed. Lock the wheel brakes and remove the footrests or move them to the “up” position. 4. Prepare to move the patient: a) Assist the patient to put on slippers b) Obtain help from another person if the patient is immobile, or too heavy. 5. Raise the head end of the bed so that the client is in the sitting position. 6. Assist the client to sit on the side of the bed a) Support the head and neck with one arm. b) Use your other arm to move the patient’s leg over the side of the bed. Page : 60
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c) Allow the patient’s feet to rest on the floor d) Maintain the patient in this position for a short time. 7. Prepare to raise the patient to a standing position a) Spread the patient’s feet and brace your knees against the patient’s knees b) Place your arms around the patient’s waist 8. Use the rocking motion of your legs to assist the patient to stand. The patient may use his/her hands to help push upward from the bed. 9. Support the patient into a position immediately in front of the wheelchair. Encourage the patient to use armrests for support while you lower him or her into chair. 10. Reposition foot rests; secure the patient in a chair. Cover the patient with a blanket. 11. Wash your hands 12. Check on the patient frequently 13. Document the transfer and the patient’s response.
Study questions
1. State the principle underlying proper body mechanics and relate a nursing consideration. 2. State the purposes of range of motion exercise. 3. Identify the principles related to safe movement of patients in and out of bed. 4. Demonstrate the ability to move a partially mobile patient safely from bed to chair and back. 5. Mention different positions used for various examinations and treatment.
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UNIT 4 NUTRITION AND METABOLISM 1. Fluid & Electrolyte balance Normal body function depends on a relatively constant volume of water and definite concentration of chemical compounds (electrolyte). Water – is the most important nutrient of life. 60-65% of the body weight is water and no physiology can function without it. Electrolyte – is a compound that dissociate In a solution to break up into separate electrically charged particles (ions) – cation, anions. Distribution of Body Water in Adult Body water is contained within two major physiological reservoirs (compartments) 1. Intracellular fluid about 40% of body weight (25 liter) 2. Extracellular fluid about 20% of body weight (20 liter) in which: a) 5 liter in intra vessel b) 15 liter interstissual – tissue space the space between blood and the cells. Apart from this the extra cellular fluid contains other fluids, which are usually negligible, considering their concentration in the body. These are CSF, Ocular fluid, Cynovial fluid, Pleural fluid, Pericardial and Peritoneal fluid.
Water Balance Normal body water is in a dynamic state. There is constant loss constant replacement, i.e., Intake is equal to output.
Electrolyte Composition of the Fluid Electrically charged particles act as a conductor of electrical current in the solution .E.G. NaCl
Na + Cl-
Intracellular fluid and extra cellular fluid are separated by cell membrane, which is semi permeable. Body fluid composed of water, electrolyte, and non-electrolyte. The difference is maintained by the cells, which actively reject certain electrolytes, and retain others. E.g. Na+ is higher in concentration in extra cellular fluid. The difference is maintained by cellular action referred as sodium pump, which reject sodium from other cells.
Disturbances in Fluid Balance 1. Fluid deficit – negative fluid balance – dehydration fluid loss exceeds the fluid intake. Causes:- fluid deficit is caused by: a) Excessive fluid loss from GIT – Vomiting and Diarrhea b) Excessive perspiration – high fever, exposure to high environmental temperature. c) Hemorrhage d) Blood loss especially in big wounds 2. Decreased fluid intake due to: a) Inability to swallow
Effects and Manifestations of fluid deficit yy The effect depends on severity: yy Usually, the first sign is thirst, dry skin, yy Decreased blood pressure yy Oliguria yy Retention of waste acidosis yy Increased haemoglobin and hematocrit yy Loss of strength and apathy yy Disturbance in cellular function in the brain
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Coma - Death Excess fluid Causes of excess fluid in the body 1. Increased venous pressure = increased hydrostatic pressure at venous end. 2. Obstruction of Lymphatic drainage 3. Deficiency of blood protein 4. Increased Capillary permeability 5. Renal insufficiency â&#x20AC;&#x201C; increased intake and decreased output 6. Excessive Hormone. E.g. Mineral corticoid hormone.
ACID BASE BALANCE Acids are substances, which contain hydrogen ions that can be freed or donated by the chemical reaction to the other substances. Conversely, bases are chemical substances that combine with hydroxyl ions in a chemical reaction. The acidity or alkalinity of a solution depends upon the concentration of hydrogen ions and hydroxyl ions.
Acid Base Regulation Body fluid normally have a PH of 7.35 â&#x20AC;&#x201C; 7.45. The chief acid regulating from metabolism is H2CO3 which is formed by a combination of CO2 + H2 O. This combination is promoted by carbonic anhydrase within the cells. Acids must be rapidly neutralized or weakened by chemical reaction. There must be a constant elimination of them from the body. Carbolic acid is removed by lungs by eliminating carbon-dioxide.
Control Mechanism of body PH The optimum PH of the body fluid is maintained by: 1. Acid base buffer system 2. Respiratory System regulation. 3. Kidney regulation
Respiratory Regulation of Acid-Base Balance Carbon-dioxide is constantly produced in cellular metabolism and diffuses from the cells into the blood and erythrocyte, and as a result CO2 is in greater concentration in the blood. When it enters pulmonary capillaries than in the air in the alveoli of the lungs Kidney Regulation The kidneys play an important role in maintaining acid base balance by excretion of H+ and forming hydrogen carbonate. Acidosis A condition in which hydrogen ion concentration is increased in the body and the PH falls below normal. There are two types of Acidosis: Respiratory acidosis and metabolic acidosis.
A. Respiratory acidosis Causes: yy Hypoventilation related to acute and chronic pulmonary diseases yy Circulatory failure yy Depression of CNS yy Drugs such as atropine yy Gulian Bari Syndrome yy Poliomyelitis yy Decreased or increased potassium in the blood.
B. Metabolic Acidosis Causes: yy Increased acid production yy Uncontrolled diabetes mellitus yy Increased alcohol intake
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yy Excessive administration of drugs e.g. ASA, Amonium Chloride yy Renal failure yy Dehydration yy Severe Diarrhea and vomiting.
Common signs and symptoms of respiratory acidosis yy Restlessness, apprehension, slow mental response, weakness, headache, confusion Coma, yy PH is < 7.35 yy Decreased bi carbonate yy Increased arterial CO2 and decreased O2 yy Increased urinary acidity yy Increased ammonia in urine yy Low PH in urine
Metabolic acidosis yy Headache, fatigue, drowsiness yy Serum PH < 7.35 yy Serum bicarbonate is low yy Depression in CNS
Nursing intervention yy Improve respiratory ventilation (e.g. administer bronchial dilators, antibiotics and oxygen as ordered. yy Maintain adequate hydration (2to3Litres of fluid per day). yy Carefully regulate mechanical ventilation if used. yy Monitor fluid intake and output, vital signs, arterial blood gases (ABGS), and PH. yy Monitor Arterial blood gas values yy Administer IV sodium bi carbonate carefully if ordered yy Correct underlying problem as ordered
Alkalosis is acid - base imbalance in which there is a decrease in H+ concentration below 35 n mol/L and increase in the PH in excess of 7.45 due to carbonic acid deficit or an excess amount of bicarbonate (HCO2). Types of alkalosis 1. Respiratory Alkalosis 2. Metabolic Alkalosis 3. Respiratory Alkalosis Causes: 1. Hyperventilation (excessive loss of carbolic acid) related to anxiety, Hysteria, CNS disease which causes over stimulation of respiratory center. 2. High fever 3. Hypoxia 4. Severe pain 5. High altitude Signs and symptoms yy Serum PH >7.45 yy Serum Bicarbonate decreases yy Serum potassium decreases yy Cardiac arrythemia is present yy Increased Na+ and K+ excretion in urine yy Decreased chloride ion and hydrogen ion excretion yy Hyperventilation yy Increased rate and depth of respiration
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yy Decreased arterial blood CO2 yy Dizziness, tetany, muscle spasm (carpopedal spasm) yy Cramps, tingling sensation in extremities yy Convulsions.
Nursing Interventions yy Monitor vital signs and ABGS yy Assist the patient to breathe more slowly yy Administer CO2 inhalations, or help patient breathe into a paper bag (to exhale CO2)
Metabolic Alkalosis Causes: yy Abnormal loss of acid associated with vomiting and aspiration yy Diuretics â&#x20AC;&#x201C; through excess urination yy Excessive ingestion of alkaline i.e. sodium bicarbonate.
Signs and symptoms yy Serum PH > 7.45 yy Serum H+ < 35 n mal/L yy Increased serum bicarbonate yy Decreased serum potassium yy Cardiac arrythemia yy Increased Na + and K+ excretion in urine yy Decreased chloride ion and hydrogen excretion yy Hyperventilation yy Increased rate and depth of respiration yy Decreased arterial blood CO2 yy Dizziness, Tetany, muscle spasm (carpopedal spasm) yy Cramps, tingling in extremities yy Convulsions.
Nursing interventions yy Monitor the vital signs and ABGS yy Assist the client to breathe more slowly yy Help the patient to breathe in a paper bag (to inhale CO2)
Metabolic Alkalosis Causes: 1.Abnormal loss of blood associated with vomiting and aspiration. 2.Diuretics â&#x20AC;&#x201C; through excess urination 3.Excessive ingestion of alkaline e.g. sodium bi-carbonate
Signs and symptoms yy Serum PH >7.45 yy Serum H+ <35 n mal/L yy Increase serum bicarbonate yy Decreased Serum potassium yy Cardiac arrhythmia yy Hypoventilation yy Slow, shallow respiration yy Increased PaCO2 or normal
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yy Decreased Pa O2 if prolonged alkalosis yy Increased sodium and potassium ions excretion yy Decreased chloride and hydrogen ions excretions yy Dizziness, tremors, twitching, Tetany, cramping, tingling in limbs, convulsions. yy Others like nausea, vomiting and diarrhea.
Nursing interventions yy Monitor patient’s fluid losses closely yy Monitor vital signs, especially respiration yy Administer ordered IV fluids carefully yy Reverse underlying problems.
Nutrition Nutrition is the study of nutrients and how the body utilizes the nutrients in food. Nutrition has a great impact on human wellbeing, behavior, and the environment. Nutrients are substances needed for growth, maintenance, and repair of the body. The body can make some nutrients if adequate amount of necessary precursors (building blocks) are available. Essential nutrients are those that a person must obtain through food because the body cannot make in sufficient quantities to meet its needs. The six classes of nutrients are carbohydrates, fats, proteins, Water, minerals and vitamins. Carbohydrates, fats and protein provide energy and are called macronutrients, Vitamins and minerals regulate body process and are called micronutrients. Water is necessary for virtually everybody function.
A HEALTHY DIET A healthy diet is one that provides an adequate amount of each essential nutrient needed to support growth and development, perform physical activity, and maintain health. In addition to meeting physiological requirements, diet is also used to satisfy a variety of personal, social and cultural needs. These factors must be considered in diet planning. The diets of all individuals must consist of foods that are easily attainable and affordable. People can use an infinite variety and combination of foods to form a healthy diet. The current philosophy is that no good foods or bad foods exist, and that all foods can be employed in moderation.
Dietary Guidelines The purpose of dietary guidelines is to provide a healthy public with practical and positive suggestions for choosing a diet that meets nutritional requirements, support activity, and reduces the risk of malnutrition and chronic diseases. These guidelines are not intended as a diet prescription for specific individuals, but serve as a starting point from which people can plan healthy diets of each essential nutrient needed to support growth and development, perform physical activity, and maintain health.
A Guide for Healthy Diet Guide Line Eat a variety of foods
Rationale No single food supplies all 40-plus essential nutrients in amounts needed variety also helps reduce the risk of nutrient toxicity and accidental contamination.
Balance the food you eat with physical activity – maintain or Excess weight increases the risk of numerous chronic diseases, improve your health. such as hypertension, heart diseases, and diabetes. Choose a diet with plenty of vegetables and fruits.
Plant foods provide fiber complex carbohydrates, vitamins, minerals, and other substances important for good health.
Choose a diet low in fat, saturated fat, and cholestrol.
High fat diets increase the risk of obesity, heart diseases, and certain types of cancer.
Choose a diet moderate in sugar’s
Foods high in added sugar are “empty calories”. Both sugar and starches promote tooth decay.
Choose a diet that is moderate in salt and sodium.
A high salt intake is associated with high blood pressure
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Therapeutic nutrition Therapeutic nutrition is a modification of nutritional needs based on the disease condition or the excess of deficit of a nutrition status. Combination diets, which include alterations in minerals, vitamins, proteins, carbohydrates, fats as well as fluids, are prescribed in therapeutic nutrition.
Gastrostomy/ Jejunostomy feeding A gastrostomy feeding is the installation of liquid nourishment through a tube that enters a surgical opening (Called a gastrostomy) through the abdominal wall into the stomach. A jejunostomy feeding is the installation of liquid nourishment through a tube that enters a surgical wound or opening (a jejunostomy) through the abdominal wall into the jejunum. These feedings are usually temporary measures. When there is an obstruction in the esophagus, they may become permanent for e.g. after removal of the esophagus. Inserting a Nasogastric Tube Purpose: yy To administer tube feedings and medications to patient’s unable to eat by mouth or swallow a sufficient diet without aspirating food or fluid into the lungs. yy To establish a means for suctioning stomach contents to prevent gastric distension, and vomiting.. yy To remove laboratory contents for laboratory analysis. yy To lavage (wash) the stomach in case of poisoning or over dosage of Medication Equipment yy A Ryle’s tube plastic or rubber tube yy A basin filled with warm water yy Adhesive tape (2.5 cm wide). yy Disposable gloves yy Lubricant yy 20-50 ml syringe with adapter yy Basin if reqd yy Stethoscope yy Suction apparatus if reqd yy Gauze pieces yy Container to collect specimens yy Towel or pillow. yy If patient’s health permits and yy 5-10 ml syringes. Procedure 1. Explain the procedure to the patient and gain his confidence 2. Explain that the passage of the tube is not painful but is unpleasant 3. Position the patient in a high fowlers position, if health permits to support head on pillow. 4. In infant’s place with rolled towel or pillow under the head and shoulders 5. Place the towel across the chest 6. Ask the patient to hyperextend his neck by leaning backwards, use a torch to observe the intactness of the tissue of the nostrils 7. If a rubber tube is to be passed, place it on ice. This makes the tube stiff and facilitates the insertion. 8. If a plastic tube is used place it in warm water. This makes the tube more flexable. 9. Determine how far it is to be inserted Use the tube to mark off the distance from the tip of the patient’s nose to the tip of the ear lobe and from the tip of the ear lobe to tip of the sternum . This length approximate the distance from the nostrils to the stomach. yy For infants and young children, measure from the nose to the tip of the ear lobe and then to the xiphoid process. yy Mark this length with adhesive tape, if the tube does not have marking 10. Lubricate the tip of tube with water or lubricant to ease insertion. Page : 67
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11. Insert the tube with the natural curve towards the patient in to the selected nostril. Ask the patient to hyperextend the neck and gently advance the tube toward the nasopharynx. Do not hyperextend or hyperflex an infant’s neck. 12. Direct the tube along the floor of the nostril and toward the ear on that side. 13. If the tube meets resistance, withdraw it, relubricate it and insert it in the other nostril.(The tube should never be forced against resistance)n the throat and may 14. Once the tube reaches the oropharynx (throat) the patient will feel the tube in the throat and may gag or vomit. Ask the patient to tilt the head forward and encourage the patient to drink and swallow. If the patient has discomfort stop passing the tube momentary. Let the patient rest, take a few deep breaths, and take sips of water to calm the reflex. 15. While the patient cooperates, pass the tube 5-10 cms (2-4 Inc) with each swallow, until the indicated length is inserted. 16. If the patient continues to gag and the tube does not advance with each swallow, withdraw it slightly, and inspect the throat by looking through the mouth. (The tube may be coiled in the throat, if so withdraw it until it is straight, and try again to insert it). 17. Check the correct placement of the tube: ÔÔ Aspirate stomach contents, and check their acidity. ÔÔ Ascultate air insufflations’. ÔÔ If the signs do not indicate placement in the stomach, advance the tube 5cm, and repeat the test. ÔÔ For the tube that is to be placed in the duodenum or jejunum, advance the tube 5-7.5cm per hour until the Xray study confirms its placement. 18. Secure the tube by taping it to the bridge of the patient’s nose. ÔÔ Cut 7.5cm of tape and split it lengthwise at one end, leaving 2.5cm tab at the end. ÔÔ Place the tape over the bridge of the patient’s nose and bring the split ends under the tubing and back up over the nose. ÔÔ For infant’s or small children, tape the tube to the area between the end of the nostril and the upper lip, as well as to the cheek. ÔÔ Attach the tube to the suction source or feeding apparatus as ordered, clamp the end of the tubing. 19. Secure the tube to the patient’s gown. Loop an elastic band around the end of the tubing, and attach the elastic band to the gown with a safety pin or attach a piece of adhesive tape to the tubing, and pin the tape to the gown. 20. Document relevant information, means by which correct placement was determined and patient’s responses 21.Establish a plan for providing daily nasogastric tube care. ÔÔ Inspect the nostril daily for discharge and irritation ÔÔ Clean the nostril and tube with moistened cotton tipped applicators ÔÔ Apply water soluble lubricants to the nostril if it appears dry or crusted. ÔÔ Change the adhesive tape if reqd ÔÔ Give frequent mouth care 22. If suction is applied ensure that the patency of both the nasogastric and suction tubes is maintained. 23. Document all relevant information: Type of tube inserted Date and time of tube insertion Type of suction used. Color and amount of gastric contents Client tolerance of the procedure.
NASOGASTRIC TUBE FEEDING. Purposes: yy To restore or maintain nutritional status yy To administer medications Equipment yy Correct amount of feeding solution yy 20-50 ml syringe with adaptor yy Kidney tray or basin yy Calibrated plastic feeding glass or feeding cup yy Water 60 ml at room temperature Procedure: 1. Prepare the patient and the feed Page : 68
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ÔÔ Explain the procedure to the patient ÔÔ Provide privacy ÔÔ Position the patient in a fowlers position in bed or sitting position in a chair ÔÔ Position a small child or infant in the mother’s lap during feeding. 2. Assess tube placement. Attach the syringe to the open end of the tube; aspirate alimentary secretions check PH. 3. Assess residual feeding contents ÔÔ Aspirate all the stomach contents, and measure the amount prior to administering the feed. If 50 ml or more undigested formula is withdrawn in adults, or 10 ml or more in infants, check with the nurse before feeding. ÔÔ Reinstill the gastric contents into the stomach if this is the agency or physicians practice. 4. Remove the syringe bulb or plunger, and pour the gastric contents via . the syringe into the nasogastric tube. 5. Administer the feed. Before giving the feed ÔÔ Check the tube is in correct position ÔÔ Warm the feed to room temperature ÔÔ Connect the syringe to the open end of the feeding tube ÔÔ Pour the liquid feed into the barrel of the syringe and allow it to slowly flow ÔÔ Do not forcefully push the feed into the tube the patient may vomit. ÔÔ Pour some water into the feeding tube after giving the feed. ÔÔ Clamp the feeding tube and cover the end of the feeding tube with a gauze piece held by an elastic band. ÔÔ Place the patient in a comfortable position and tell the patient to remain in the sitting position for at least 30 min after the feed. 6. Dispose of all the equipment used for feeding , wash and replace all articles in the proper place. 7. Document all relevant information yy Document the feed given, the amount and kind of feed taken, duration of the feed, and assessment of the patient. yy Record the volume of the feed and water administered on the client’s fluid balance chart. yy Prevent dehydration; give the patient supplemental water in addition to the prescribed tube feed as ordered.
TOTAL PARENTRAL NUTRITION Parentral nutrition is a method where by nutrients may be introduced into the system via the enteral route. It is also referred to as intravenous hyperalimenation (IVH). By passing the normal gastro intestinal system, this route provides a nitrogen source for those unable to ingest protein, carbohydrate (adequate caloric), or fats. peripherally, using isotonic concentrations of glucose, crystalline aminoacids, and fats; or because the solution may be irritating to the veins, nutrients can be administered through a central, high-flow vein. Hypertonic glucose, along with crystalline aminoacids, fats, electrolytes, Vitamins and trace elements is given through central vein access. The technique requires special handling and management of the patient and is the most expensive method of feeding. This method should be used only if the intestines do not work properly, if the patient has a fistula or obstruction and if the bowel requires rest.
Application of Nursing Process Assessment yy Complete physical assessment and patient history yy Assess the patients weight and record it yy Identify the caloric intake necessary to promote positive nitrogen balance, tissue repair, and growth. yy Check the label of solution with the physicians order yy Check the rate of infusion as per physicians order yy Assess the ability of the patient to understand instructions during the procedure yy Ensure the patency of the central venous line following the insertion yy Observe the catheter insertion site for signs of infection, thrombophlebitis or possible infiltration yy Inspect dressings over the central line to ensure a dry non contaminated dressing.
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Implementation yy Assisting with catheter insertion yy Maintaining central venous infusions yy Changing parentral hyper alimination, Dressing and Tubing yy Maintain Hyper alimentation (iv drips) for children. Evaluating/Expected Outcome yy Catheter is placed correctly with no infiltration. yy Solution is infused as prescribed flow rate and tolerated by the patient yy Dressing remains dry and intact during interval between changes yy Insertion site remains free of infection and inflammation, sepsis does not occur. yy The patient receives nutrients necessary for tissue repair and sustenance.
Study Questions yy Describe the electrolyte composition of the body yy Define electrolytes yy Mention the manifestation of fluid disturbance yy Describe causes of acid base imbalance yy Mention any two procedures for ensuring nutritional maintenance yy State Procedure for nasogastric tube insertion yy Describe a condition in which NGT feeding is indicated.
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UNIT FIVE ELIMINATION OF GASTRO INTESTINAL AND URINARY OUTPUTS Gastric Lavage 1. Definition - Gastric Lavage is the irrigation or washing out of the stomach Purpose 1. To remove alcohol, Narcotics or any other poisoning which has been swallowed 2. To clean the stomach before operation 3. To relieve congestion, thereby stimulating peristalsis e.g. pyloric stenosis. 4. For diagnostic purposes.
1. Gastric Lavage Using a Simple Rubber Tube. Equipment yy A clean trolley yy A bowl containing large esophageal tube in ice cold water. yy Rubber tubing with clamp yy Large jug (5 litres) yy Metal or plastic funnel yy Receptacle for return fluid yy Solution as prescribed â&#x20AC;&#x201C;Usually to care for acidic poisoning we use sodium bicarbonate 1 teaspoonful to 500 ml of water at a temperature of 370c to380c.) yy A small jug to carry the solution to the funnel yy Lubricant e.g. liquid paraffin yy Bowl for gauze swabs yy Rubber sheet and towel to put over the patientâ&#x20AC;&#x2122;s chest yy Mackintosh or newspaper to protect the floor below the receptacle on the floor. yy Used swab container yy A mouth wash tray to be kept ready for mouth wash after lavage yy A gallipot to receive dentures if the patient has any yy A basin containing mouth gag tongue depressor tongue forceps if the patient is unconscious yy Mackintosh to protect the bed linen yy Litmus paper yy Specimen bottles if the laboratory tests are reqd yy Measuring jug. Procedure 1. Explain the procedure to the patient ask him/her to remove artificial dentures if any 2. Protect patient with rubber sheet and towel 3. Protect the bed linen by spreading the mackintosh on the bed 4. Place mackintosh or news paper under the receptacle on the floor 5. Elevate the head of the bed if the patient is conscious and condition permits. But if unconscious, place in prone position with the head over the edge of then bed or head lower than the body. 6. Measure the tube from the tip of the nose to the ear lobe and from the bridge of the nose to the sternum.(32-36 cm)
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7. Gently pass the tube over the tongue, slightly to one side of the midline towards the pharynx.( If patient is conscious the mouth gag may be used.) 8. Ask patient to swallow while inserting the tube and allow breathing in between swallowing. 9. If air bubbles, cough and cyanosis are noticed the tube is withdrawn and procedure commenced again 10. After inserting, place funnel end in a basin of water to check if the tube is in the air passage 11. Fill the small pint measure and pour gently until the funnel is empty, then invert over the pail. 12. Take specimens if reqd, and continue the process until the return fluid becomes clear and the prescribed solution has been used. 13. Remove the tube gently and give the patient a mouthwash 14. Measure the amount of fluid returned and record 15. Report any abnormality e.g. blood stain or blood clots Document Time of treatment Amount & kind of solution used Nature of returned fluid Reaction of the patient during and after procedure
2. Gastric Aspiration Aspiration is to withdraw fluid or gas from a cavity by suction. Purpose 1. To prevent or relieve distention following abdominal operations 2. In case of gastro-intestinal obstruction to remove the stomach or gastric contents 3. To keep the stomach empty before an emergency abdominal operation is done 4. To aspirate the stomach contents for diagnostic purposes Types of gastric aspiration are 1. Intermittent method – In this case, aspiration is doneas the condition requires or as ordered. 2. Continuous method – the tube is attached to a drainage bag. Methods of applying suction 1. Simple suction by the use of a syringe 2. An electric suction machine The continuous method is indicated when it is absolutely necessary and desirable to keep the stomach and duodenum empty and at rest. Equipment yy A tray containing a Ryle’s Tube yy Syringe for aspiration yy Gallipots with Lubricants e.g. Liquid Paraffin or Vaseline to lubricate the nostrils. yy Litmus Paper yy Water in a small bowl to test if the tube is in the stomach yy Gauze swabs in a bowl yy Soda bicarb solution or saline to clean the nostrils yy Test tubes and laboratory forms if necessary yy Rubber mackintosh and towel to protect the patient’s chest yy Used swab container. Procedure 1. Explain the procedure to the patient in order to gain his/her confidence and cooperation 2. Prop up the patient with the help of pillows and a backrest 3. Clean and lubricate the nostrils 4. Lubricate the Ryle’s tube with water 5. Insert the tube as directed in nasal feeding and ask the patient to swallow as the tube goes down. 6. Instruct the patient to open the mouth to make sure the tube is in the stomach and not coiled in the throat. 7. After being sure the tube is in the right position, inject about 15-20cc of saline or water into the stomach
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8. Draw the plunger to withdraw the fluid collect specimens, if needed 9. If the Ryle’s tube is to be left in situ then a clamp is used to close the end, but if it is for one aspiration and to be removed immediately. It should be withdrawn very gently to avoid irritating the mucous lining. NB 1. Special care of the nose and mouth to prevent dryness should be considered. 2. Always measure the amount withdrawn accurately noting color, contents, and smell 3. Record findings on the fluid chart properly 4. Report any change in the patient’s condition regarding pulse, respiration Temperature and Blood pressure 5. Record fluid output correctly
3. Enema: - It is the introduction of fluid into the rectum and sigmoid colon for cleansing, therapeutic or diagnostic purposes. Purposes yy For emptying the bowel yy For diagnostic purpose (Barium enema) yy For introducing drugs/substances (retention enema) Solution used: 1.Normal Saline\ 2.Soap solution – Soap 1gm in 20 ml of water 3.Epsum salt 15 gm -120 gm in 1000 ml of water.
Mechanisms of solutions used in enema 1. 2. 3. 4.
Tap water: increase peristalsis by causing mechanical distension of the colon. Normal saline solution Soap solution : increases peristalsis due to irritating effect of soap to the lumenal mucosa of the colon Epsum salt: The concentrated solution causes flow of ECF (extra cellular fluid) to the lumen causing mechanical distension resulting in increased peristalsis.
Classification 1. Cleansing (evacuation) enema 2.Retention enema 3.Carminative enema 4.Return flow enema
Cleansing enema : 1. High enema • It is given to clean as much of the colon as possible • The solution container should be 30-40 cm above the rectum 2. Low enema • It is administered to clean the rectum and sigmoid colon only Guidelines Enema for adults are usually given at 40-430c and for children at37.70c Hot – cause injury to the bowel mucosa Cold – uncomfortable and may trigger a spasm of the sphincter muscles. The amount of solution to be administered depends on: The kind of enema, age of the person and, person’s ability to retain the solution. Age
Amount
I8 Months
50-200 ml
I8 montyhs-5 yrs
200-300 ml
5-12 yrs
300-500 ml
12 yrs & above
500-1000 ml
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The rectal tube should be appropriate: is measured in French scale Age
Size
Infants/small children
10-12 fr
Toddlers
14-16 fr
School age child
16-18 fr
Adults
22-30 fr
22-30 fr
Purpose yy To stimulate peristalsis and remove feces or flatus (for constipation) yy To soften feces and lubricate the rectum and colon yy To clean the rectum and colon in preparation for an examination E.g. Colonoscopy yy To remove feces prior to a surgical procedure or delivery yy For incontinent patients to keep the colon empty yy For diagnostic test. yy E.g. before certain x-ray exam – barium enema yy Before giving stool specimens for certain parasites. Procedure yy Inform the patient about the procedure yy Provide privacy yy Attach rubber tube with enema can nozzle and clamp yy Place the patient in the lateral position with the Rt Leg flexed for adequate exposure of the anus (facilitates the flow of solution by gravity into the sigmoid and descending colon which are on the side). yy Fill the enema can with 1000 ml of solution for adults. yy Lubricate about 5 of mackintosh under the bedcm of the rectal tube – facilitates insertion through the sphincter and minimizes trauma. yy Hang the can = 45 cm from bed or 30 cm from patient on the stand yy Place a piece of mackintosh on the bed yy Make the tube air free by releasing the clamp and allowing the fluid to run down into the bedpan and open clamp - prevents unnecessary distention. yy Lift the upper buttock yy Insert the tube ÔÔ 7-10 cm in an adult smoothly and slowly ÔÔ 5-7.5 cm in the child ÔÔ 2.5-3.75 cm in an infant. yy Raise the solution container and open the clamp to allow fluid to flow. yy Administer the fluid slowly if client complains of fullness or pain stop the flow for 30 min and restart the flow at a slower rate decreases intestinal spasm and premature ejection of the solution. yy Do not allow all the fluid to go as there is a possibility of air entering the rectum or when the patient cannot hold any more and wants to defecate, close the clamp and remove the rectal tube from the anus and offer the bedpan. yy Remove bedpan and clean the rectal tube. Note: If resistance is encountered at the internal sphincter, ask the patient to take a deep breath, then run a small amount of solution (relaxes the internal anus sphincter)
Retention Enema yy Administration of solution to be retained in rectum for short or long period for local or general effects yy E.g: Antispasmodic enema, oil retention enema. Principles Medication is given slowly by means of a rectal tube The amount of fluid given is usually 150-200 cc
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Cleansing enema is given after the retention time is over. Temperature of the enema fluid is 370c or body temperature Purpose yy To supply the body with fluid. yy To give medication e.g. stimulants – paraldehyde or anti spasmodic yy To soften impacted fecal matter. Other equipment is similar except that the tube for retention enema is smaller in width. Procedure Similar with the cleansing enema but the enema should be administered very slowly and always be preceded by passing a flatus tube. Note: 1. Most medicated retention enema must be preceded by a cleansing enema. A patient must rest for ½ hrs before giving retention enema 2. Elevate the foot end of the bed to help the patient to retain the enema. 3. The amount of fluid is usually 150-200 cc 4. The temperature of the enema fluid is 37.40c or body temperature. 5. Kinds of solution used to supply body with fluid are plain water, normal saline, glucose 5% soda bicarbonate 2-5%. 6. Olive oil 100-200 cc to be retained for 6-8 hrs is given for severe constipation.
Rectal Washout or Bowel wash: is the process of introducing large amount of fluid into the large bowel for flushing purpose and allows return or washout fluid Purpose
yy To prepare the patient for x-ray examination and sigmoidoscopy yy To prepare the patient for rectum and colonic operations
Solution used yy Normal saline yy Soda-bi-carbonate solution (to remove excess mucus) yy Tap water yy KMNO4 sol. 1: 6000 for dysentery or weak tannic acid yy Tr Asafetida in 1: 1000 to relieve distention. Procedure yy Explain the procedure to the patient yy Provide privacy yy Insert the tube like the cleansing enema yy The patient lies on the bed with hips close to the side of the bed yy Open the clamp and allow about 1000 cc of fluid to run into the bowel, then siphon the fluid back into the bucket by lowering the other end of the tube into the bucket. yy Carry on the procedure until the return flow is clear. Note: yy The procedure should not take > 2 hrs yy Should be finished 1 hr before exam or x-ray to give time for the large intestine to absorb the rest of them fluid yy Give cleansing enema ½ hr yy Before the rectal washout yy Allow the fluid to pass slowly
Amount of solution yy 5-6litres or until the wash out return rectum fluid becomes clear.
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Passing a flatus tube Purpose yy To decrease flatulence (severe abdominal distension) yy Before giving a retention enema Procedure yy Explain the procedure to the patient yy Place the patient in left lateral position yy Lubricate the tube about 15 cm. yy Insert the tube into the rectum yy The free end to be placed under the water level in a basin yy Air can be seen bubbling through the solution yy Leave the rectal tube in place for a period of no longer than 20 min – It can affect the ability to voluntarily control the sphincter if placement is prolonged. yy Reinsert the rectal tube every 2-3 hrs if the distention has been unrelieved or re accumulates – It allows gas to move in the direction of the rectum yy Teach the patient to avoid eating substances that cause flatulence
Urinary Catheterization Definition – It is the introduction of a tube (catheter) through the urethra into the urinary bladder. ÔÔ Is performed only when absolutely necessary for fear of infection and trauma. Note: It is strictly a sterile procedure, ie. The nurse should always follow aseptic technique Catheter: is a tube with a hole at the tip Types of catheters 1. Straight (plain Indian rubber ) catheter. 2. Retention (Foleys, indwelling ) catheter. Selecting an appropriate catheter May be made of yy Plastic – for 1 week yy Latex – 2-3 (rubber) yy Silicon – 2-3 months yy Pelyvinylchloride (PVC) - - 4-6 1. Select the type of material in accordance with the estimated length of the catheterization period: 2. Determine appropriate catheter size ÔÔ Are determined by diameter of lumen ÔÔ Graded on French scale or number ÔÔ Catheter size depends on the size of the urethral canal ÔÔ 8-10 Fr – children ÔÔ 14-16 Fr – female adults ÔÔ 18Fr – adult males ÔÔ NB. Fr= French Scale. 3. Determine the appropriate catheter length by the patient’s gender ÔÔ For adult males – 40 cm catheter ÔÔ For adult females – 22 cm catheter Select appropriate balloon size for inflation yy 5 ml – for adults yy 3 ml - for children
Catheterization using a straight catheter Purpose To relieve discomfort due to bladder distension
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To assess the residual urine To obtain a urine sample To empty the bladder prior to surgery. Equipment A tray containing the following items (sterile) yy Kidney tray yy Gallipot yy Gauze pieces yy Towel yy Solution yy Lubricant yy Catheter yy Syringe yy Water Specimen bottle yy Gloves
Clean articles yy Screen to provide privacy yy Rubber sheet yy Torch yy Measuring jug yy Waste receiver Procedure Explain the procedure to the patient Prepare the client and equipment for perineal wash Position the patient –dorsal recumbent (pillows can be used to elevate the buttocks in females Drape the patient Wear gloves Wash the perineal area with warm water and soap Rinse and dry the area Prepare the equipment Spread a sterile sheet under the patient Drape the patient with sterile sheet or OT towels Clean the area with antiseptic solution. Lubricate the insertion tip of the catheter (5-7 cm) Expose the urinary meatus adequately by retracing the tissue or the labia minora in an upward direction – female. Retract the foreskin of uncircumcised male Grasp the penis firmly behind the glans and hold , straighten the down ward curvature of the penis vertical allow it to go to the body – male. Hold the catheter.5 cm away from the insertion tip Insert the catheter into the urethral orifice Insert 5 cm in females and 20 cm in males or until urine comes out. Collect the urine –for specimens (about 30 ml) Empty or drain the bladder and remove the catheter For adults having urinary retention an order is needed on the amount of urine to be expelled. Note: yy If resistance is encountered during insertion, do not force it – forceful pressure can cause trauma. Ask the patient to take deep breaths – It relaxes the external sphincter (slight resistance is normal)
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yy Dorsal Recumbent yy Female – for a better view of the urinary meatus and to reduce the risk of catheter contamination. yy Male – allows greater relaxation of the abdominal and perennial muscles and permits easier insertion of the tube. yy Straight catheter: is a single lumen tube with a small eye or opening about (1.25 cm) from the tip:
Inserting a Retention (Indwelling) Catheter. Retention (Foley’s Catheter – It contains a second, smaller tube through out its length on the inside – this tube is connected to a balloon near the insertion tip. Purpose yy To manage incontinence yy To provide for intermittent or continuous bladder drainage and irrigation yy To prevent urine from contacting an incision after perineal surgery (prevent infection) yy To measure urine output needs to be monitored hourly Procedure yy Explain the procedure to the patient and gain his confidence yy Provide privacy yy Prepare the equipment like: yy Foley’s Catheter (Sterile) yy Syringe, yy Sterile water yy Tape yy Urine collecting bag and tubing yy After catheter insertion the balloon is inflated to hold the catheter in place within the bladder. ÔÔ The outside end of the catheter is bifurcated i.e., it has two openings, one to drain the urine, the other to inflate the balloon. ÔÔ The balloons are sized by the volume of fluid or air used to inflate them 5 ml – 30 ml (15 commonly) indicated with the catheter size 18 Fr – 5 ml. yy Test the catheter balloon. yy Follow steps as insertion straight catheter yy Insert the catheter an additional 2.5 - 5 cm (1-2 in) beyond the point at which the urine began to flow (the balloon of the catheter is located behind the opening at the insertion tip) – this ensures that the balloon is inflated inside the bladder and not in the urethra (as this may cause trauma.) yy Inflate the balloon with the prefilled syringe Apply slight tension on the catheter until you feel resistance Resistance indicates that the catheter balloon is inflated appropriately and that the catheter is well anchored in the bladder. yy Release the resistance yy Tape the catheter to the inside of the patient’s thigh ÔÔ It restricts the movement of the catheter and irritation in the urethra when the patient moves ÔÔ Movement causes increased risk of penile scrotal excoriation. ÔÔ Establish effective drainage ÔÔ The bag should be off the floor and suspended from the cot – to prevent contamination ÔÔ Document the pertinent data.
Removal yy Wash your hands and wear gloves yy Withdraw the solution or air from the balloon using a syringe yy Remove the catheter gently
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Study questions 1. Define gastric lavage 2. Mention indications of gastric lavage 3. Define enema 4. State how the mechanism of action of soap solution enema exerts its function. 5. Mention conditions that differentiate between male and female catheterization.
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Nursing Training Manual
Chapter : Elimination of Gastro Intestinal & Urinary Outputs
UNIT SIX I. MEDICATION ADMINISTRATION Pharmacology is the study of drugs. Drugs are chemicals that alter functions of living organism. Therapeutic agents are drugs or medications that, when introduced in to living organism, modify the physiologic functions of that organism. Drug metabolism in the human body is accomplished in 4 basic stages: absorption, transportation, biotransformation, and excretion. For a drug to be completely metabolized, it must first be given in sufficient concentration to produce desired effect on body tissues. When this critical drug concentration level is achieved, body tissue change. Route of absorption Drugs are absorbed by the mucus membranes, the gastro intestinal tract, the respiratory tract, and the skin. The mucus membranes are one of the most rapid and effective routes of absorption because they are highly vascular. Oral drugs (Drugs that are given by mouth) are absorbed in the gastro intestinal tract. The rate of absorption depends on the PH of the stomach contents, the food contents in the stomach at the time of ingestion, and the presence of disease conditions. Most of the drug concentrate dissolves in the small intestine where the large vascular surface and moderate PH level enhance the process of breaking down the drug. Parental methods are the most direct, reliable, and rapid route of absorption. This method of administration includes intradermal, subcutaneous, intramuscular (IM), and intravenous (IV). The actual site of administration depends on the type of drug, its action, and the patient. Another route of medication include respiratory tract by inhalation, sublingual, buccal and topical. Transportation: - The 2nd stage of metabolism refers to the way in which a drug is distributed, transported from the site of introduction to the site of action. When the body absorbs a drug, a portion of the drug binds to plasma protein and may compete with other drugs for this storage site. Another portion is transported in free form through the circulatory system to all parts of the body. It is the free drug that is pharmacologically active, as the drug moves from the circulatory system; it crosses cell membranes to reach its site of action. As the drug is metabolized and excreted, protein bound drug is freed for action. Lipid-soluble drugs are distributed to and stored in fat and then released slowly into the bloodstream when drug administration is discontinued. The amount of the drug that is distributed to body tissues depends on the permeability of the membranes and blood supply to the absorption area. Biotransformation: - The 3rd stage of metabolism takes place as the drug, which is a foreign substance in the body, is converted by enzymes into a less active and harmless agent that can be easily excreted. Most of this conversion occurs in the liver, although some conversion does take place in the lungs, kidney plasma and intestinal mucosa. Excretion: - The final stage in metabolism takes place when the drug is changed into an inactive form or excreted from the body. The kidneys are the most important route of excretion because they eliminate both the pure drug and the metabolism of the parent drug. During excretion, these two substances are filtered through glomeruli, secreted by the tubules, and either reabsorbed through the tubules or directly excreted. Other routes of excretion include the lungs (which exhale gaseous drugs), feces, saliva, tears, and mother’s milk.
Factors Affecting Drug Metabolism Many factors affect drug metabolism, including personal attributes, such as body weight, age and sex, physiologic factors, such as state of health; diurnal; rhythm; and circulatory capability. Genetic and immunologic factors play a role in drug metabolism, as do psychologic, emotional and environmental influences, drug tolerance, and cumulation of drugs. Responses to drugs vary, depending on the speed with which the drug is absorbed into the blood or tissues and the effectiveness of the body’s circulatory system. Safety procedures When you administer drugs, you must follow certain safety roles, which are also known as “the five rights”. These rules should be carried out each time you give a drug to a patient The five right, know the side effects of the drus 1. Right medication – check the drug card, medication sheet with the label on the drug container, know the action of the drug, dosage and method of administration, know the side effects of the drugs. 2. Right patient –Check the patient’s identification –Name, Age, and ward 3. Right time 4. Right method/route of administration 5. Right amount/dosage –check all calculations of divided dose with another nurse. Page : 80
Nursing Training Manual
Chapter : Medication Administration
Application of nursing process
• Assessment /Data base • Assess route for drug administration • Assess specific drug action for patient • Observe for sign and symptoms of side effects or adverse reactions. • Assess need for accuracy of drug calculation
Routes of drug administration Oral Administration Definition: Oral medication is drug administered by mouth. Purpose a) When local effects on GI Tract are desired b) When prolonged systemic action is desired. Contra- indications 1. For a patient with nausea and vomiting 2. When digestive juices inactivate the effect of the drug. 3. When there is inadequate absorption of the drug, which leads to inaccurate determination of the drug absorbed. 4. When the drug is irritating to the mucus membrane of the alimentary canal. Types of Oral Medication 1. Lozenges –Sweet medicinal tablet containing sugar that dissolve in the mouth so that the medication is applied to the mouth and throat. 2. Tablets –A small disc or flat round piece of dry drug containing one or more drugs made by compressing a powdered form of drug (s). 3. Capsules –Small hollow digestible case usually made of gelatin, the patient. filled with a drug to be swallowed by the patient. 4. Syrups –Sugar containing medicine dissolved in water. 5. Tinctures –Medicinal substances dissolved in water 6. Suspensions –Liquid medication with un dissolved solid particles in it 7. Gargles – Mild antiseptic solution used to clean the mouth or throat. 8. Powder –A medicinal preparation consisting of a mixture of two or more drugs in the form of fine particles. Equipment yy A tray containing the foll:yy Medicine cloth or hand towel yy A bowl of water with ounce glass and medication caps yy A measuring spoon yy Drinking water in a bottle yy Medication ordered yy Treatment Book or medication chart Procedure yy Wash your hands. yy Explain the procedure to the patient yy Prepare the tray and take it to the patient’s room yy Check the medication order yy Read the label yy Place solution and tablets in a separate container. yy If suspension, shake the bottle well before pouring yy Take it to the patient’s bedside. r or senior nurse yy Identify the patient carefully using all identification variables i.e. (patient’s name, bed number and diagnosis) yy Remain with the patient till he/she swallows the medicine. yy Offer additional water to drink unless contraindicated
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Chapter : Medication Administration
yy Record the medication given, refused or omitted immediately yy Inform the Doctor or senior nurse in charge. yy Terminate the procedure take care of the equipment clean and return to their proper places. yy Wash your hands. Note: 1. Remember the 5 R’s ÔÔ Right patient ÔÔ Right medication ÔÔ Right route ÔÔ Right route ÔÔ Right time. 2. Always keep the bottle tightly closed 3. Clean and keep the label of the bottle clear 4. Keep medication in a dark cool place 5. Check the expiry date of the drugs held 6. Keep the rim of the bottle clean 7. Concentrate and give undivided attention to your work while preparing and giving medications. 8. Senior nurses must make sure that the drugs held are checked and signed. 9. Never give medicines from an unlabeled container 10. Never return a drug dose once poured out from the bottle, discard it. 11. Check the patient’s vital signs, may be necessary before and after administration of some drugs e.g. digitalis, ergometrine 12. Never give medicine that some other nurse has poured out and left. 13. Never leave medicines at the bedside of the patient and within reach of children.
Suppository Purpose yy To produce a laxative effect. (bowel movement), suppository is used frequently instead of enema since it is inexpensive yy To produce local sedative effect in the treatment of hemorrhoids or rectal abscess. yy To produce general sedative effects when medications cannot be taken by mouth. yy To check rectal bleeding. yy To reduce temperature. Equipment yy Suppository as ordered yy A gallipot with gauze pieces yy Gloves or finger stalk yy Toilet paper yy Receiver for soiled swabs yy Bedpan, if the treatment is in order to produce defecation. yy Screen to provide privacy yy Rubber sheet or mackintosh and towel Procedure 1. Check medication order 2. Review the patient’s record for rectal surgery/bleeding 3. Wash hands 4. Prepare the necessary articles and bring it to the bedside of the patient. 5. Use gloves 6. Explain the procedure to the patient 7. Provide privacy 8. Place the patient in Sims position 9. Drape the patient and avoid unnecessary exposure Page : 82
Nursing Training Manual
Chapter : Medication Administration
10. Remove suppository from wrapper and lubricate rounded end 11. Lubricate gloved finger of dominant hand 12. Ask the patient to take slow, deep breaths through mouth and to relax the anal sphincter. 13. Retract the patientâ&#x20AC;&#x2122;s buttocks with non dominant hand 14. With index finger of dominant, gently insert suppository through anus, past the internal sphincter, and place against rectal wall, 10 cm for adults or 5 cm for children and infants. 15. Withdraw finger and wipe the patientâ&#x20AC;&#x2122;s anal area clean of suppositories used: 16. Remove and dispose of gloves. 17. Wash hands 18. If suppository contains a laxative or fecal softener, be sure that the patient will receive help to reach bedpan or toilet. 19. Keep patient flat on back or on the side for 5 minutes. 20. Return in 5 min to determine if suppository has been expelled. 21. Observe the patient for effects of suppository 30 min after administration. 22. Record medication administration.
Kinds of suppositories used: yy 1. Bisacodyl (Ducolax) is commonly ordered for its laxative action. It stimulates the rectum and lubricates its contents. Normally 15 minutes is needed to produce bowel movement. yy 2. Glycerine suppository is used for bringing about bowel movement. yy 3. Bismuth for checking diarrhea. yy 4. Opium, sodium barbital etc for sedation.
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Nursing Training Manual
Chapter : Medication Administration
II. Parentral Drug Administration A. Intradermal injection Definitionâ&#x20AC;&#x201D;It is an injection given into the dermal layer of the skin Purpose For diagnostic purpose a. Mantoux test b. Antibiotic sensitivity test c. For therapeutic purpose it may be given like in vaccination Site of injection yy The inner part of the forearm (Midway between the wrist and elbow). yy Upper arm, at deltoid area for BCG Vaccination Equipment yy A tray containing the foll:yy Sterile syringes and needles yy Alcohol swab, file, marking pen yy Drug to be injected yy Used swab receiver Procedure yy Explain the procedure to the patient yy Take the equipment to the bedside of the patient yy Locate the site of injection yy Clean the skin with swab and inject the drug about 0.1, o.2 inch into the epidermis after the bevel of the needle is no longer visible. Do not massage the site. yy Check for the immediate reaction of the skin (10-15 minutes later for tetanus, 20-30 minutes later for penicillin) yy If it is for sensitivity test mark the area around site of injection. yy Chart the data and time of the administration of the drug. yy Take care of the equipment and return to their places. yy Do not forget to do the reading after 72 hrs if it is for Mantaux test or tuberculine test. yy Document the procedure.
B. Sub-Cutaneous Injection Definition---Injecting of drug under the skin in the sub-cutaneous tissue, (under the dermis)
Purpose yy To obtain quicker absorption than oral administration yy When it is impossible to give medication orally Equipment yy A tray containing the following:yy Sterile syringes and needles yy Alcohol swab, file yy Drug to be injected yy Used swab receiver Site of injection yy Outer part of the upper arm yy The abdomen below the costal margin to the iliac crest. yy The anterior aspect of the thigh.
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Chapter : Medication Administration
Procedure yy Take the equipment to the bedside of the patient yy Explain the procedure to the patient yy Check the name of the medication and the patients chart yy Locate the site of the injection yy Draw your medication yy Expell air from the syringe yy Clean the site (usually it is in the upper arms, thighs or abdomen yy Grasp the area between your thumb & forefinger to make it tense. yy Insert the needle elevate about 450-600 angle yy Pierce the skin quickly and advance the needle yy Aspirate to determine that the needle has not entered a blood vessel yy Inject the drug slowly. yy After injecting withdraw the needle and massage the area with alcohol swab. yy Chart the amount and time of administration immediately. yy Take care of the equipment – wash, sterilize and return to its place yy Watch for side effects of the drug.
Note If repeated injections are given the nurse should rotate the site of injection so that each succeeding injection is about 5 cm away from the previous one
C.Intra muscular injections Sites for IM Injections yy Dorsogluteal muscle yy Deltoid muscle yy Vastus Lateralis Definition : It is an introduction of a drug into a body’s system via the muscles. Purpose To obtain quick action next to the intravenous route To avoid an irritation from the drug if given through other route. Equipment yy A tray containing the foll:yy Ordered drug (Ampoule or vial) yy Sterile syringes and needles yy Alcohol swab, file yy Drug to be injected yy Used swab receiver yy Patient’s chart Procedure yy Take the equipment to the bedside of the patient yy Explain the procedure to the patient yy Check the name of the medication and the patients chart yy Locate the site of the injection yy Draw your medication yy Expell air from the syringe
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yy Clean the site (usually it is in the Dorsogluteal muscle, Deltoid muscle, and Vastus Lateralis E.g. gluteal muscle â&#x20AC;&#x201C;using the iliaccrest as the upper boundary divide the buttocks into four. Clean the upper outer quadrant with alcohol swabs. yy Stretch the skin and inject the medicine yy Draw back the piston(plunger) to check whether or not you are in the blood vessel (if blood returns, withdraw and get a new needle & re inject in a different spot) yy Push the drug slowly into the muscle. yy When completed, withdraw the needle and massage the area with a swab gently to aid absorption. yy Place the patient in a comfortable position yy Take care of the equipment you have used & return to their respective places yy Chart the amount, time, route and type of the medicine yy Check the patientâ&#x20AC;&#x2122;s reaction. Note: yy The strict aseptic technique should be absorbed throughout the procedure yy Injections should not be given in areas such as inflamed, edematous, those containing moles and infected skin.
D. I.V. Injections Definition: -It is the introduction of a drug in solution form into a vein, often the amount is is not more than10 ml at a time. Sites for I.V. Injections
1. Dorsal venous network 2. Dorsal metacarpal veins 3. Cephalic Veins 4. Radial Veins 5. Ulnar Veins 6. Baslic Veins 7. Median cubital Veins 8. Greater saphenous vein Purpose yy When a given drug is irritating to the body tissue if given through other routes. yy When quick action is required yy When it is particularly desirable to eliminate the variability of absorption yy When blood drawing is needed for investigations. Equipment yy A tray containing the foll:yy Sterile syringes and needles yy Medication yy Tourniquet, Alcohol swab, file
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Chapter : Medication Administration
yy Gloves yy Used swab receiver yy Patient’s chart Procedure yy Take the equipment to the bedside of the patient yy Explain the procedure to the patient yy Check the name of the medication and the patients chart yy Place the rubber sheet and towel under the arm of the patient to protect the bed. yy Expose the arm and apply tourniquet yy Tell the patient to open and close his fist yy Palpate the vein and clean with alcohol swab the site of the injection (which is mainly the mid cubital vein of the arm. yy Clean with a circular motion; proceed from centre of the site outwards yy Hold the needle at about 450 angles in line with the veins yy Puncture the vein and drawback to check whether you are in the vein or not.(blood return should be seen if you are in the vein) yy Once you know that you are in the vein, release the tourniquet and gently lower the angle of the needle. yy When it is nearly paralled to the vein instill the medication. Give the medication very slowly unless there is an order to give it fast. (Normally 40-60 drops per minuteis given) yy Check the patient’s pulse in between. Any complaint from the patient should not be ignored. yy Apply pressure over the site of after removing the needle to prevent bleeding. Tell the patient to flex his elbow. yy Watch the patient for a few minutes before leaving him. yy Place the patient in a comfortable position yy Wash, sterilize and.,take care of the equipment you have used & return to their respective places yy Chart the amount, time, route and type of the medicine yy Check the patient’s reaction. Note: yy Make the patient comfortable before and after giving the injection. yy It is the fastest way of drug administration yy Never recap a used needle.
E.Intravenous Therapy Definition: It is the administration of a large amount of fluid into the system through a vein.
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Chapter : Medication Administration
Purpose yy To maintain fluid and electrolyte balance yy To introduce medication particularly antibiotics
Equipment yy A tray containing the foll:yy Sterile syringes and needles yy I.V. fluid as ordered yy Rubber sheet or procedure mackintosh and towel yy Tourniquet, Alcohol swab, Arm board or splint yy Adhesive tape or Plaster , Gloves yy Bandage and scissors, , the patient should first be made comfortable yy I.V.Stand, Used swab receiver yy Patientâ&#x20AC;&#x2122;s chart
Preparation of the patient Since an infusion therapy takes several hours to complete, the patient must first be made comfortable. If the Patient needs to go to the wash room he must be helped so that after going to toilet he will feel comfortable.
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Chapter : Medication Administration
Procedure Assemble all the equipment needed for the procedure in the patient’s unit or near his bed. Confirm that you are going to give the right patient the treatment and explain the procedure to gain his confidence. Provide privacy by means of a screen or draw the curtains if available. Connect the I.V. Bottle to the I.V.Set expel all air bubbles from the tubing Wash your hands yy Place the procedure mackintosh and towel under the arm yy Apply tourniquet about 3 cm above the intended site of entry. yy Observe and palpate for suitable veins yy Clean the skin with alcohol swabs thoroughly yy Pierce the skin and puncture the vein. yy Hold the needle at 450 angle line with the vein yy Check if you are in the vein by drawing back with the syringe (you are in the vein if blood returns) yy Release the tourniquet gently yy Start the flow of solution by opening the clamp. yy Support the needle with a sterile gauze or cotton swab to keep it in position in the vein yy Fix the I.V.Tubing with adhesive tape to prevent pull on the needle. yy Place the splint under the arm and fix it with bandages. yy Adjust the rate of flow.number of drops in a ml—Rate of flow is regulated by the foll formula Number of ml of sol, Number of drops in a ml. Number of hrs over which sol is to be given x 60 minutes. 1 Ml = 15 drops, E.g. if 1000 ml of 5% Glucose is to run for 24 hrs how many drops per min should it run? 1000 ml x 15 drops/ml =1ooo x 15 = 10 drops / minute 24 x 60 min 24 x 60 min. Note: The arm splint should be long enough to extend beyond the wrist and elbow joint. The splint should be padded. Infusion bottle should be labeled with the date, time infusion is started, and drops per minute, and any added medications. yy Extend and place the arm in the most comfortable position. yy Usual areas used for infusion are: a) The median basilica vein on the inner surface of the arm. b) A vein on top of the foot c) In an infant the jugular and scalp veins.
Blood Transfusion Definition : It is giving of blood to a patient through a vein. Purpose yy To counteract severe hemorrhage and replace the blood loss. yy To prevent circulatory failure in operations where blood loss is considerable, such as in rectal resection, hysterectomy and arterial surgery. yy In severe burns to make up for the loss by burning but only after plasma and electrolytes have been replaced. yy For treatment of severe anaemia due to cancer, marrow aplasia and similar conditions. yy To provide clotting factors normally present in the blood, which may be absent as a result of disease. Equipment yy A tray containing the foll:yy Sterile syringes and needles yy Bottle or Bag containing blood, with the patient’s name, blood group and Rh factor and date of collecting blood . yy Blood giving set.
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Chapter : Medication Administration
yy Rubber sheet or procedure mackintosh and towel yy Tourniquet, Alcohol swab, Arm board or splint yy Adhesive tape or Plaster , Gloves yy Bandage and scissors, , the patient should first be made comfortable yy I.V.Stand, Used swab receiver yy Patient’s chart. Procedure yy Explain the procedure to the patient yy Before the blood transfusion is administered, the nurse has to check the blood group & Rh factor if cross match of the donor’s & recipient’s blood is done and is compatible. And also check for HIV other blood borne pathogens. yy Prepare the tray with the necessary items yy Before taking it to the patient’s bed side once again check the patient’s name, hospital number or IP Number, blood group Rh factor expiry date and the patient’s case documents. yy Blood should be given within 21 days of its withdrawal date, if sodium citrate is used it can be used within 36 days. yy Plain the procedure and gain his confidence. yy Hang the blood bottle or Bag on the I.V.Stand and cover it with a towel. yy Wash your hands yy Check and record the vital signs of the patient before administering blood yy Place the patient in a comfortable position yy Place the procedure mackintosh and towel under the arm yy Apply tourniquet about 3 cm above the intended site of entry. yy Observe and palpate for suitable veins yy Clean the skin with alcohol swabs thoroughly yy Pierce the skin and puncture the vein.(The needle should be short and wide so that it does not cause occlusion easily) yy Hold the needle at 450 angle line with the vein yy Check if you are in the vein by drawing back with the syringe (you are in the vein if blood returns) yy Release the tourniquet gently yy Start the flow of blood by opening the clamp. yy Support the needle with a sterile gauze or cotton swab to keep it in position in the vein yy Fix the I.V.Tubing with adhesive tape to prevent pull on the needle. yy Place the splint under the arm and fix it with bandages. yy The drops/min at the beginning should be very slow yy Watch the patient closely for signs of reaction. yy If there are no signs of reaction and the patient is comfortable regulate the rate of flow according to the patient’s condition & the order. yy Remove the equipment you have used, wash and return to its proper place. yy Record the time you started the blood & any other pertinent information. yy Check the vitals of the patient and record accordingly. Note: yy Always remember to have anti-histamine injection ready in case the patient has a reaction from the blood. yy Be familiar with the signs and symptoms of blood reactions which are:
Immediate reaction: a) Headache b) Bodyache and backache c) Chills and rigor d) Pyrexia or rise in body temperature e) Rash or urticaria
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Late Reaction a) Dyspnea and anxiety b) Renal shutdown in severe cases c) Hematuria d) Chest pain and rigor with chills.
Nursing Interventions in Transfusion Reaction Reactions following blood transfusion may occur for various reasons. Patient must be informed that the supply of blood is not completely risk-free, but that it has been tested carefully. Nursing management is directed toward preventing complications and promptly initiating measures to control any complications that occur. The following steps are taken so that a diagnosis may be made regarding the type and severity of the reaction. yy The transfusion set is disconnected, but the intravenous line is kept patent with a normal saline solution (0.9%) in case intravenous medication should be needed rapidly. yy The blood bottle or bag and tubing are saved not discarded. They are sent to the blood bank for repeat typing and culture. The identifying tags and numbers are verified. yy The symptoms are treated as prescribed and vital signs are monitored. yy The patient’s blood is drawn for plasma, hemoglobin, and culture and retyping. yy A urine sample is collected as soon as possible and sent to the lab for a hemoglobin determination. Subsequent voiding of urine should be observed and recorded oc the patient’s chart yy The blood bank is notified that a suspected transfusion reaction has occurred. yy The reaction is documented according to the institution’s policy.
Venous Cut Down Definition: Dissection of a vein for inserting I.V.Cannula or needle. Purpose yy When vein puncture is difficult. yy When prolonged continuous infusion is needed yy When rapid infusion is important and emergency situation combine these indications. Equipment (All Sterile) yy A bowl with artery forceps and dissecting forceps covered yy Cotton balls in a galipot yy Solution for cleaning yy Gloves yy Fenestrated towel or procedure towel with a hole in the centre. yy Syringe and needles yy Scalpel (surgical knife) 1 yy Mosquito forceps 3 yy Aneurysm needle 1 yy Black silk yy Intravenous cannula or veinflow 2d Needle 1 yy Small, straight scissors 1 yy Small,curved scissors 1 yy Needle holder 1 yy Round Needle 1 yy Cutting Needle 2 yy Tissue forceps 1 yy Gauze pieces yy Probe yy Fine dissecting forceps 1
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yy Local anesthesia
Clean articles yy Receiver for used swabs yy A stand light if available yy Adhesive plaster yy Dressing scissors yy I.V.Stand and drip set up Procedure yy Assemble all equipment in the patientâ&#x20AC;&#x2122;s unit or near then bedside of the patient yy Explain the procedure to the patient yy Shave the area if needed yy Place the patient in a comfortable position yy Wash your hands yy Then the nurse can open the bottle and pour the cleaning lotion into the small bowl or gallipot for the doctor. yy The doctor then scrubs his hands, puts on gloves, cleans and drapes the area, he will insert the I.V. yy The channel is securely tied with silk and skin closed. yy The nurse applies a dressing and secures it with adhesive plaster. yy Remove all equipment, wash and send for sterilization
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III. Administration of Drugs by other routes Administering Vaginal Medications Purpose yy To treat or Prevent infection yy To remove an offensive or irritating discharge yy To reduce inflammation yy To relieve vaginal discomfort. Equipment yy Prescribed vaginal suppository yy Clean gloves 1. Check medication order 2. Wash hands 3. Prepare all articles required for the procedure 4. Identify the patient 5. Provide privacy by means of a screen 6. Inspect the patient’s external genitalia and vaginal canal 7. Explain the procedure to the patient 8. Place the patient in a dorsal recumbent position 9. Keep the patient’s abdomen and lower extremities draped. 10. Use gloves 11. Provide adequate lighting 12. Take the suppository from the wrapper and Insert the suppository with the Lubricated gloved finger of the dominant hand. Offer the patient a perineal pad after cleaning the patient. 13. Record medication administration.
Administering Opthalmic Medication Purposes: Instillation: To provide an eye medication the patient requires. Irrigation: Wash out to clear the eye of noxious or other foreign material, or excessive secretions in the preparation of surgery. yy Check the patient’s medication order yy Ask the patient if he has any known allergies to eye medications. yy Assess the patient’s consciousness and ability to follow directions. yy Explain the procedure to the patient yy Wash hands yy Arrange all articles needed near the bedside of the patient yy Apply clean gloves yy Ask the patient to lie supine or to sit back in the chair with the head slightly hyper extended. yy Wash away any crusts or drainage along the patient’s eyelid margins or inner canthus. yy Soak any crusts that are dried and difficult to remove by applying a damp cotton ball over the eye for a few minutes yy Hold the cotton swab just below the lower eyelid and gently press down with index finger against the bony orbit. yy Ask the patient to look at the ceiling. yy Instill eye drops while explaining steps to the patient. A. With dominant hand resting on the patient’s forehead, hold filled medication eye dropper or ophthalmic solution approximately 1-2 cm above the conjunctival sac. B. Drop prescribed number of of medication drops into the conjunctival sac. C. If the patient blinks or closes the eye or if the drops land on the outer margins, repeat the procedure. D. For drugs that cause systemic effects with a clean tissue apply gentle pressure with your finger and clean tissue on the patient’s naso-lacrimal duct for 30-60 seconds. Page : 93
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Chapter : Wound Care
E. After instilling drops, ask the patient to close eyes gently yy Instill eye ointment. ÔÔ Ask the patient to look at the cealing ÔÔ Holding the ointment applicator above lower lid margin, apply thin stream of ointment evenly along the inner edge of lower eyelid on conjunctiva from inner canthus to outer canthus. ÔÔ Tell the patient to close his eye and rub lid gently in circular motion with a cotton swab, if rubbing is not contraindicated. ÔÔ Document the medication on the patient’s chart
Administering Ear Medications Purpose yy To relieve pain yy To treat infection yy To better visualize during examination. Equipment 1. Check the medicinal order and the original physician’s order 2. Wash hands carefully 3. Prepare the medication following the “Five Rights” 4. Identify the correct patient 5. Wear gloves 6. Ask the patient to lie on the side of the un affected ear 7. Remove excessive drainage with a dry wipe 8. Expose the external ear canal by properly adjusting the patient’s ear lobe. For adults, pull the lobe up, back and outward For children , pull the lobe down and back. 9. Hold the dropper or tip of the squeeze bottle above the opening of the external auditory canal. Allow the prescribed number of drops to fall on the side of the canal 10. Do not touch any part of the ear with the dropper or squeeze bottle during administration. 11. Instruct the patient to remain the side lying position for 5-10 minutes with the effect ear upward. 12. If the procedure is ordered for both the ears, allow 5-10 minutes between instillation. Report the above steps for the other ear. 13. Dispose of gloves and wash hands 14. Document the procedure.
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IV. Inhalation Definition : It is the act of drawing in of gas vapor or steam into the lungs for therapeutic purposes it could be in dry, moist or vapor form.
Oxygen Administration Purpose To provide and maintain a normal supply of O2 for blood, and tissues. O2 may be administered in 3 ways 1. By mask 2. Nasal catheter 3. Oxygen tent.
Giving O2 by mask There are many kinds of masks used for O2 administration the common ones are: 1. The Venture Mask 2. The BLB masks (Boothby, Lovelace & Bulbulain) 3. Oxygen Tent The Venture mask gives a controlled amount of O2 i.e.it is not high to cause respiratory depression & it is sufficient to relieve anoxia. It gives 24-35% of O2. The BLB mask provides an oxygen concentration of 90% with the flow meter set at 7 liters per minute. This kind of mask allows the patient to eat, drink and to expectorate. If the patient cannot breathe through his nose, the BLB mask should not be used. Equipment yy A cylinder of O2 with a reducing valve and pressure tubing to be connected with the O2 cylinder. yy Mask yy Safety pin to secure the tubing to the bed linen yy Tissue paper to clean the nostrils with. If the patient is unconscious, a tray containing a gallipot of saline or water, an artery forceps and a soiled receiver container to receive the soiled swabs is required in order to clean the nostrils. Procedure 1. The adjustment is turned on before bringing the cylinder to the bedside. 2. Explain the treatment to the patient 3. Bring the equipment near the bedside of the patient 4. Ask him to clean his nostrils help him if he is unable to do so. 5. Connect the tubing to the mask and open the fine adjustment to the required rate of flow. Then apply the mask to the patient’s face making sure that it rests comfortably on the patient’s face. See that the tubing is secured to the bed linen by means of safety pins. Stay with the patient till he is reassured if it is his first time to be on oxygen therapy.
Giving O2 by Nasal Catheter Equipment yy O2 cylinder with regulating valve and pressure gauge and tubing yy Wolf’s bottle, glass connection, yy Rubber catheters wrapped in a gauze swab yy Lubricant, adhesive plaster and safety pins yy A gallipot of water or saline yy Container to Receive soiled articles. Procedure 1. The procedure is the same as giving oxygen by mask: 2. Connect the fine catheter to the pressure tubing. Turn on the fine adjustment to the required rate of flow the maximum liter flow being 6-7 liter / minute. 3. Catheter is lubricated preferably with water and passed backward into pharynx till the tip of the catheter is opposite the uvula. The catheter can also be inserted by measuring the distance from the patient’s nose to his ear lobe. It is then taped in place. Never force the catheter against an obstruction.
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Chapter : Wound Care
Note: Oxygen catheter are removed every 8 hrs. And a clean catheter is inserted into the other nostril. A patient receiving oxygen by catheter requires special mouth and nose care since the catheter tends to irritate the mucus membrane. Oxygen dries and irritates the mucus membrane therefore, should be passed through water (Humidified) before it is administered by catheter. The advantage of administration of oxygen by catheter is the freedom of movement that it gives to patients receiving oxygen. By this method patient can obtain about 50% concentration of oxygen.
Steam Inhalations Definition : It is the intake of steam alone or with medication through the nose or mouth. Purpose 1. In order to produce a local effect on the upper respiratory passage during cold, sinusitis, laryngitis, bronchitis etc. common drugs used are (Tincture Benzoin , Eucalyptus, menthol, Camphor). 2. To allay spasm e.g. Asthma, Angina pectoris 3. To increase circulation in the lungs by increasing or decreasing the secretion of the bronchi. E.g. ammonia inhaled in cases of fainting and syncope stimulated the respiratory center and heart action 4. To moisten secretions e.g. Tracheotomy. There are two Types of Inhalation 1. Intermittent (interrupted) e.g. Nelson’s inhaler 2. Steam Inhalation
Nelson’s Inhaler Equipment yy Nelson’s Inhaler with the mouth piece yy Large bath towel yy A bowl to carry the inhaler yy Face towel to wipe the face as patient required yy A gauze piece to place over the mouth piece to prevent burning of the lips. yy A measuring jug with boiling water 820C yy The drug ordered might be eucalyptus, tincture of benzoin (about 5 cc). Procedure yy Explain the procedure to the patient. yy Provide privacy by means of a screen. yy Close the windows yy The inhaler should be warmed and glass connection boiled. yy Measure the drug as ordered. Pour 300 ml of boiling hot water; into the inhaler add 5 cc of tincture benzoin or any drug that is ordered. The level of fluid should not be above the level of the spout. yy Fix the mouth piece firmly in the inhaler in the direction opposite to the air inlet and cover the inhaler with a bath
towel.
yy Place the patient in an upright sitting position and make sure that he is well supported. yy Place the inhaler on a cardiac table or on the pillow over the lap of the patient and ensure that he can bend over the inhaler easily yy Put the spout for the escape of steam away from the patient’s side. yy Cover his head with a bath towel or Blanket. yy Tell the patient to breathe in by putting his lip to the mouth piece which is protected with a piece of gauze, and breathe out by removing his lips for a moment from the mouth piece. yy The treatment can take from 5-10 minutes after which the patient should be kept warm and comfortable for some time. Note: 1. If a Nelson’s inhaler is not available a 25 inches basin may be used. 2. The medication should be added to the boiling water as ordered. 3. The patient should be covered up to the waist with a blanket or a large bath towel. 4. For helpless patient’s stay and assist them throughout the procedure. 5. Report the amount or nature of any sputum or discharge. Page : 96 Page : 96
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Care of the equipment after use. yy Pour out the water from the inhaler (not onto a sink) ace the equipment in the proper place yy Wash the inhaler with hot water. yy Boil the mouth piece. yy Replace the equipment in the proper place yy Document the procedure.
Emergency tray and trolley yy List of emergency drugs
- List of emergency equipment
yy O2 - Tourniquet yy Morphine sulphate
- O2 mask or nasal catheter
yy Adrenaline (Epinephrine)
- Dressing scissors
yy Levophed
- Splint
yy Phenargan
- Small mackintosh and towel
yy Aminophyllin
- Tongue depressor
yy Allercur
- Mouth gag
yy Carmine (Nikethamide)
- Air way
yy Lasix
- Files
yy Syringes and needles both
- Bottle with Alcohol or methyl spirit serum and hypodermic needles
yy Digoxin
- cotton swabs, adhesive plaster.
yy NaHCO3 (Sodium bicarbonate)
- Bandages
yy Vitamin K
- Ryles tube or Levinâ&#x20AC;&#x2122;s tube
yy 0.9% Normal Saline
- Receiver to contain soiled material
yy 5% Glucose with iv set complete yy Inj Largactil yy Ing Diazepam yy Inj Ergometrine yy KCL (Potassium chloride)
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Chapter : Wound Care
UNIT SEVEN WOUND CARE The skin acts as a barrier to protect the body from the potentially harmful external environment. When the skin’s integrity (intactness) is broken, the body’s internal environment is open to microorganisms that cause infection. Any abnormal opening in the skin is a wound. yy A wound may be accidental such as abrasion (rubbing off the skin’s surface.); a puncture wound (stab wound); or laceration (a wound with torn, ragged edges) and is usually contaminated) yy A wound may be intentional such Surgical incision (a wound with clean edges) which are made under sterile conditions.
Wound Healing yy Wound healing differs according to how much tissue has been damaged. It occurs by first, second, and third intention. yy First Intention healing occurs In wounds with minimal tissue loss, such as surgical incisions or sutured wounds. The edges are approximated (close to each other); thus they seal rapidly. Scarring and infection rate with first intention healing are very low. yy Second intention healing occurs with tissue loss, such as in deep laceration, burns, and pressure ulcers, because the edges do not approximate, openings fill with granulation tissue that is soft and pinkish. Later epithelial cells grow over the granulation tissue greater than that for first intention healing. yy Third Intention healing occurs when there is a delay in the time between the injury and the closure of the wound. For e.g. a wound may be left open temporarily to allow for drainage or removal of infectious materials. This type of healing sometimes occurs after surgery, when the wound closes later. In the meantime, wound surfaces start to granulate. Scarring is common. Purpose yy To keep the wound clean yy To prevent wound from injury and contamination yy To keep the drugs applied locally in position yy To keep edges of the wound together by immobilization yy To apply pressure. Equipment Sterile
- Unsterile
yy OT towel (sterile)
- Cheatle forceps in a container
yy Sterile bowl or kidney tray
- Rubber sheet
yy Sterile gauze pieces and cotton swabs
- Adhesive tape or plaster
yy Sterile gallipot
- Bandages
yy 3 Dissecting forceps
- Scissors
yy OT towel (sterile)
- Ointment and any other type of drugs - as needed
yy Antiseptic solution as ordered
- Receiver for soiled materials
yy Methyl spirit Benzoin or ether
- Spatula if needed.
yy Artery Forceps Technique
Aseptic technique to prevent infection Procedure yy Explain the procedure to the patient yy Provide privacy yy A clean trolley or tray is taken yy The sterile equipment is assembled on one side and the clean equipment on the other side. Make sure it is covered.
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yy Wash your hands yy Drape and place the patient in a comfortable position. yy Place the mackintosh and sterile towel under the affected site. yy Remove the outer layer of the dressing e.g. adhesive tape and bandages yy Remove the inner layer of the dressings using the first sterile dissecting forceps and discard both the soiled dressing and the forceps in the respective containers yy Take the second dissecting forceps. Clean the wound with cotton balls soaked in antiseptic solution. yy Again use the second forceps to clean the skin around and remove adhesive with ether. yy Apply medication if any and dress the wound with sterile gauze.
Method of Application yy Ointment and paste must be smeared with a spatula on gauze and then applied to the wound. yy Solutions or powder can be applied direct on the wound. yy Make sure that the wound is properly covered. yy Fix dressing in place using adhesive tape or bandage. yy Leave the patient comfortable and tidy. yy Record the condition of the wound yy Clean and replace all the equipment to their respective places. Note : The above mentioned equipment can be prepared in separate packs if central sterilization department is available.
Dressing of a Septic Wound Purpose yy To absorb material being discharged from the wound yy To apply pressure to the area yy To apply local medication yy Prevent pain, swelling and injury. Equipment Sterile
Unsterile
OT towel (sterile)
Cheatle forceps in a container
Sterile bowl or kidney tray
Rubber sheet
Sterile bowl or kidney tray
Adhesive tape or plaster
Sterile gauze pieces and cotton swabs
Adhesive tape or plaster
Sterile gallipot
Bandages
3 Dissecting forceps
Scissors
OT towel (sterile)
Ointment and any other type of drugs as needed
Antiseptic solution as ordered
Receiver for soiled materials
Antiseptic solution as ordered
Receiver for soiled materials
Antiseptic solution as ordered
Receiver for soiled materials
Antiseptic solution as ordered
Receiver for soiled materials
Methyl spirit Benzoin or ether
Spatula if needed.
yy Artery Forceps yy Sterile test tube or slides. yy Sterile cotton tipped applicator yy Sterile pair of gloves, if needed, in case of gas gangrene, rabies etc. yy Sterile scissors and sterile safety pins.
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Chapter : Peri Operative Nursing Care
Procedure yy Explain the procedure to the patient yy Provide privacy yy A clean trolley or tray is taken yy The sterile equipment is assembled on one side and the clean equipment on the other side. Make sure it is covered. yy Wash your hands and wear gloves if necessary yy Drape and place the patient in a comfortable position. yy Place the mackintosh and sterile towel under the affected site. yy Remove the outer layer of the dressing e.g. adhesive tape and bandages yy Remove the inner layer of the dressings using the first sterile dissecting forceps and discard both the soiled dressing and the forceps in the respective containers yy Observe the wound and check if there are drainage tubes in situ. yy Take the specimen for culture or slide if ordered (Do not cleanse the wound with antiseptic before you obtain the specimen) yy Start cleansing the wound from the cleanest part of the wound to the most contaminated part using antiseptic solution.. yy (H2O2 3% is commonly used for septic wounds. Discard the cotton swab used for cleaning after each stroke over the wound. yy Apply medication if any and dress the wound with sterile gauze make sure that the wound is completely covered yy Fix dressing in place using adhesive tape or bandage. yy Leave the patient comfortable and tidy. yy Record the condition of the wound yy Clean and replace all the equipment to their respective places. yy Discard soiled dressings properly to prevent cross infection in the ward. Note: • If sterile forceps are not available, use sterile gloves. • Immerse used forceps, scissors and other instruments in strong antiseptic solution before cleansing and discard soiled dressing properly • In a big ward it is best to give priority to clean wounds and then to infected /septic wounds, when changing dressings, as this might lessen the risk of cross-infection. • Privacy to be provided for the patient while dressing the wound • Wounds should not be too tightly packed in effort to absorb discharge as this may delay healing.
Dressing With Drainage Tubes Purpose It helps to prevent haematoma or collection of fluid in the affected area. Equipment Same as for other dressings Procedure yy Explain the procedure to the patient yy Provide privacy yy A clean trolley or tray is taken yy The sterile equipment is assembled on one side and the clean equipment on the other side. Make sure it is covered. yy Wash your hands and wear gloves if necessary yy Drape and place the patient in a comfortable position. yy Place the mackintosh and sterile towel under the affected site. yy Remove the outer layer of the dressing e.g. adhesive tape and bandages yy Remove the inner layer of the dressings using the first sterile dissecting forceps and discard both the soiled dressing and the forceps in the respective containers yy Pay attention so that the drainage tube is not pulled out with the old dressing.
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yy Observe the wound and check if there are drainage tubes in situ. yy Take the specimen for culture or slide if ordered (Do not cleanse the wound with antiseptic before you obtain the specimen) yy Start cleansing the wound from the cleanest part of the wound to the most contaminated part using antiseptic solution.. yy (H2O2 3% is commonly used for septic wounds. yy Discard the cotton swab used for cleaning after each stroke over the wound. yy Grasp the top of the drainage tube with sterile forceps. Pull it up a short distance while using gentle rotating and cut off the tip of the drain with sterile scissors (the length to be cut depends on the instructions received). yy Place sterile safety pin through the drainage tube close to the wound using sterile gloves and sterile gauze, if it is in the abdomen yy To stop the drainage tube slipping down out of sight. yy Apply medication if any and dress the wound with sterile gauze make sure that the wound is completely covered yy With spatula apply ointment to the skin directly around to prevent irritation and excoriation. Cut the gauze towards the center to fit around the rubber drainage tube, so that it fits properly around the tube thus preventing discomfort. yy Fix dressing in place using adhesive tape or bandage. yy Leave the patient comfortable and tidy. yy Record the condition of the wound yy Clean and replace all the equipment to their respective places. yy Discard soiled dressings properly to prevent cross infection in the ward.
Wound Irrigation Purpose yy To clean and maintain. Equipment yy Sterile
- Unsterile
yy OT towel (sterile)
- Cheatle forceps in a container
yy Sterile bowl or kidney tray
- Rubber sheet
yy Sterile gauze pieces and cotton swabs
- Adhesive tape or plaster
yy Sterile gallipot
- Bandages
yy 3 Dissecting forceps
- Scissors
yy OT towel (sterile) yy Solutions(H2O2 or Normal saline
- Receiver for soiled materials
yy Methyl spirit Benzoin or ether
- Spatula if needed.
yy Artery Forceps yy Sterile gallipot or kidney tray yy Sterile cotton balls yy Sterile catheter â&#x20AC;˘ Sterile Syringe 20 cc Procedure yy Explain the procedure to the patient yy Provide privacy yy A clean trolley or tray is taken yy The sterile equipment is assembled on one side and the clean equipment on the other side. Make sure it is covered. yy Wash your hands and wear gloves if necessary yy Drape and place the patient in a comfortable position. yy Place the mackintosh and sterile towel under the affected site. yy Remove the outer layer of the dressing e.g. adhesive tape and bandages
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Chapter : Peri Operative Nursing Care
yy Remove the inner layer of the dressings using the first sterile dissecting forceps and discard both the soiled dressing and the forceps in the respective containers yy Put the receiver under the patient to receive the outflow. yy Use Syringe with desired amount of solution fitted with the catheter. yy Use forceps to direct the catheter into the wound. First inject the solution such as H2O2 at body temperature gently and wait for the flow. This must be followed. yy Observe the wound by normal saline for rinsing. yy Make sure the wound is clean and dried properly yy Discard the cotton swab used for cleaning after each stroke over the wound. yy Fix dressing in place using adhesive tape or bandage. yy Leave the patient comfortable and tidy. yy Record the condition of the wound yy Clean and replace all the equipment to their respective places. yy Discard soiled dressings properly to prevent cross infection in the ward.
Suturing Definition: It is the application of stitches on body tissues with the surgical needle and catgut or thread. Purpose yy To approximate wound edges until healing occurs. yy To speed up the healing process. yy To minimize the chance of infection Equipment A tray or trolley covered with a sterile OT Towel Sterile needle holder Sterile needles cutting and round Sterile Black silk and Catgut Sterile artery forceps, dissecting forceps Sterile suture scissors Sterile cotton in a Galipot Sterile solution for cleaning Sterile gauze pieces Receiver for soiled material. Plaster, dressing scissors, Local anaesthesia Sterile syringes and needles Sterile gloves Sterile towels for draping the needle. Procedure yy Explain the procedure to the patient yy Adjust the light yy Wash your hands yy Clean the wound thoroughly yy Wash your hands again yy Put on sterile gloves yy Drape the wound with sterile OT Towels yy Infiltrate the edges of the wound to be sutured with local anesthesia yy Approximate the edges of the fascia with the help of the tissue forceps and using round body needle and cat-gut Suture the fascia layer first. yy Using the cutting needle and silk suture the outer layer of the skin approximate the edges of the fascia with the help of the tissue forceps
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yy Clean with Betadine and cover with sterile gauze yy Remove all equipment, wash and return to its proper place and send for sterilization yy Wash your hands. Note: yy Do not suture wounds that are over 12 hrs old. However, such wounds have to be seen by a doctor since excision of all dead and devitalized tissue and eventful suturing may be required. yy Check that the patient gets his order for T.A.T. before he leaves the hospital yy Do not suture deep wounds yy Before you suture any wound be sure it is free of any foreign bodies.
Removal of stitch (use aseptic technique )
Principles yy Sutures may be removed all at a time or may be removed alternatively. yy Do not cut stitches in more than one place as a part of it may be left behind and may cause infection. yy Suture is lifted slightly by the knot to allow scissors to go under and one part of the suturing from the cleanest part of the wound to the most contaminated part. yy Cleanse the skin around with antiseptic. Remove â&#x20AC;&#x201C; adhesive plaster with ether and discard the forceps. yy Take a pair of scissors in the right hand yy Take a dissecting forceps in the left hand yy Pull â&#x20AC;&#x201C;up gently the knot resting against the skin with the forceps, pass the point of the scissors under the knot then cut the stitch on one side and remove. yy Place the removed stitches on a sterile piece of gauze yy Inspect the scar for wound healing and apply betadine on the skin punctures yy Apply dressing yy Keep the patient comfortable and tidy yy Record the state of the wound yy Clean and return equipment to their proper places.
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Clips Definition: Metal suture used to stitch the skin Purpose yy To approximate wound edges until healing occurs. yy To speed up the healing process. yy To minimize the chance of infection Equipment yy Same as for suturing with stitches yy Mitchel Clips applier yy Metal clips yy Tissue forceps (Toothed dissecting forceps) yy Procedure yy The first part of the procedure is the same same as for suturing with stitches except that instead of suturing the skin with thread and needle .you would apply clips with the applier. Removal of clips yy Technique---Use aseptic technique Equipment yy Sterile Gauze, Sterile cotton balls, yy Sterile kidney tray. Sterile forceps-3 yy Sterile clip removing forceps yy Antiseptic solution (Savlon 1% and iodine) yy Used swab receiver yy Savlon, Betadine and ether yy Adhesive tape, bandage Procedure yy Explain the procedure to the patient and organize the needed equipment yy Provide privacy yy Drape the patient and position him comfortably yy Protect the bed linen with a rubber sheet and towel yy Remove old dressings and discard them into a soiled container. yy Cleanse the wound with antiseptic solution starting from the cleanest part of the wound to the most contaminated part and discard the cotton ball. yy Take the clip remover with the right hand and dissecting forceps in the left. yy Insert the lower blade of the clip remove below the middle of the clip using the dissecting forceps as a support. yy Hold the clips in place, and close the blade firmly as this will cause the clips to leave the skin. yy Place a gauze piece to receive the removed clips yy Apply iodine to the skin punctures and dress the wound if required.Secure the dressing in place with adhesive tape yy Leave the patient comfortably and tidy yy Clean and return the equipment to its proper place
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Chapter : Care Of the Dying and Post Mortem Care
UNIT EIGHT PERI OPERATIVE NURSING CARE PRE & POST OPERATIVE NURSING CARE Pre-operative Purpose yy To prepare the patient emotionally, mentally and physically for surgery yy To prevent any complications before, during and after surgery. Equipment yy It is important that the patient be in a good state of physical health before surgery Unless it is an emergency operation yy He should have a balancd diet, fluid sleep and rest before his surgery yy The patient’s mental state is important to his recovery. yy Try to relieve his fears about the operation and any fear of death: yy Explain to him what will be done and that every measure will be taken for his safety. Procedure The day before surgery:
Physical preparation yy Give the patient a complete bed bath to keep the body clean before surgery. Give special attention to the umbilicus and other areas of the body. Keep the fingernails and the nails of the toes short and clean. yy Be sure the patient’s hair is clean. If the surgery is on the face, neck, shoulders or upper chest, the hair should be washed thoroughly, combed and tied up to keep it from touching the operative area. If the surgery is on the head the area must be shaved and the hair washed. yy If an enema has been ordered, give it when ordered and be sure that it is effective. Chart the results.
Psychological preparation yy If the patient does not understand what will be done Explain briefly what the operation is and how it will help him. Avoid telling him anything that would disturb him and make him worry. yy It is important that the patient has a good sleep the night before his operation. Make him comfortable and turn out the light in his room early, if he is unable to sleep report to the doctor yy The patient and relative must sign the consent for the surgery. yy Instruct the patient about deep breathing and coughing exercises.
Day of surgery should yy If the surgery is in the morning be sure the patient is prepared early anything abnormal such as pain, fever, cough, rapid pulse or elevated blood pressure must be reported immediately. The surgery may have to be cancelled or delayed until the patient is well. yy If the surgery is in the morning nothing should be taken by mouth after midnight (N.P.O.) If the surgery is in the afternoon, fluids and food should not be taken in the morning depending on the orders. yy Shave the hair from the skin of the operative area thoroughly. Someone should check to see if all the hair has been removed. Wash the skin well with soap and water before and after shaving. yy Check the orders for pre-operative treatment such as enema, catheterization, passing a Ryle’s tube and leaving it in situ. yy The patient’s temperature, pulse, respiration and blood pressure should be taken and recorded on the chart just before surgery. yy Give the premedication as ordered, being careful to give the right drug to the right patient, and check the patient’s case records. Page : 105
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Just before surgery yy In case the patient does not have an indwelling catheter in situ ask him if he would like to pass urine, yy Assist the patient to move on to the stretcher. The patient may be very sleepy or dizzy from the premedication given and may hurt himself and fall down. yy Support the stretcher to keep it from rolling as the patient moves onto it. yy Make sure his elbows are close to his sides or over his chest to prevent them from being hurt as the stretcher passes through doorways. yy Reassure him as you take him to the operating room. yy Make sure the chart is complete and is accompanied with the patient to the operation theatre.
Shaving Purpose yy To minimize the danger of infection by decreasing the number of bacteria on the skin. Equipment yy Basin of warm water. yy Wash cloth yy Soap, Towel , Razor and blades yy Scissors yy Procedure mackintosh and towel. Procedure yy Explain the procedure to the patient yy Provide privacy by means of a screen yy Prepare the equipment and bring it to the bedside of the patient yy Fold the top linen and cover the patient. . yy Leave the soap lather on while you shave the patient yy When all the hair has been shaved off, rinse the skin with clear water. (If hair is long it could be cut short before shaving the part) yy Be sure to wash all the creases and folds very well. yy Rinse with clean water. yy Repeat washing until the area is clean. yy Dry the skin well yy Make the patient comfortable.
Specific Area to be shaved: the head Head operations yy Explain the reason for shaving the head to the patient yy If hair is long, it must be cut short, yy Wash the head and hair well yy Shave the area of the operation as directed Eye operations yy Cut the eyelashes as close as possible on both sides yy Use some Vaseline on the blades of the scissors before you begin to prevent the eyelashes from falling into the eye. yy Shave the eyebrows on both sides only if ordered. Face operation yy Shave the site of the operation yy If the patient is a man, make sure that the face is completely free of beard. yy Wash the face; be careful not to get soap into the patientâ&#x20AC;&#x2122;s eyes.
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Anterior neck operations yy Wash the patients head and neck well yy If the patient is a female, braid and tie her hair and keep it away from her neck. yy Shave the front and sides of the neck from the chin to the end of sternum, and out to the shoulders. yy The area must be clean. Posterior neck operations yy The head and neck should be washed. yy Shave at least 15 cms, and around the site of incision. Spinal operations yy Confirm the site of operation yy Shave 15-20 cm, all around the area of incises Breast operations yy Shave the anterior and posterior chest from neck to waist line on the side where the surgery will be yy Shave the axilla on that side and the arm as far down as the elbow. Kidney operations yy Turn the patient on the side with the operative side upward. yy Shave from the sternum to the groin and across the side the same width up to the spinal column. Abdominal operations yy Shave the whole abdomen from the end of the sternum down to the pubes yy The umbilicus must be clean Perineal and rectal operations yy The pubic and perineal hair must be shaved from the pubes to anal area. yy Shave at least 15 cm down the inside of the thighs both sides. Limb Operations yy The whole limb should be washed well yy Shave at least 15 cm all around the operative site. yy If the operation is on the upper arm or the upper leg. The axilla or perineum should be shaved as well. yy If the operation is near the hand or foot cut the nails very short and clean them well.
Intraoperative Nursing Care yy Observing a patient undergoing surgery may be a component of a nursing studentâ&#x20AC;&#x2122;s experience. Doing so will not only give the student a better idea of surgical procedures, but it will also help in understanding the patientâ&#x20AC;&#x2122;s feelings and apprehensions. Special training is mostly given in operation room technique and anaesthesia.Nurses assist surgeons in the operating room yy The two basic categories of assistants are the sterile assistant and the circulating assistant. yy The sterile assistant or scrub nurse He or she is scrubbed, gowned, gloved, and functions within a sterile field. The duties include handling instruments to the surgeon, threading needles, Cutting sutures, assisting with retraction and suction and handling specimens. yy The Circulating assistant He/she works outside the sterile field. Duties include opening sterile packs, delivering supplies and instruments to the sterile team, delivering medications to the sterile nurse, labeling specimens, and keeping records during surgical procedure. This person acts as a patients advocate by monitoring the situation and maintaining safety in the operating room. The Operation Theatre nurses must be registered nurses.
Post Operative Care. Purpose yy To prevent any complications from anaesthesia. yy To detect any sign of postâ&#x20AC;&#x201C;operative complications yy To rehabilitate the patient
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Equipment yy A unit with a bed, oxygen apparatus, sphygmomanometer, stethoscope, suction apparatus I.V.stand, Gauze pieces in a galipot, crash cart ready with all emergency drugs, Kidney tray and bed blocks. Procedure yy Prepare a post operative bed. yy Assist the operating room nurse in placing the patient in the bed, an unconscious patient may be placed on either his right or left side unless specified. yy Check post operative orders and adjust flow of I.V.fluids. yy Take blood pressure, pulse, and respiration as ordered (usually every 15 minutes until the patient is stable) yy Encourage patient to cough and breathe deeply. yy Check dressing for any excessive bleeding or drainage. yy Check for tubes to be connected to drainage bottles- no kinks in tubing. Secure tubing with bedding. yy If patient vomits, turn his head to the side to prevent aspiration and chocking. yy Observe patient closely for any signs of shock and haemorrhage. yy Document all the findings on the patients chart yy Report any untoward symptom immediately.
Charting yy The time of return from the operating room yy General Condition and appearance yy State of consciousness yy Color of the skin yy Temperature of the skin to touch yy Skin—moist or dry. yy Blood pressure, pulse and respiration yy Any unusual condition such as bleeding, drainage, vomiting etc.
General instructions ÁÁ If patient shows any signs of shock immediate action should be taken and then reported to the doctor. The head of the bed should be lowered and bed blocks may be used. ÁÁ Do not leave the unconscious patient alone. ÁÁ Keep patient flat in bed with then head turned to one side.( no pillows) and avoid chilling. ÁÁ Watch color of skin, lips, and fingernails carefully. ÁÁ If there is any bleeding carry out the necessary measures and report immediately? ÁÁ If the patient is having any pain after he is awake, analgesics may be given according to orders. ÁÁ Limit visitors in the patients room ÁÁ Carryout post operative orders carefully ÁÁ Document all findings. ÁÁ Place patient in a comfortable position.
Post Operative Care of Specific Surgeries Brain surgery yy Patient must lie on his back without pillows unless ordered otherwise. yy Room should be cool and dark to prevent irritation to the brain (Cerebral irritation)
Breast surgery yy Encourage deep breathing often, because of danger of pneumonia yy Special arm exercises should be given
Abdominal surgery yy Encourage deep breathing yy Turn the patient from side to side often Page :108
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yy On the first post operative day make the patient sit on the edge of the bed. yy And start walking the second post operative day unless contraindicated. yy Intake/output chart to be recorded. yy Make sure that the gastric suction is functioning properly if used. yy Frequent mouth washes to be given to patients who are not allowed to take anything orally Eye surgery yy The patient must lie very still because the incision and sutures can be damaged by pulling on the eye muscles. Both eyes may be covered. yy The room must be cool, quiet and dark yy The patient must be fed.
Spinal surgery yy Must lie on abdomen with the bed flat , supported with pillows and the head turned to one side. yy Pressure points to be attended to prevent pressure sores
Thyroidectomy yy Place the patient in a high fowler’s position. This will make it easier for the patient to breathe since the pressure of the dressing and swelling may give a chocking feeling. yy An emergency tracheotomy set should always be at the bedside or nursing station for the first 3 days, in case of haemorrhage or swelling of the trachea yy The complication” thyroid crisis” must be reported immediately as death can occur if condition is not treated quickly.
Tonsillectomy (Child) yy Let the child lie on the abdomen or side to prevent blood drainage into the throat, lungs or stomach. yy Watch carefully for excessive bleeding (Adult) yy If conscious, he may sit in a semi-fowlers position in order to spit out the blood collected in the mouth more easily. yy Watch carefully for excessive bleeding.
Study questions 1. Mention the purpose of pre operative nursing care. 2. Why is shaving indicated before surgery? 3. Differentiate between the roles of a scrub nurse and a circulating nurse in the OT. 4. State the purpose of post operative nursing care 5. List some important equipment to provide care for immediate post operative patients 6. Why is informed written consent required before surgery?
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Nursing Training Manual
Chapter : Introduction
UNIT NINE CARE OF THE DYING AND POST MORTEM CARE A . Care of the dying Death:-It is a natural part of life and comes to all beings. It is the end of life and all the vital processes. Legal death is the total absence of brain activity as assessed and pronounced by the physician.
Spirituality and Death Death often forces people to consider profaned questions: the meaning of life, the existence of the soul, and the possibility of an afterlife. Individuals faced with death, their close friends, and family often relies on a spiritual foundation to help them to meet these challenging concepts. Spirituality takes several forms. Bernard and Schneider mention three levels of spiritual support for dying persons. yy The first level is drawing strength from God yy The second level is strength generated by prayer. yy The third level is strength from caring relationships with others. For those whose spirituality does not include beliefs rooted in organized religion, support may take the form of compassionate care and the acceptance of personal beliefs. Consider the spiritual dimension of your patients needs. Meeting basic human needs is an expression of caring that dying individuals will appreciate even if they can no longer communicate with you verbally.
Stages Of Dying Elisabeth Kubler-Ross (1969) has beautifully described the phases of dying, which mirror those of the grieving process. As a person learns of his or her own impending death, he or she experiences grief in relation to his or her own loss. yy The first stage, as Dr Ross views this process, is that of denial. The denial may be partial or complete and may occur not only during the first stages of illness or confrontation but later on from time to time. This initial denial is usually a temporary defense and is used as a buffer until such time as the person is able to collect him or herself, mobilize his or her defenses, and face the inevitability of death. yy The second stage is often anger; the person feels violent anger at having to give up life. This emotion may be directed toward persons in the environment or even projected into the environment at random. Dr Ross discusses this reaction and the difficulty in handling it for those close to the patient by explaining that we should put ourselves in the patients place and consider how we might feel intense anger at having our life interrupted abruptly. yy The third stage is bargaining. The person attempts to strike a bargain for more time to live or more time to be without pain in return for doing something for God. Often during this stage the person turns or returns to religion. yy The fourth stage is depression. Usually, when people have completed the processes of denial, anger, and bargaining, they move into depression. Dr Ross writes about two kinds of depression. One is preparatory depression; this a tool for dealing with the impending loss. The second type is reactive depression. In this form of depression, the person is reacting against the impending loss of life and grieves for him or herself. yy The final stage of dying is that of acceptance. This occurs when the person has worked through the previous stages and accepts his or her own inevitable death. With full acceptance of impending death comes the preparation for it, however, even with acceptance, hope is still present and needs to be supported realistically. Many factors influence how individuals accept death. Personal values and beliefs about life; views of personal successes, both financial and emotional; the way they look physically when experiencing the dying process; their family and friends and their families attitudes and reactions; their past experiences in coping with difficult or traumatic situations, and finally, the health care staff Who are caring for them during this process. â&#x20AC;&#x201C; All affect an individualâ&#x20AC;&#x2122;s attitude toward dying.
Nursing Process : Assessment Observe the physical symptoms yy Evidence of circulatory failure yy Variation in blood pressure and pulse Page :110
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yy Disequilibrium of body mechanisms yy Deterioration of physical and mental capabilities yy Absence of corneal reflex Observe the client’s ability to fulfill basic needs without complete assistance. yy Assess the nature and degree of pain the client is experiencing. yy Observe for impending crisis or emergency situation. yy Observe for psychosocial condition. yy Need to establish a relationship for support. yy Grief pattern and stage of grief the patient is experiencing yy Need to express feelings and verbalize fears and concerns. Determine anxiety level which may be expressed in physical or emotional behavior. yy Sleep disturbance yy Palpitations yy Digestive complaints yy Anger or hostility yy Withdrawal Determine depression level that the patient may be experiencing. yy High fatigue level or lethargy yy Poor appetite, nausea, or vomiting. yy Inability to concentrate yy Expressions of sadness, hopelessness, or uselessness. Planning/Objectives yy To assist the dying patient to cope with the dying process yy To handle own feelings of loss and sadness that arise when caring for a patient who is dying yy To provide support for the patient and the patient’s family during the dying process. yy To complete the actions necessary to care for the patient who has died. Implementation / procedure Assist the dying patient 1. Minimize the patient’s discomfort as much as possible. a) Provide warmth b) Provide assistance in moving, and position patient frequently. c) Provide assistance in bathing and personal hygiene. d) Administer the appropriate medications before the pain becomes severe. 2. Recognize the symptoms of urgency or emergency conditions and seek immediate assistance. 3. Notify the charge nurse if there is an impending crisis and perform emergency actions until help arrives. 4. Encourage dying patient’s to do as much as they can for themselves so that they do not just give up-a state that only reinforces low self-esteem. 5. Provide emotional nursing care for the patient. a. Form a relationship with the dying patient. Be willing to be involved, to care, and to be committed to caring for a dying patient. b. Allocate time to spend with the patient so that not only physical care is administered. c. Recognize the grief pattern and support the patient as he/she moves through it. d. Recognize that your physical presence is comforting by staying physically close to the patient if he or she is frightened. Use touch if appropriate and nonverbal communication. e. Respect the patient’s need for privacy and withdraw if the patient has a need to be alone or to disengage from personal relationships. f. Be tuned into patients cues that he or she wants to talk and express feelings, cry, or even intellectually discuss the dying process. g. Accept the patient at the level on which he or she is functioning without making judgments. 6. Provide the level of care that encourages the patient to retain confidence in the health care tea. Page : 111
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7. Assist the patient through the experience of dying in whatever way you are able to do so. 8. Support the family of the dying patient a. Understand that the family may be going through anticipatory grief before the actual event of dying b. Understand that different family members react differently to the impending death and support the different reactions. c. Be aware that demonstrating your concern and caring assists the family to cope with the grief process. 9. Be aware of your own personal orientation toward the dying process.ng a. Explore your own feelings about death and dying with the understanding that until you have faced the subject of death you will be inadequate to support the patient or the family as they experience the dying process. b. Share your feelings about dying with the staff and others; actively work through them so that negativity does not get transferred to the patient.
Care after Death Definition : This is the care given to the body after death. It is also called Post mortem- care. Purpose burial 1. To show respect for the dead 2. To prepare the body for funeral (burial / cremation) 3. To prevent spread of infection 4. To show kindness to the family. Equipment yy A bucket with water, mug and a basin yy Wash cloths and towel yy Gloves yy Cotton, gauze, bandages 2 inches size yy A clean sheet to pack the body yy Forceps-Artery and dissecting yy Name tag. Procedure yy Note the exact time of death and chart it yy Call the doctor to declare the death and certify it. yy If the family members are not present send for them. yy Assemble all the required equipment near the bedside of the patient yy Provide privacy by means of a screen yy Close the doors of the room or draw the curtains to cut of the view from other patients yy Raise the bed to a comfortable working level yy Wash hands and wear clean gloves yy Remove NG Tubes, oxygen catheter, I.V.Drips, Leads and other devices from the body. yy Place the patient in the supine position yy Give the patient a sponge bath, close his eyes, plug the nose, ears, and rectal orifice with cotton swabs. yy Replace soiled dressings with clean ones when possible yy Brush or comb the patientâ&#x20AC;&#x2122;s hair and braid it. yy Care for the valuables and personal belongings, make a duplicate list and hand it over to a responsible family member in the presence of a witness. yy Allow the family members to view the patient and remain in the room. yy Position the hands of the patient to the sides of the body, cross the forearms over the chest and tie the thumbs together with a bandage. yy Tie the big toes together and affix the name tag to the body according to the policy of the agency. yy Wrap the patient up in a clean sheet and.await the arrival of the ambulance or transfer to the morgue yy Remove the gloves, wash handDocument the procedure and keep a copy of the death certificate pinned to the body. Page :111
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Study questions 1. Define death. 2. What are the stages experienced by a dying person? 3. How do you confirm the occurrence of death? 4. What are the purposes of post mortem care? Hands and using circular movements, massage the middle of the patient’s lower back. yy Next stroke upwards and massage the areas over the right and left shoulder blades, again using circular motions. yy Then stroke downward and end by massaging the iliac crests, the large muscles or the right and left buttocks.k yy Repeat this process for three to five minutes, then take of any extra lotion left on the skin with a towel. yy When massaging the back, check the skin for redness since they may develop into pressure sores or Decubitis ulcers. yy Decubitus ulcers or pressure sores are among the complications of bed rest. yy They usually form on bony parts of the body such as the elbows and hips, knees, and the sacrum or big bone at the back of the pelvis. yy The area first looks red, and then an open sore develops. yy If the ulcer is not treated in time, damage continues and the tissues below the skin are affected, even the muscle and bone are involved. yy Untreated sores may easily become infected. Causes: yy Immobilization & lack of normal movements yy friction, yy moisture & heat yy Shearing force
Sensory & motor deficit Circulatory deficiencies yy Poor nutrition yy Edema yy Infection yy Advancing age & debilitation yy Equipments
Stages of Decubitus Ulcer : yy Pressure ulcers are categorized into four stages depending on the level of tissue involvement, or depth of the sore. yy The tissue being referred to includes the skin and underlying dermis, fat, muscle, bone, and joint. yy Knowing the appropriate stage assists in the prognosis and management of the ulcer. yy Stage 1 : ÔÔ It is the most superficial, indicated by nonblanchable redness that does not subside after pressure is relieved, ÔÔ Redness increased to a dusky, cyanotic blue gray color which is the result of skin capillary occlusion and subcutaneous weakening. yy Stage-2 is damage to the epidermis extending into, but no deeper than, the dermis. ÔÔ In this stage, the ulcer may be referred to as a blister or abrasion. yy Stage-3 involves the full thickness of the skin and may extend into the subcutaneous tissue layer. ÔÔ This layer has a relatively poor blood supply and can be difficult to heal. ÔÔ At this stage, there may be undermining damage that makes the wound much larger than it may seem on the surface.
Nursing Management For Skin Risk : 1. Releiving pressure. 2. Proper positioning. 3. Pressure relieving devices. 4. Improving mobility.
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5. Improving sensory perception 6. Improving tissue perfusion. 7. Improving nutritional status. 8. Reducing friction/shear. 9. Minimize moisture.
RELIEVING PRESSURE. yy Frequent changes of position are needed to relieve and redistribute pressure. yy This can be accomplished by teaching the patient to change position or by turning or repositioning the patient. yy Turned or reposition 1 or 2 hrs intervals according to skin status. yy Encourage patient to shift weight actively every 15min. yy Check for improperly fitted or worn braces and restraints yy Keep linen dry and free from wrinkles and hard objects such as crumbs and food particles etc.
PROPER POSITIONING yy Patient should be positioned laterally, prone and dorsally in sequence unless not tolerated or contra-indicated. yy Recumbent position is preferred to the semi fowlers Position because of increase supporting surface area in this position. yy In addition to regular turning, reposition of ankle, elbow and shoulder. yy Another way to relieve pressure is bridging technique as pillow support. yy Encourage the person sitting in a wheelchair to raise themselves every 10 minutes to relieve pressure, or assist the person to do so. yy Change the personâ&#x20AC;&#x2122;s position at least every 2 hours. Some people will require positioning more often. yy Pressure Relieving Devices: yy Special equipment and bed may be used to relieve pressure on skin. (Mattress or air mattress may be used to prevent pressure on skin.) yy These are designed to provide support for specific body areas. yy Patient sitting in wheel chair should have wheel chair cushion. yy Use mechanical aids, such as foam padding, or an alternating pressure mattress, to relieve pressure on bony parts of the body such as the back of the pelvis (sacrum). yy Raising the heels makes them less likely to develop pressure sores yy Elevate the head of the bed no higher than 30 degrees, to prevent a shearing effect on the tissues yy Check for improperly fitted or worn braces and restraints.
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