Fundamentals of Nursing Skill Lab Manua
Fundamentals of Nursing Skill Lab Manua
Fundamentals of Nursing Skill Lab Manua
Produced By
1. Jimma University
2. Wallo University
3. Hawassa University
4. Mekele University
5. Haromaya University
6. Gondar University
7. Hawassa Health Science college
8. Harar Health Science College
9. Sheba University
10. Alkan University College
11. Bahirdar Health Science College
12. Central University College
13. Ethiopian Nurse Association
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Fundamental of Nursing skill lab manual
For Health Science Student
Table of contents
Table of contents................................................................................................................................................................................ i
Contributors .................................................................................................................................................................................... vii
Preface ............................................................................................................................................................................................. xi
Acknowledgement ......................................................................................................................................................................... xiv
List of acrnomies and abbreviations ............................................................................................................................................... xv
CHAPTER ONE: INTRODUCTION TO NURSING PROFESSION ............................................................................................. 1
1.1. History of Nursing ..................................................................................................................................................... 1
1.2. Nursing Processes ...................................................................................................................................................... 3
CHAPTER TWO: DOCUMENTATION (RECORDING AND REPORTING) .............................................................................. 7
2.1. Documentation and charting ...................................................................................................................................... 7
2.2. Caring for a patient during admission ...................................................................................................................... 11
2.3. Transfer of the patient .............................................................................................................................................. 14
2.4. Caring for a patient on discharge ............................................................................................................................. 16
Discharging a patient against medical advice (AMA) ..................................................................................... 18
2.5. Critical incident reporting ........................................................................................................................................ 19
2.6. Nursing progress note .............................................................................................................................................. 21
CHAPTER THREE:INFECTION PREVENTION......................................................................................................................... 25
3.1. Hand Hygiene .......................................................................................................................................................... 25
3.1.1. Hand washing ........................................................................................................................................ 25
3.1.2. Hand antisepsis...................................................................................................................................... 27
3.1.3. Antiseptic hand rub ............................................................................................................................... 28
3.1.4.Surgical hand scrub……………………………………………………………………………………………………………………….29
3.2. Donning and removing Personal protective equipment ............................................................................................ 29
3.2.1. Donning and removing gloves ............................................................................................................... 30
3.2.2. Donning and removing surgical Gowns ................................................................................................ 34
3.2.3. Donning a Cap, Mask and goggle ......................................................................................................... 34
3.3. Preparing and Maintaining a Sterile Field ................................................................................................................ 36
3.4. Instrument processing .............................................................................................................................................. 38
3.4.1. Decontamination, cleaning, drying and packing................................................................................... 38
3.4.2. Sterilization ........................................................................................................................................... 40
3.4.3. High level disinfection .......................................................................................................................... 41
3.5. Healthcare waste management ................................................................................................................................. 43
Waste Segregation ........................................................................................................................................... 43
3.6. House keeping .......................................................................................................................................................... 44
3.6.1. Patient unit care ..................................................................................................................................... 44
3.6.2. Terminal cleansing of the patient care unit ............................................................................................ 46
3.7. Linen processing ...................................................................................................................................................... 47
CHAPTER FOUR: MANAGING PATIENT SAFETY AND COMFORT ............................................................................. 49
4.1. Applying cotton rings............................................................................................................................................... 50
4.2. Applying foot – board .............................................................................................................................................. 51
4.3. Applying pillows ...................................................................................................................................................... 53
4.4. Applying air rings .................................................................................................................................................... 53
4.5. Applying bed cradle ................................................................................................................................................. 54
4.6. Adjusting side rails of the bed .................................................................................................................................. 56
4.7. Applying sand bag ................................................................................................................................................... 57
4.8. Applying splint......................................................................................................................................................... 58
4.9. Appling fracture board ............................................................................................................................................. 60
4.10. Applying back rest ................................................................................................................................................. 61
CHAPTER FIVE: BODY MECHANICS AND MOVING ....................................................................................................... 62
5.1. Maintaining body alignment .................................................................................................................................... 62
5.1.1. Checking proper/normal alignment of spine ......................................................................................... 62
5.1.2. Checking proper standing body alignment ............................................................................................ 63
5.1.3. Checking proper sitting posture............................................................................................................. 64
5.1.4. Checking proper alignment of client in lying posture............................................................................ 65
5.2. Lifting the patient ..................................................................................................................................................... 67
5.2.1 Dangling ................................................................................................................................................. 67
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Fundamental of Nursing skill lab manual
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5.2.2. Log rolling............................................................................................................................................. 69
5.2.3. Moving patient up in bed with two nurses using draw sheet ................................................................. 71
5.3. Positioning the patient .............................................................................................................................................. 72
5.3.1. Front lying (prone) ................................................................................................................................ 73
5.3.2. Semi-prone position(or Sims‘ position) ................................................................................................. 75
5.3.3. Supine (back lying) ............................................................................................................................... 77
5.3.4. Dorsal recumbent position .................................................................................................................... 79
5.3.5. Lateral recumbent (on either side) ......................................................................................................... 81
5.3.6. Knee chest ............................................................................................................................................. 83
5.3.7. Fowler's position (semi-upright with back and knee rests elevated) ...................................................... 84
5.3.8. Trendelenburg position.......................................................................................................................... 87
5.3.9. Lithotomy position ................................................................................................................................ 88
5.4. Patient ambulation.................................................................................................................................................... 90
5.4.1. Preparing the Client to Walk/ambulate.................................................................................................. 91
5.4.2. Assisting patient with assistive devices ................................................................................................. 92
5.4.2.1. Gait belt .............................................................................................................................. 92
5.4.2.2. Cane.................................................................................................................................... 94
5.4.2.3.Walker ................................................................................................................................. 96
5.4.2.4. Crutch ................................................................................................................................. 98
5.4.2.1. Two-point gait .................................................................................................. 100
5.4.2.2. Three point gait ................................................................................................. 101
5.4.2.3. Four point gait .................................................................................................. 103
5.4.2.4. Swing to gait ..................................................................................................... 104
5.4.2.5. Swing through gait ............................................................................................ 105
5.4.2.6. Up and down stair gait ...................................................................................... 107
5.5. Patient transfers ...................................................................................................................................................... 108
5.5.1. Transferring a Client from Bed to Chair………………………………………………….………..115
5.5.2. Transferring a Client from Bed to Stretcher .................................................................................... 1106
5.6. Range of motion exercise/ROM ............................................................................................................................. 112
CHAPTER SIX: ESSENTIAL ASSESSMENT COMPONENTS .......................................................................................... 115
6.1. Measuring patient vital sign ................................................................................................................................... 115
6.1.1. Taking patient body temperature ......................................................................................................... 115
6.1.1.1. Taking patient body temperature Oral…………………………………….…………….122
6.1.1.2.Taking patient body temperature (axilary)......................................................................... 117
6.1.1.3. Measuring rectal temperature ........................................................................................... 118
6.1.1.4. Measuring tympanic temperature ..................................................................................... 120
6.1.2. Assessing patient pulse ........................................................................................................................ 121
6.1.3. Assessing patient respiration ............................................................................................................... 123
6.1.4. Assessing patient blood pressure ......................................................................................................... 124
6.1.5. Measuring height and weight .............................................................................................................. 126
6.2. Collecting Specimen……………………….………………...……………...……………………………………………………146
6.2.1.Taking urine specimen ......................................................................................................................... 127
6.2.1.1. Random collection ............................................................................................................ 128
6.2.1.2.Timed urine specimen collection ....................................................................................... 129
6.2.1.3.Mid stream (clean-voided) urine specimen ........................................................................ 130
6.2.1.4.Catheterized urine specimen for female client ................................................................... 132
6.2.1.5.Catheterized urine specimen for male client ...................................................................... 133
6.2.2.Collecting stool specimen .................................................................................................................... 135
6.2.3.Taking blood specimen ........................................................................................................................ 136
6.2.3.1.Vein puncture .................................................................................................................... 137
6.2.3.1.Capillary or peripheral blood specimen ............................................................................. 138
6.2.3.1.Arterial specimen by puncture ........................................................................................... 139
6.2.4.Taking sputum specimen ...................................................................................................................... 141
6.2.5.Obtaining wound drainage specimen for culture .................................................................................. 142
6.2.6.Collecting Nose, Throat, and Sputum Specimens ................................................................................ 144
CHAPTER SEVEN: MAKING AND MAINTAINING BED ................................................................................................. 146
7.1. Stripping of a bed ................................................................................................................................................... 147
7.2. Making unoccupied bed ......................................................................................................................................... 148
7.2.1. Closed bed ........................................................................................................................................... 148
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Fundamental of Nursing skill lab manual
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7.2.2. Open bed ............................................................................................................................................. 151
7.3. Making an occupied bed ........................................................................................................................................ 152
7.4. Making cardiac bed ................................................................................................................................................ 155
7.5. Post operative/anesthetic bed making .................................................................................................................... 157
7.6. Marking an amputation bed.................................................................................................................................... 159
7.7. Fracture bed making............................................................................................................................................... 161
7.8. Baby crib ................................................................................................................................................................ 163
CHAPTER EIGHT: HYGIENE CARE AND GROOMING .................................................................................................. 164
8.1. Bed bath ................................................................................................................................................................. 164
8.2.Giving tub bath ....................................................................................................................................................... 167
8.3.Giving back care ..................................................................................................................................................... 169
8.4.Mouth care .............................................................................................................................................................. 171
8.5.Care of dentures ...................................................................................................................................................... 173
8.6.Giving bedpan and urinals ...................................................................................................................................... 174
8.7.Perineal care ............................................................................................................................................................ 177
8.8.Sitz bath .................................................................................................................................................................. 179
8.9.Hand and foot care .................................................................................................................................................. 181
8.10.Facial hair shaving ................................................................................................................................................ 183
8.11.Assisting individuals to dress ................................................................................................................................ 185
8.12.Giving hair Care .................................................................................................................................................... 186
8.13.Hair shampoo ........................................................................................................................................................ 187
8.14.Giving pediculosis treatment ................................................................................................................................. 189
8.15.Care of eye …………………………………………………………………………………………..…………..192
8.16.Ear care/irrigation ................................................................................................................................................. 192
CHAPTER NINE: MEDICATION AND FLUID THERAPY ................................................................................................ 194
9.1. Medication preparation .......................................................................................................................................... 194
9.1.1. Withdrawing Medication from a Vial.................................................................................................. 194
9.1.2. Withdrawing Medication from an Ampoule ........................................................................................ 195
9.1.3. Mixing medications from two vials into one syringe .......................................................................... 196
9.1.4. Preparing an Intravenous Solution ...................................................................................................... 198
9.1.4.1. Plastic Bag ........................................................................................................................ 199
9.1.4.2. Glass Bottle ...................................................................................................................... 200
9.2. Medication administration ..................................................................................................................................... 200
9.2.1. Administering oral medication (Per Os) (Po) ...................................................................................... 200
9.2.2. Administering sublingual medication .................................................................................................. 202
9.2.3. Administration of eye drops and ointment .......................................................................................... 204
9.2.4. Administration of ear drops ................................................................................................................. 206
9.2.5.Topical Administration of medication……………………………………………….………………211
9.2.6. Instillation of nasal drops .................................................................................................................... 210
9.2.7. Administering rectal medications ........................................................................................................ 211
9.2.8. Administering Vaginal Medications .................................................................................................... 213
9.2.9. Administering nebulizer Medications.................................................................................................. 215
9.2.10. Parentral medication administration .................................................................................................. 217
9.2.10.1.Administering an Intradermal Injection ........................................................................... 218
9.2.10.2.Subcutaneous Injection .................................................................................................... 220
9.2.10.3.Intramuscular Injection .................................................................................................... 222
9.2.10.4.Intravenous Injections...................................................................................................... 225
9.2.10.5.Intravenous infusion ........................................................................................................ 227
9.2.10.6.Intravenous Therapy ........................................................................................................ 227
9.2.10.7.Administering an IV Solution .......................................................................................... 228
9.2.10.8. Adding Solution to a Continuous Infusion Line ............................................................. 231
9.2.10.8.1..Infusion Controller or Pump Regulation ...................................................... 232
9.2.10.8.2. Volume Control Chamber (Buretrol) Regulation ......................................... 232
9.2.10.8. 3.Adding a Solution to an Existing Heparin or PI Lock.................................. 233
9.3. Blood transfusions.................................................................................................................................................. 234
CHAPTER TEN: SKIN INTEGRITY AND WOUND CARE ................................................................................................ 239
10.1. Wound dressing.................................................................................................................................................... 239
10.1.1. Dressing clean wound ....................................................................................................................... 241
10.1.2. Dressing septic wound....................................................................................................................... 243
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10.1.3. Dressing with Drainage Tube ............................................................................................................ 246
10.2. Wound Irrigation .................................................................................................................................................. 248
10.3. Suturing................................................................................................................................................................ 250
10.4. Stitch removal ...................................................................................................................................................... 252
10.5. Clips Application ................................................................................................................................................. 254
10.6. Removal of clips .................................................................................................................................................. 256
CHAPTER ELEVEN: COLD AND HEAT APPLICATION ................................................................................................. 258
11.1. Application of cold .............................................................................................................................................................. 258
11.1.1. Tipped Sponge Bath ......................................................................................................................................... 258
11.1.2. Cold compress ................................................................................................................................................... 259
11.1.3. Application of ice pack ..................................................................................................................................... 261
11.1.4. Application of ice collar .................................................................................................................................... 262
11.2. Application of heat............................................................................................................................................................... 263
11.2.1.Application of warm soak ........................................................................................................................................ 263
11.2.2. Applying Hot Compress .......................................................................................................................................... 266
11.2.3.Application of hot compress ..................................................................................................................................... 266
11.2.4.Application of hot water bag .................................................................................................................................... 267
CHAPTER TEWELVE: NUTRITON AND METABOLISM ................................................................................................ 270
12.1. Feeding a helpless patient .................................................................................................................................... 270
12.2.Feeding the Helpless Patient General Instruction .................................................................................................. 270
12.3.Gastrostomy feeding ............................................................................................................................................. 266
12.4.Parentral Feeding .................................................................................................................................................. 267
12.5.Nasogastric tube insertion ..................................................................................................................................... 266
12.6.Nasogastric tube medication administration.......................................................................................................... 273
12.7.Gastric aspiration .................................................................................................................................................. 273
12.8.Gastric lavage........................................................................................................................................................ 276
12.9.Gastric Gavage ...................................................................................................................................................... 279
12.10.Removal of a Nasogastric Tube .......................................................................................................................... 282
12.11.Measuring Intake and Output .............................................................................................................................. 283
CHAPTER THIRTEEN: ELIMINATION ............................................................................................................................... 287
13.1. Urinary elimination ............................................................................................................................. 287
13.1.1.Urinary catheterization ....................................................................................................... 287
13.1.1.1..Catheterization using a straight or plain catheter ............................................. 288
13.1.1.1.1. Female urinary catheterization with plain or straight catheter
13.1.1.1.2.Male catheterization with plain or straight catheter.......... 289
13.1.1.2. Catheterization using indwelling catheter ........................................................ 288
13.1.1.2.Insertions of indwelling catheter for male patient ................ 292
13.1.1.2.Insertions of indwelling catheter for Female patient ............ 294
13.1.2..Applying a Condom Catheter ............................................................................................ 296
13.1.3.Bladder Irrigation (open and closed method) ..................................................................... 297
13.1.4.Suprapubic catheter care .................................................................................................... 299
13.2. Bowel elimination .............................................................................................................................. 299
13.2.1.Enema ................................................................................................................................ 300
13.2.1.1.Cleansing enema/evacuating enema/ ................................................................ 300
13.2.1.2.Retention enema ............................................................................................... 302
13.2.1.3.Rectal wash out ................................................................................................. 303
13.2.2.Inserting a rectal tube ......................................................................................................... 305
13.2.3.Colostomy care and irrigation ............................................................................................ 306
13.2.4.Digital removal of fecal impaction ..................................................................................... 307
CHAPTER FOURTEEN: PERI-OPERATIVE CARE ........................................................................................................... 310
14.1. Preoperative care…………………………………….………….……..…………………………….………….307
14.2. Intraoperative care ………………………...…….……………………………….……………..……………….307
14.3. Post operative care …………………………………………………………………..……………………………….……………………………………-307
CHAPTER FITEEN: OXYGENATION .................................................................................................................................. 317
15.1.Monitoring with pulse oximetery .......................................................................................................................... 317
15.2.Oxygen Administration ......................................................................................................................................... 318
15.2.1..Oxygen administration via face mask................................................................................................ 320
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Fundamental of Nursing skill lab manual
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15.2.2. Oxygen by Nasal cannula (nasal prongs)…………………………………………………………………………….……..……….319
15.2.3. Giving oxygen by tent/blood…………………………………….……………………..…………………..322
15.3. Airway suctioning …………………………………………………………………....................………………324
15.3.1.Performing Nasopharyngeal and Oropharyngeal Suctioning ............................................................. 325
15.3.2. Performing endotracheal/tracheostomy Suctioning……………………………………………….….328
15.4. Tracheostomy care ............................................................................................................................................... 332
15.5. Postural drainage…………………………………………..…………………………………………..………..332
15.6. Cardiopulmonary resuscitation (CPR)…………………………………………………………….……………343
15.6.1. Adult CPR…………………………………………………………………..………………………344
15.6.2.CPR for child below 8 years old ......................................................................................................... 347
15.6.3.One rescuer CPR procedure for infant (to approximate 1 year) ......................................................... 349
CHAPTER SIXTEEN: THERAPEUTIC AND DIAGNOSTIC PROCEDURE ................................................................... 353
16.1. Assisting with thoracentesis ................................................................................................................................. 353
16.2. Assisting with Water-seal chest drainage system ................................................................................................. 356
16.3. Assisting with Bronchoscopy ............................................................................................................................... 359
16.4. Assisting with an abdominal paracentesis ............................................................................................................ 362
16.5. Assisting with liver biopsy ................................................................................................................................... 363
16.6. Assisting with Bone marrow puncture/biopsy...................................................................................................... 366
16.7. Assisting with Cast application and removal ....................................................................................................... 368
16.7.1.Cast application .................................................................................................................................. 368
16.7.2.Care of patient with cast ..................................................................................................................... 369
16.7.3.Cast Removal ..................................................................................................................................... 370
16.9. Assisting with Traction Application .................................................................................................................... 372
16.9.1. Skin Traction ..................................................................................................................................... 372
16.9.2. Skeletal traction ................................................................................................................................. 373
16.10. Assisting with lumbar puncture .......................................................................................................................... 374
CHAPTER SEVENTEEN: CARE OF THE TERMINALLY ILL AND POST MORTEM CARE .................................... 377
17.1. Care of terminally ill patient…………………………………………………...………………………….……378
17.2. Post mortum care ……………….………………………………………….…………………………….……..380
References .................................................................................................................................................................................... 382
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List of figure
Contents Pages
Figure 1: Hospital progress Note .................................................................................................. 23
Figure 2: Admition and discharge card ......................................................................................... 23
Figure 3: Opening sterile pack ...................................................................................................... 37
Figure 4: Proper Spinal posture ................................................................................................... 63
Figure 6: Proper sitting posture and center of gravity…………………………………………………………..………….66
Figure 5: Proper Alignment and Posture: Standing Male and Female ......................................... 64
Figure 7: Proper lying posture with center of gravity ................................................................... 66
Figure 8: Logrolling with two persons …………………………………………………………..70
Figure 9: Log rolling with three persons....................................................................................... 70
Figure: 10: Proper prone position ................................................................................................. 75
Figure.11: Proper Semi prone position ......................................................................................... 77
Figure 12: Proper supine position ................................................................................................. 78
Figure 13: Proper dorsal recumbent position ............................................................................... 80
Figure 14: Proper Lateral Recumbent position ............................................................................ 82
Figure 15: Proper knee chest position........................................................................................... 84
Figure 16: Proper fowler‘s position .............................................................................................. 87
Figure 17: Dorsal Lithotomy position........................................................................................... 90
Figure 18: Gait belt ....................................................................................................................... 94
Figure 19: Canes .......................................................................................................................... 96
Figure 20: Walker ......................................................................................................................... 98
Figure 21: Axillary crutch ............................................................................................................. 99
Figure 22: Forearm crutch ............................................................................................................ 99
Figure 23: Mitering bed corner ................................................................................................... 150
Figure 24 : Post operative/Anesthetic bed .................................................................................. 158
Figure 25: Effurage (left) and Petrissage(right) .......................................................................... 170
Figure 26: Type of urinals: Males, Females ............................................................................... 175
Figure 27: shampooing ............................................................................................................... 187
Figure 28: Vials........................................................................................................................... 194
Figure 29: Withdrawing medication from vial ........................................................................... 194
Figure 30: Sublingual and buccal areas for medication administration. .................................... 204
Figure 31: Administering a Rectal Suppository.......................................................................... 213
Figure 32: Administering a vaginal suppository along the posterior wall of the vagina. ........... 214
Figure 33: Self-administration with a Metered-dose Inhaler. ..................................................... 216
Figure 34: Administering intradermal injection ........................................................................ 220
Figure 35: Subcutaneous injection sites: A. Abdomen; B. Lateral and anterior aspect of upper
arm and thigh; C. Scapular area on back; D. Upper ventrodorsal gluteal area ........................ 221
Figure 36: Sites for administering an intramuscular injection .................................................... 223
Figure 37 Administering intramuscular injections in to the ventrogluteal site ........................... 224
Figure 38: Connect locking cannula to a Y-site injection port of primary infusion set............. 227
Figure 39: Vein for inserting cannula ......................................................................................... 228
Figure 40: Intravenous therapy ................................................................................................... 229
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Fundamental of Nursing skill lab manual
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Figure 41: Male catheterization .................................................................................................. 291
Figure 42: Oxygen administration via face mask ....................................................................... 322
Figure 43: Oxygen administration via nasal cannula .................................................................. 324
Figure 44: Cleaning tracheotomy inner cannula ......................................................................... 334
Figure 45: structure of tracheostomy .......................................................................................... 335
Figure 46: Tracheostomy string .................................................................................................. 336
Figure 47: Checking client responsiveness in CPR .................................................................... 343
Figure 48: Positioning the client for giving rescue breathing ..................................................... 344
Figure 49: Listening (left) and giving rescue breathing (right) in CPR ...................................... 344
Figure 50: Checking returning of pulse in CPR.......................................................................... 345
Figure 51: Selecting proper site for chest compress in CPR ...................................................... 346
Figure 52: Selecting proper site for chest compress in CPR ...................................................... 346
Figure 53: Selecting proper site for chest compress in CPR ...................................................... 349
Figure 54: checking pulse in infant in CPR ................................................................................ 351
Figure 55: Giving chest compression infant in CPR .................................................................. 351
Figure 56: Three bottle system ................................................................................................... 357
Figure 57: Material for cast removal .......................................................................................... 371
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Contributors
No. Contributors Profession Name Of Facility
1 Abebe Abera MSc in Nursing Jimma University
2 Agezen Asegid MSc in Nursing Hawassa University
3 Amare Tarekege MSc in Nursing Hawassa University
4 Anteneh Messele MSc in Nursing Gondar University
5 Arif Ali Nurse Alkan University College
6 Aselefech Kinfe Nurse Central University College
7 Asfaw Mekonnen MPH Central University College
8 Assefa Tola MPH Harar Health Sciences College
9 Bereket Honja Nurse Hawassa Health Sciences College
10 Daniel G/Tsadike MSc in Nursing Central University College
11 Fethia Mohammed Nurse Haramaya University
12 Fiseha Girma MSc in Nursing Mekelle University
13 Fisseha Hagos MSc in Nursing Sheba University
14 Fissiha Zewdu MSc in Nursing Gondar University
15 Frezer Girma Nurse Alkan University College
16 Fufa Daba MPH Hawassa Health Sciences College
17 Gashaye Asrat MPH Alkan University College
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24 Kelemua Gulilat MPH B/Dar Health Sciences College
25 Martha Habtesilassie Nurse Ethiopia Nursing Association
26 Meron Yeshitila MSc in Nursing Haramaya University
27 Moges Workneh Nurse Wollo University
28 Natnael Dessalegn Nurse Wollo University
29 Netsanet Habte MSc in Nursing Gondar University
30 Shiferaw Letta MSc in Nursing Haramaya University
31 Sintayehu Beyene Nurse Harar Health Sciences College
32 Tariku Eshete MSc in Adult Nursing Harar Health Sciences College
33 Tekeba H/Wolde MPH Hawassa Health Sciences College
34 Tesfaye Demeke MSc in Nursing Gondar University
35 Tirunesh Mulgeta Nurse B/Dar Health Sciences College
36 Wadu Wolanchc MSc in Nursing Jimma University
37 Yemiamrew Getachew MSC in Mental Health Wollo University
38 Yemisrach Koku Nurse B/Dar Health science College
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Preface
Progress in Nursing services and consequently the introduction of new technique, methods and
procedures point towards the need for subsequent revised and enlarged editions of books and
manuals on Nursing. Advances in the field of Nursing education, which have increased so much
in number and value that it now seems wise to bring out a new edition periodically to get abreast
with the new techniques and procedures.
Use of specific technique for single procedure where challenging in our country because of
difference place of training among instructor, difference of information among books and lack of
nationally recognized and well organized procedure manual. Previously students and instructor
faces difficulty to which they follow to practice their profession scientifically with acceptable
manner.
More than the above listed problems nurse educators in our country have always been facing
with the need to have reference materials suited to present day practice standards. However,
books that met this criterion were written in the context of developed countries where advanced
equipments, and commercially prepared articles and materials are used for performing most
Nursing procedures. This procedure manual, which could be applicable in our context and suited
to COC perception, will help students and instructors to apply their profession with minimal
problem.
AIDSTAR-One, under PEPFAR initiative, provides technical assistance to the Ministry of Health on
infection prevention and patient safety to protect patients, healthcare workers and the community at large
from infection. As part of its sustainable intervention, AIDSTAR-One Ethiopia is working on
strengthening and sustaining pre-service education which aims to ensure that new health professionals
entering the Nursing and midwifery professions have the required knowledge and competencies at 6
government Universities, 4 Regional Health Science Colleges and three selected private Health Science
University Colleges. Pre-service training is considered to be cost-effective, sustainable and the most
appropriate alternative that allows service staff to devote their full attention to programme
implementation.
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Under the pre-service education program, AIDSTAR One project developed a plan of action to
implement competency based teaching and performance assessment strategies to target universities and
health science colleges. Nursing schools play a key role in preparing the future cadres of health
professionals who will be providing health care services in the community, whether in the public or
private sector. It is recognized that investment to enhance teaching in these institutions is as important as
other key public health interventions, as well as being of support to those interventions.
Effective teaching contributes to improving the quality of health care in a country; also, upgrading
teaching represents a long-term response to the health care needs of a community. Teaching materials and
objective structured practical examination checklists will be of great benefit to guide and support
teaching institutions in their efforts to further enhance the quality of their teaching, student performance
assessments and, eventually, to produce qualified professionals ready to sustain the challenges ahead.
A well designed competency based learning tool that is kept up to date can become a valuable source of
information to the target institution. Taking in to consideration the advantages and benefits of competency
based learning tools and assessment guidelines harmonized Nursing skill Lab manual development
workshop was organized for 6 target universities and 7 health science colleges from August 13-18, 2013
by AIDSTAR One. A total of 39 representatives from the target institutions developed the first draft of
the manual.
During this review; first all experts decide on the sub content of each chapter, then logical
arrangement of chapters was decided after vigorous discussions were made. The contributors
have taken care to present the material in a concise, straight forward and simplified format in an
easy to follow language. For each chapter specific objective, for each procedure objective,
definition, purpose, indication and procedure where stated. Additionally for some procedure
precaution and notes where indicated.
This Nursing skill lab manual included more than 350 Nursing procedures under sixteen chapters
including basic, intermediate and advanced Nursing skill. During this manual preparation current
training at TVET by level is also considered by the authors. Six public universities, four public
health Science College and two private colleges were participated during preparation of this
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manual. Each institution brings their own already on work teaching manual form from their
respective organization to consider\or as an input for advancing this skill lab manual.
This particular skill lab manual gives much emphasis for fundamentals of Nursing procedure.
Other Nursing skill like those in Gyne/Obs, pediatrics, and emergency Nursing course were not
included for better management of the preparation.
Finally, this Nursing procedure manual is not the only reference for Nursing procedures and user
required to use other textbook supplementary to this manual.
Since an editor read and collects material for all Nursing procedure and consider recent COC
concern on all specific Nursing procedure title, they are confident that this procedure manual will
bring the Nursing practice in the country into one line and useful tool for students and
professional workers in different setting.
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Acknowledgement
First we want to forward our heartfelt thanks to institutions sending appropriate professional for
development of the manual.
Our deep gratitude also goes to AIDSTAR-One, under PEPFAR initiative for initiating and
coordinating the harmonization of fundamental of Nursing skill Lab manual. This organization
also provides financial support for facilitation of workshop and final edition.
Our deep gratitude should be spontaneously goes to contributors who exhibit unreserved
devotion on the work from first to the end.
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CHAPTER ONE
INTRODUCTION TO NURSING PROFESSION
1.1. History of Nursing
She suggested that: "Nursing is an art, and if it is to be made an art, it requires as exclusive
devotion, as hard a preparation, as any painter’s or sculptor’s work, for what is 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 the fine Arts". (Cited in Donahue 1996:501)
2. Mallison (1993:7) emphasizes in the difficulty to express by writing the multidimensional whole of
Nursing as she suggests that:
“Nursing like dance or painting is not primarily an art of the written word. It is partly
Kinaesthetic - transmitted in facial expressions, posture, touch, silences, gestures, timing, intent.
Attempts to pin it down with language is like chasing butterflies: It's most beautiful in motion,
flitting freely outside the net of words".
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3. Henderson (1966:39) stated that:
"the unique function of the nurse is to assist the individual sick or well, in the
performance of those activities contributing to health or its recovery (or to a peaceful
death) that he would perform unaided if he had the necessary strength, will or knowledge,
and to do this in such a way as to help him to gain independence as rapidly as possible"
and she went on to describe what are these activities. (cited in Lister 1997).
Modern Nursing in Ethiopia started in the later part of the 19th century by Swedish
Missionaries who came to Eritrea in 1866. Years later the Nursing service was extended to
other parts of the country still by expatriate nurses from Sweden, Russia, and France. During
this time some clinics and hospitals were opened in some parts of the country. Thus the need
for nurses was felt more than ever. Around 1928 elderly women were recruited and were
given short term training to serve as nurses and midwives. In 1949 the first School of
Nursing (The Ethiopian Red Cross) was opened in the former Haile Selassie I Hospital (Now
Yekatit 12 Hospital beginning of the modern nurses‘ education). Students were recruited
from 8th grade and the training duration was 3 ½ years. In the following years other schools
of Nursing were opened. One of the schools (Gonder) was training community nurses who
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were basically working in the community while the other schools train bed side nurses who
work mainly in hospital settings.
In 1977, three years after the downfall of the Emperors regime, the nurse training was revised
at a national level and a decision was made to train one category of nurse namely
"Comprehensive nurse" who can function at all levels of health institutions. Thus the training
of community nurses was discontinued. The academic entry requirement at this time was
raised to 12th grade completion and the duration shortened to 2 ½ years. After the dawn fall
of the Derge regime, since 1991, the training duration reduced by ½ years to only 2 years and
the comprehensive form of training changed to specialized form of training.
The training of different types of nurses then started for two years in most training
institutions and begins to train clinical nurses, public health nurses & midwives. However
this fragmented form of training is not appreciated by most faculty members of the respective
institutions.
A remarkable event to be mentioned in the history of Nursing in Ethiopia is the launching of
post basic baccalaureate program in Nursing in1994 in the former Jimma institute of health
science (now Jimma University). The annual average output of baccalaureate program
trainees were not more than 30 and deployed in schools and management positions.
At present, there are a number of governments owned and NGO and private owned
Universities/schools/Colleges offering Nursing education in the country in Level II, IV, BSc
and MSc level. At the end of the training period, regional health bureau of respective region
registered and licensed them to practice the profession in the country through the health
professionals' council and COC exam.
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Characteristics of Nursing process
1. Based on scientific problem solving 4. Continuous
2. Systematic 5. Dynamic
3. Client centered
There are five steps, or phases, in the Nursing process: assessment, diagnosis, planning,
implementation, and evaluation. These steps are not distinct; rather, they overlap and build on
each other. To carry out the entire Nursing process, you must be sure to complete each step
accurately and then build upon the information in that step to complete the next one.
A. Nursing Assessment
The first step, or phase, of the Nursing process is assessment. During this phase, you are
collecting data (factual information) from several sources. The collection and organization of
these data allow you to:
1. Determine the patient‘s current health status.
2. Determine the patient‘s strengths and problem areas (both actual and potential).
3. Prepare for the second step of the process—diagnosis.
Subjective Data
What the patient tells you
The history, from chief complaint through Review of Systems
Example: Mrs. G is a 54-year-old hairdresser who reports pressure over her left chest ―like an
elephant sitting there,‖ which goes into her left neck and arm.
Objective Data
What you detect on the examination
All physical examination findings
Example: Mrs. G is an older white female, deconditioned, pleasant, and cooperative.
BP 160/80, HR 96 and regular, respiratory rate 24, afebrile.
Methods of assessment are:-
1. Nursing health history
2. Physical assessment
3. Diagnostic evaluation
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B. Nursing Diagnosis
Diagnosis means reaching a definite conclusion regarding the patient‘s strengths and human
responses. This diagnostic process is complex and utilizes aspects of intelligence, thinking, and
critical thinking.
Nursing diagnosis is a clinical judgment about individual, family, or community responses to
actual or potential health problems/life processes. Nursing diagnoses provide the basis for
selection of Nursing interventions to achieve outcomes for which the nurse is accountable.
C. Nursing planning
Planning involves a series of steps in which the nurse and the client prioritize problems and set
goals or expected out comes to resolve or minimize the identified problems of the client
D. Nursing implementation
Implementation refers to the action phase of the Nursing process in which Nursing care plan is
put into action.
It is focused on resolving the patient‘s Nursing diagnoses and collaborative problems and
achieving expected outcomes, thus meeting the patient‘s health needs.
E. Evaluation
Evaluation simply means assessing what progress has been made toward meeting the expected
outcomes; it is the most ignored phase of the Nursing process.
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CHAPTER TWO
DOCUMENTATION (RECORDING AND REPORTING)
Learning Objectives: At the end of this chapter, learner will be able to:
1. Apply general rules for charting
2. Explain purpose of admission, transfer and discharge of patient
3. Identify Nursing considerations related to admission, transfer and discharge a client from
the health care facility.
4. Display sympathy for a patient discharging against medical advice
5. Demonstrate proper practice of incident report in line with key elements of incidence report
6. Discuss Nursing actions to decrease the risk of liability and importance of incidence report
2.1. Documentation and charting
Learning Objectives: At the end of this practical session, students will be able to:
Purpose
Accurate data needed to plan the client‘s care in order to ensure the continuity of care
A method of communication among the health care team members responsible for the
client‘s care
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Written evidence of what was done for the client, the client‘s response, and any revisions
made in the plan of care
Compliance with professional practice standards (e.g., American Nurses Association)
Compliance with accreditation criteria (e.g., the Joint Commission on Accreditation of
Healthcare Organization [JCAHO])
A resource for review, audit, reimbursement, education, and research
A written legal record to protect the client, institution, and practitioner
2.1.2. Charting
Purpose
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E. Objective information: The nurse records what he/she ―sees‖ avoid saying ―condition
better,‖ or ―pulse improved‖. Record the actual condition. Also expressions do not show
much thought on the part of the nurse.
F. Legibility: Print as plainly and distinctly as possible. Do not use any fancy words. There
should be no question to the words and figures used. This is especially true when
recording temperature, pulse, respiration and dosage of medicine.
G. Neatness: No blotches on chart sheets. No wrinkling of sheets. Proper spacing of items
and words. Begin each statement with a capital letter. Place a period after all
abbreviations and at the end of each statement.
H. Errors: If an error is made, use a ruler and draw one line through it, print nearly above
―Error‖ and sign your name. No erasing and using correction fluid is permitted on the
chart.
I. Each nurse should do her/his own charting, that is, she/he should name and the father‘s
initial.
J. Composition: Chart carefully, composition and spelling must be correct. Consult a
dictionary when in doubt. Only approved abbreviations can be used on Nursing record. If
in doubt consult the supervisor. Do not use chemical formulas for drug as KMNO4
instead of potassium permanganate.
K. Sentences: and not be complete but, they must be clear, avoid as needless repetition of
word ―Pt‖. Remarks should reflect as nearly as possible the patient‘s condition. (Watch
your grammar).
L. Temperatures should be recorded on the graphic sheet.
M. All orders should be written and signed. Verbal or telephone should be written in the
order sheet and signed by the doctor on the next visit.
N. Time of charting: Charting must be done immediately after procedure or observation.
This is an absolute must. Chart the hour, as possible state order must be recorded with
the exact hour the treatment or medication given. The exact time of sleeping pills and
narcotics must also be given. Do not record events taking place at different hours on the
same line. Be sure to write A.M or P.M. when charting the hour. Twelve noon is written
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12 M.D and twelve midnight is written 12 M.N Be careful not to confuse Ethiopian and
European time.
O. Space: Do not crowd notations nor skip lines unnecessarily.
P. Color of ink: All charting must be done in black or blue – black important events are
charted in red on the graphic sheet. E.g. Transfusion, vaccination, day of surgery.
Q. Chart headings: All headings are to be filled in when the patient is admitted, thereafter,
each sheet, which is added, must be properly filled out. No nurse shall every chart on a
sheet that is not properly filled out even though someone else may have done so. Even
though some one else has failed to do his duty, it will not excuse another for making
same mistake. Always give the complete name, the name of the doctor, the room number
and also the hospital chart number if there is one.
R. Orders of assembling patients chart
a. Order sheet
b. Doctor‘s progress notes
c. Nursing notes
d. Temperature graph
e. Laboratory reports
f. Input and out put note
S. Patients or relatives and friends of patients are not allowed to read the chart.
T. Sign each entry with your full legal name and with your professional credentials, or per your
institutional policy.
U. Never change another person‘s entry, even if it is incorrect.
V. Use quotation marks to indicate direct client responses (e.g., ―I feel lousy‖).
W. Document in chronological order (if chronological order is not used, state why).
N.B: The order of assembling chart may differ from hospital to hospital.
Equipment for charting and writing notes
Report format
Patient chart
Pen
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Procedure
The format of the chart varies from hospital to hospital. Most important is the content of the
notes.
1. First, your notes should describe the assessment that you completed at the beginning of your
shift.
2. Some hospitals require that all parts of the assessment to be documented; others require that
only abnormalities be documented.
3. As your shift progresses, you should always include certain items in your notes, including
changes in the patient‘s medical, mental, or emotional condition.
4. You should also chart if no change occurred in the patient‘s condition so that treatments can
be modified as necessary. Normal aspects of the patient‘s condition should be noted also.
5. Reactions to any unscheduled or p.r.n. medications must be recorded. To complete this of the
entry, note the time the medication was given the problem for which the medications were
given the expected solution.
6. Finally it is important to record the patient's response to teaching. Theses notes may describe
return demonstrations, verbalization of learning, or resistance to instruction.
7. Frequently, respective aspects of Nursing can, such as vital signs, and intake and output, and
recorded on flow sheets.
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Definition: Admission is the entry of a patient in to a hospital ward for therapeutic or diagnostic
purpose. Hospitalized individuals have many needs and concerns that must be identified then
prioritized and for which action must be taken.
Purpose
A. Emergency admission: means of the patients are admitted in acute conditions requiring
immediate treatment, e.g. patient with accidents poisoning, burns and heart attack
B. Routine admission: the patients are admitted for investigation and medical or surgical
treatment is given accordingly, e.g. patient with hypertension, diabetics and bronchitis
General instruction
1. Nurse should make every effort to be friendlily and courteous with the patient
2. Make proper observations or the patient‘s condition. Report
3. Orient the patient and his relatives to hospital and ward policies
4. Observe policies in dealing with medico-legal cases
5. Deal with the patients belonging very carefully communicable diseases
6. Isolate the patient if suffering from communicable disease
7. The nurse should be recognized the various needs of the patient and meet them without delay
8. The needs to understand the fears and anxiety of patient and help to overcome
9. The nurse should find out the likes and dislikes of the patient and include the patient in his
plan of care
10. The nurse should be address the patient by their name and proper title
11. Patient‘s valuables and clothes should handover to the relatives with proper recording
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Equipment
1. Bed (open bed)
2. Articles for physical examination like BP apparatus, Stethoscope, Weight balance,
Thermometer, Patient chart
3. Nurse report book
4. Necessary Supplies such as bath basin, pitcher/glass, tissue paper, soap, hospital gown,
slipper, towel and bed pan (Urinal)
5. Special Equipment & Supplies if necessary such materials are suction machine, cardiac
monitoring and oxygen
Procedure
1. The patient room should be prepared and well ventilated.
2. Check for orders of admission.
3. Make introduction and orient the patient
A. Greet the patient
B. Introduce self to the patient and the family
C. Explain what will occur during the routines admission process such as admission
bath, put on hospital gowns etc.
D. Orient patient to individual unit: Bed, bathroom, call light, supplies and belonging;
and how these items work for patient use.
E. Orient patient to the entire unit: location of nurses‘ office, lounge and hospital routine
such as meal time. Visiting hour etc.
F. Explain anything you expect a patient to do in detail which helps the patients
participate in their care.
G. Introduce other staff and roommates.
4. Check about financial issue, payment scheme (free or paying)
5. Provide privacy when the patient undress
6. Assist the patient to dress hospital gown
7. 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)
8. Assist a patient into a comfortable position in bed or chair
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9. Perform baseline assessment
a. Observation and physical examination such as:
10. Inform support person / relative / when they can return, and inform about visiting house
11. Provide patient with full water jag, bedpan, urine, glass, towel, call signal etc.
12. Take care of the patient's personal property
Items that are not needed can be sent home with family members
Other important items can be kept at bedside or should be put in safe place by cabling
with patient's name.
13. Make out a chart for the patient & inform the health provider
14. Issue visitor pass.
15. Documentation
Check order and carry them out.
Record all parts of the admission process
Other recording include
Notification to dietary departments
Starting kardex and medication records
If there is specific form to the facility, complete it.
N.B. Additional measures can be carried out according to the patient problems (diagnoses).
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Definition:
o Transfer is defined as preparing patient, completing necessary records and shifting patient
to another department within the hospital or to another hospital/home
o Transfer/referral is the preparation of a patient and the referral records to the shift the
patient to another department within the hospital or to another hospital
Purpose
1. Internal transfer: to transfer the patient in a unit that provide special care or care suited to his
need, e.g. from general ward to ICU
2. External transfer: to transfer the patient from one hospital to another hospital for the purpose
of special care, e.g. from general hospital to specialized hospital- cancer center
Preliminary assessment
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Equipment
Learning Objectives: At the end of this lesson, learner will be able to:
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Definition:
o Patient discharge is sending the hospitalized patient to home or to referral after successful
discharge planning process.
o Patient discharge planning is systematic process for preparing the patient to leave the
hospital & for continuity of care at home.
Purpose
To continue self care at home
To adjust the patients setting out of the hospital
To ensure adequate home health care support
To minimize the patient‘s anxiety at discharge
Indications for discharge
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Medications (Treatments)
Activity
Diet
Need for Follow up and others as needed
9. Do final assessment of physical and emotional status of the patient and the ability to continue
own care.
10. Check and return all patients‘ personal property (bath items in patient unit and those kept in
safe area).
11. Help the patient or family to deal with business office for customary financial matters and in
obtaining supplies.
12. Accompany patient to the gate, if possible
13. Write Discharge summaries note which usually include:
Time and date of discharge
Description of client‘s condition at discharge
Treatment (e.g. Wound care, Current medication)
Diet
Activity level
Restrictions
N.B: If a patient insists upon going home against medical advice he should be
requested to sign a statement indicating that he is responsible for his action.
1. When the patient want to leave an agency without the permission of the physician –
unauthorized discharge the following activities are indicated:
2. Ascertain why the person wants to leave the agency
3. Notify the physician of the client‘s decision
4. Offer the patient the appropriate form to complete
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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)
2.5. Critical incident reporting
Learning Objectives: At the end of the lesson, learner will be able to:
1. Define incident report
2. List the purpose of incident report
3. Display empathetic approach for victims
4. Demonstrate proper practice of incident report in line with key elements of incidence report
5. Discuss Nursing actions to decrease the risk of liability and importance of incidence report
Definition: Incident reports, or occurrence reports, are used to document any unusual occurrence
or accident in the delivery of client care, such as falls or medication errors.
Reporting is the verbal communication of data regarding the client‘s health status, needs,
treatments, outcomes, and responses. When a report is given, it needs to summarize the current
critical information that facilitates clinical decision making and continuity of care. The Nursing
process provides structure for an organized report, a challenge inherent in verbal
communications.
In accord with the agency‘s policies, nurses are required to file incident reports when a situation
arises that could or did cause client harm. When filing an incident report, the nurse should state
only the facts surrounding the incident. The nurse‘s opinions or conclusions about the incident
are not to be documented. Also, the client‘s medical record should not contain any reference to
the filing of an incident report.
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Any deviation from usual medical care that causes an injury to the patient or poses a risk of harm
which includes errors, preventable adverse events and hazards should be reported to responsible
body. Adverse events may be preventable or non- preventable. It goes on to say that, in seeking
to improve safety, one of the most frustrating aspects for patients and professionals alike is the
apparent failure of health-care systems to learn from their mistakes.
Purpose:
1. Record the date, exact time, and place you discovered the occurrence.
2. Identify the person(s) involved in the occurrence, including witnesses.
3. Document accurately and objectively the exact occurrences that you witnessed or first saw
after the incident; for example, record ―found the client sitting on the floor. Client stated that
. . .‖ rather than ―client fell.‖
4. Record the exact details, in time sequence, what happened, and the consequences for the
persons
5. Record your actions to provide care and results of your assessment for injuries or client
complaints.
6. Notify the supervisor on duty and record the time and name of the physician notified; if
telephone orders were received from the physician, document as previously discussed and
implement the orders.
7. Do not record your opinions, judgments, conclusions, or assumptions about what occurred,
point blame, or suggest how to prevent occurrence of a similar incident.
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8. Forward the incident report to the designated person as defined in the facility‘s policy.
Actions to Decrease the Risk of Liability
Acknowledge unfortunate incidents and express concern about these events without either
taking the blame, blaming others, or reacting defensively.
Chart timely your observations immediately, while facts are still fresh in your mind.
Follow the facility‘s policies and procedures for administering care and reporting incidents.
Acknowledge and document the reason for any omission or deviation from agency policy,
procedure, or standard.
Maintain clinical competency and acknowledge your limitations. If you do not know how to
do something, ask for help.
Promptly report any concern regarding the quality of care, including the lack of resources
with which to provide care, to a Nursing administration representative.
Time and document changes in conditions requiring notification of the physician and include
the response of the physician.
Client safety requires appropriate reporting and recording of medication errors and other
occurrences in compliance with the facility‘s policy.
Reporting accidental exposure to blood and body fluids including needle stick injuries and
proper management of accidental injuries
Provide regular reporting of all adverse events occurring in all health-care facilities.
2.6. Nursing progress note
The nurses‘ progress notes are used to document the client‘s condition, problems, and
complaints; interventions; response to interventions; and achievement of outcomes.
Progress notes is the evaluation of the client‘s response to treatment; may contain the progress
recording of interdisciplinary practitioners (e.g., dietary or social services)
The nurses‘ progress notes are used to document the client‘s condition, problems, and
complaints; interventions; response to interventions; and achievement of outcomes.
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Nurses‘ notes
Medication administration record
Personal care flow sheets
Teaching records
Intake and output forms
Vital sign records and
Specialty forms (e.g., diabetic flow sheet and neurologic assessment form)
The progress notes can be completely narrative or incorporated into a standardized flow sheet to
complement SOAP (IE), PIE, focus charting, and other documentation systems.
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CHAPTER THREE
INFECTION PREVENTION
Objectives- at the end of this chapter learner will be able to
1. Define infection prevention
2. List components of infection prevention
3. Apply principles of infection prevention
4. Demonstrate different infection prevention methods
Definition- Largely depends on placing barriers between a susceptible host (person lacking
effective natural or acquired protection) and the microorganism
3.1. Hand Hygiene
Objective- After completing this section, the learner will be able to demonstrate the
recommended hand hygiene practices in health care facilities
Definition: Hand hygiene is a general term referring to any action of hand cleansing. It includes
care of hands, nails and skin.
Hand hygiene can be accomplished by:
Hand washing
Hand antisepsis
Antiseptic hand rub
Surgical scrub plain
3.1.1. Hand washing
Objective: At the end of this lesson learner will be able to:
1. Explain the purpose of hand washing
2. Demonstrate hand washing techniques
3. Identify common malpractices related with hand washing
Definition: Hand washing is process of mechanically removing soil and debris from the skin of
hands using plain soap and water.
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Purpose
Reduce number of resident and transient microorganisms on the hands
Prevent transfer of microorganisms from health care personnel to the client
Indication
Immediately after arriving and leaving work (the health facility)
Before and after examining (coming in direct contact with) a client/patient
After touching contaminated instruments or items
After exposure to mucous membranes, blood, body fluids, secretions or excretions
Before putting on gloves and after removing them
Whenever our hands become visibly soiled
After blowing nose or covering a sneeze
Before eating or serving food
After visiting the toilet
Equipment
1. Tap water or water in a jug and a basin
2. Soap and soap rack with drains
3. Clean towel (personal or disposable)
Procedure
1. Prepare necessary equipment
2. Remove all jewelry or false finger nails. Remove your watch or wear it well
3. above the wrist.
4. Thoroughly wet hands.
5. Apply plain soap (antiseptic agent is not necessary).
6. Vigorously rub all areas of hands and fingers for 10–15 seconds, paying close attention to
fingernails (if necessary use orange stick) and between fingers.
7. Rinse hands thoroughly with clean water.
8. Dry hands with a paper towel or a clean, dry personal towel.
9. Use a paper towel when turning off water if there is no foot control or automatic shut-off.
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Objective: At the end of this lesson, learner will be able to perform hand antisepsis by using
proper technique
Definition: Washing hands with use of soap containing anti microbial agent
Purpose
To remove soil and debris
Reduce both transient and resident flora on the hands.
Indication
• Before Examining or caring for highly susceptible patients (e.g., premature infants,
elderly patients, or those with advanced AIDS)
• Before Performing an invasive procedure (e.g., intravascular device)
• Before Leaving the room of patients on Contact Precautions
Precaution
Hand washing with medicated soaps or detergents repeatedly is irritant to the skin
Equipment
1. Tap water or water in a jug and a basin
2. Soap which contains anti microbial agent (chlorohexidine, iodophors or triclosan) e.g.
Medicum, Life boy, Dettol and soap rack with drains
3. Clean towel (personal or disposable)
4. Orange stick
5. Wall clock
Procedure
1. Prepare necessary equipment
2. Remove all jewelry or false finger nails and your watch or wear it well above the wrist.
3. Thoroughly wet hands.
4. Apply soap containing antimicrobial agent
5. Vigorously rub all areas of hands and fingers for 10–15 seconds, paying close attention to
fingernails (if necessary use orange stick) and between fingers.
6. Rinse hands thoroughly with clean water.
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Objective- at the end of this lesson, the learner will be able to demonstrate antiseptic hand rub
Definition- Use of a waterless, alcohol-based hand rub product to inhibit or kill transient and
resident flora
Purpose:
Is to inhibit or kill transient and resident flora.
Equipment
1. Alcohol (60-90%) 3. measuring glass
2. glycerine 4. bottle
Preparation of hand rubs solution
A nonirritating, antiseptic handrub can be made by adding either glycerinea, proplyene
glycol or sorbitol to alcohol (2 mL in 100 mL of 60–90% ethyl or isopropyl alcohol
solution. .
Steps:
Apply enough alcohol-based hand rub to cover the entire surface of hands and fingers
(about a teaspoonful -5ml)
Continue rubbing the solution over hands until they are dry (15-30 seconds). ).
Rub the solution vigorously into hands, especially between fingers and under the nails,
until dry.
3.1.4. Surgical Hand scrub
Objective: at the end of this lesson, the learner will be able to
1. Explain the purpose of surgical hand scrub
2. Demonstrate Surgical hand scrub techniques
Definition: surgical hand scrub is mechanically remove of soil, debris, transient organisms from
the hands and forearm of sterile team member.
Purpose
Remove as many microorganisms from the hands as possible before sterile procedure
Decrease the risk of infection for high risk groups (newborn, transplant recipients)
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Equipment
1. Tap water or water in a jug and basin.
2. Soap/detergent on soap rack with drains
3. Sterile paper towel
4. Plastic nail stick/nail cleaner
Procedure
1. prepare necessary equipment
2. Remove rings, watches, and bracelets.
3. open the tap and wet hands
4. Thoroughly wash hands and forearms to the elbow with soap and water
5. Clean nails with a nail cleaner.
6. Rinse hands and forearms with water.
7. Apply an antiseptic agent (soap)
8. Vigorously wash all surfaces of hands, fingers, and forearms for at least 3-5 minutes.
9. Rinse hands and arms thoroughly with clean water, holding hands higher than elbows.
10. Keep hands up and away from the body, do not touch any surface or article. And dry
hands with a clean, dry towel.
11. Put on sterile or HLD gloves.
3.2. Donning and removing Personal protective equipment
Objective: After completing this lesson, learner will be able to describe the use of different
personal protective equipments and demonstrate how to use it
Definition: PPE is an equipment that is fluid-resistant (e.g., plastic or rubber aprons) can protect
health care workers from exposure to potentially contaminated blood or other body fluids and
clients from microorganisms present on medical staff and others working in the healthcare
setting.
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Procedure
1. Wash hands and dry them
2. Prepare necessary equipment
3. Scrub for at least 2 minutes
4. Keep hands up and away from the body, do not touch any surface or article. and dry hands
with a clean, dry towel
5. Check the package for integrity. Open the first non-sterile packaging by peeling it
completely off the heat seal (cover) to expose the second sterile wrapper, but without
touching it
6. Place the second sterile package on a clean, dry surface without touching the surface. Open
the package and fold it towards the bottom so as to unfold the paper and keep it open.
7. Using the thumb and index finger of one hand, carefully grasp the folded cuff edge of the
glove
8. Slip the other hand into the glove in a single movement, keeping the folded cuff at the wrist
level
9. Pick up the second glove by sliding the fingers of the gloved hand underneath the cuff of the
glove
10. In a single movement, slip the second glove on to the ungloved hand while avoiding any
contact/ resting of the gloved hand on surface other than the glove to be donned (contact/
resting constitutes a lack of asepsis and requires a change of glove)
11. If necessary, after donning both gloves, adjust the fingers and inter-digital spaces until
the gloves fit comfortably.
12. Unfold the cuff of the first gloved hand by gently slipping the fingers of the other hand
inside the fold, making sure to avoid any contact with a surface other hand the outer surface
of the glove (lack of asepsis requiring a change of gloves)
13. The hands are gloved and must touch exclusively sterile devices or the previously –
disinfected patient‘s body area.
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Removing gloves
14. Before removing the glove briefly immerse them in 0.5% chlorine solution,
15. Remove the first glove by peeling it back with the fingers of the opposite hand. Remove
the glove by rolling it inside out to the second finger joint
16. Remove the other glove by turning its outer edge on the fingers of the partially ungloved
hand
17. Remove the glove by turning it inside out entirely (ball forming) to ensure that the skin of
the health-care worker is always and exclusively in contact with the inner surface of the
glove.
18. Perform hand hygiene after glove removal according to the recommended indication.
B. Examination glove
Purpose:
1. When there is reasonable chance of hands coming in contact with blood or other body
fluids, mucous membranes or one intact skin
2. They perform invasive medical procedures (e.g., inserting vascular devices such as
peripheral venous lines)
3. When they handle contaminated waste items or touch contaminated surfaces.
Equipment
1. Table of soap or antiseptic
2. tap of water
3. towels
4. clean examination gloves
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Procedure
9. Pinch one glove at the wrist level remove it, without touching skin of forearm, and pill
away from the hand, thus allowing the glove to turn inside out
10. Hold the removed glove in the gloved hand and slide the fingers of the ungloved hand
inside between the glove and wrist. remove the second glove by rolling it down the hand
and fold in to the first glove
11. Discard the removed glove
C. Elbow length glove
Purpose
Used during manual removal of placenta and any other procedure where there is a contact
with a large volume of blood or body fluids.
D. Utility or heavy-duty gloves
Purpose
used for processing instruments, equipment and other items,
used for handling and disposing of contaminated waste, and when cleaning contaminated
surfaces
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Purpose
A. Masks
are worn in an attempt to contain moisture droplets expelled as the health care
workers speak, cough or sneeze
protect the wearer from inhaling both large and small particle droplets
B. Goggle/face shield
prevent accidental splashing of the mouth and face during certain procedures.
C. Cap
used to keep the hair and scalp covered so that flakes of skin and hair are not shed
into the wound during surgery
Equipment
1. Cap
2. Mask
3. Goggles/ Face Shield
Procedure
1. Wash hands.
2. Apply cap to head, being sure to tuck hair under cap. Males with facial hair should use a
hood to cover all hair on head and face
3. Secure mask around mouth and nose. For masks with strings:
a. Hold mask by top and pinch metal strip over bridge of nose.
b. Pull two top strings over ears and tie at upper back of head.
c. Tie two lower ties around back of neck so that bottom of mask fits snugly under
chin
4. For goggle Place over face and eyes and adjust to fit
5. After performing necessary tasks, remove cap and mask before leaving room.
A. Untie bottom strings of mask first, then top strings, and lift off of face. Hold mask
by strings and discard.
B. Grasp top surface of cap and lift from head.
6. To remove goggle/ face shield handle by head band or ear pieces
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5. Touching the outside of the flap only, reach around (rather than over) the sterile field to
open the flap away from you
6. Open the side flaps in the same manner, using the right hand for the right flap and the left
hand for the left flap
7. Lastly, open the inner most flap that faces you, being careful that it does not touch your
clothing or any object
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Definition
Purpose
to reduce the number of microorganisms
to removes all visible dust, soil, blood or other body fluids from inanimate objects
to eliminate microorganisms from inanimate objects
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Definition: Boiling in water is an effective practical way to high level disinfectant instrument
and other items
Purpose:
To kill all vegetative forms of bacteria, viruses (including HBV, HCV and HIV)
Equipment Water
1. Boiler
2. Stove
3. Sterile forceps
4. Sterile container ( high level disinfected container)
Procedure
1. Wash hands and dry them
2. Decontaminate and clean all instruments and other items to be high level disinfected
3. Prepare necessary equipment
4. Completely immense cleaned instruments and other items in water
5. Cover boiler with lid and bring water to a gently rolling boil
6. Start timing when rolling boil beings
7. Continue rolling boiling for 20 minutes
8. Remove items with high-level disinfected forceps
9. Place instruments in covered high level disinfected container
10. Wash hands and dry them.
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Principles of Storing
Store appropriately to protect them from dust, dirt, moisture, animals and insects.
The storage area should be located next to or connected to where sterilization occurs, in a
separate enclosed area
In smaller clinics, this area may be just a room close to the Central Supplies Department
or in the Operating Room
3.5. Healthcare waste management
Objective: At the end of this lesson, learner will be able to:
1. Identify the various types of health care wastes
2. Identify the types of risk related to health care wastes
3. demonstrate segregating of different wastes
Definition: refers to all activities, involved in the collection, handling, treatment, conditioning,
transport, storage and disposal of waste produced at healthcare facilities
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Equipment
1. Three different colored bags (Red, 4. gown
Yellow and Black) 5. apron
2. Heavy duty glove 6. boots
3. mask
Procedure
1. Wash hands
2. Wear necessary personal protective equipment
3. Separate wastes based on their level of infection
Noninfectious (Black color code): Presents no risk. Examples: paper, packaging
materials, office supplies, drink containers, hand towels, boxes, glass, plastic bottles, and
food.
Infectious (Yellow color code): Contaminated with human blood and has the ability to
spread disease. Examples: gauze, cotton, dressings, laboratory cultures, IV fluid lines,
blood bags, gloves, anatomical waste, and pharmaceutical waste.
Highly infectious (Red color code): Highly infectious Anatomical waste, pathological
waste
Sharps waste (Safety box, needle remover, or other puncture-resistant and leak-
resistant sharps containers): Syringes and needles should be discarded without
recapping.
4. Collect waste bags from the service point
5. Remove PPE
6. Wash hands
7. Documenting
3.6. House keeping
3.6.1. Patient unit care
Objective: At the end of the lesson, learner will be able
1. To define a patient‘s unit care.
2. To identify necessary equipment for cleaning patient‘s unit
3. To demonstrate cleaning of patient‘s unit
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Definition
Patient's unit is a small separate room in which the patient rest during his/her hospital
stay. Patient's unit usually consists of basic furniture and standard equipment
Cleaning of patient's unit is keeping of the patients room neat & orderly. There are two
types of cleaning that are concurrent and terminal cleaning
Concurrent Cleaning is a daily cleaning of the patients room. It consists cleaning the
room by damp mopping the floor and dusting with damp cloth.
Purpose:
Equipment
1. Wheeled utility cart 3. Cleaning cloths
2. Wheeled laundry hampers
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1. Hand washing
2. Assemble the equipment in the utility room & take it to the patient unit
3. Wear heavy duty/ utility glove
4. Clear the bed side cabinet and over bed table if used and discard any waste in the waste
basket
5. Strip the bed, remove pillow, and place the pillow on the chair & pillow case in the
hamper. Place all the line in the hamper and place blanket on the cart for special laundry
6. Clean the bed, wash the top of mattress cover
7. Turn the other side & clean the spring
8. Wash the cabinet, inside & out
9. Complete the unit cleaning by washing the chair, bed lamp ( cord unplugged) , singe cord
& over bed table
10. discard the waste if cleaning cloth are to be reused place them in the laundry hamper
11. Wash the collected utensils and place them in the utensils boiler (sanitizer) for a 30
minute
12. Remove the clean utensils from the utensil boiler ,dry and return them to the storage shelf
13. Wash hand
14. Record the procedure
Definition: The sanitation of the bed, bedside cabinet, and general area of the patient care unit
with a detergent/germicidal agent after the patient is discharged or transferred from the Nursing
care unit.
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Performed at every patient care unit before the area is prepared for the next patient.
Purpose
Prevention of the spread of microorganisms.
Removal of encrusted secretions from framework or bedside rails.
Removal of residue of body wastes from the mattress.
Deodorizing of the bed frame, mattress, and pillow.
Guidelines for Terminal Cleaning.
Check to ensure the bedside cabinet is cleared of any valuables belonging to the patient.
Check bed linens for personal items (dentures, contact lenses, money, jewelry, etc.)
belonging to the patient.
Allow the mattress and pillow to air-dry thoroughly before remaking the bed.
3.7. Linen processing
Objective: at the end of this lesson learner will be able to :-
1. Define linen and linen processing.
2. Describe key principles in handling linen
3. Demonstrate how clean linen should be stored, transported, and distributed
Definitions: Processing linen-: consists of all the steps required to collect, transport and sort
soiled linen as well as to launder (wash, dry and fold or pack), store and distribute it.
Equipment needed
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CHAPTER FOUR
MANAGING PATIENT SAFETY AND COMFORT
General objective: - At the end of the chapter the leaner will be able to
1. Identify condition needs utilization of comfort and safety device
2. Demonstrate how to apply sandbag, cotton and air ring, splint and bed cradles
3. Apply safety precaution when applying sandbag, cotton and air ring, splint and bed cradle
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Used to lift the hip from bed to prevent bed sores or pressure sore or decubitus ulcer.
To relieve pressure from small bony prominent areas such as heel, Elbow, occipital.
Improves the circulation.
Indication
Size: - Based on the body areas we are going to apply. The size differs from small to medium
size of bony prominent areas.
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Equipments
1. Cotton
2. Bandage
3. Chart showing human body prominent areas
Procedure
2. Wash hands
3. Assemble the necessary equipment
4. Prepare cotton ring based on the size of body to be applied.
5. Place cotton ring under the bony prominence such as elbow and heel
6. Wash hands
7. Document procedure
4.2. Applying foot – board
Objectives: - At the end of this lesson, learner will be able to:-
To provide support for the client‘s feet and maintain a natural foot position.
To keep the top bed covers off the client‘s felt relieving pressure.
To make the foot comfortable/prevent foot drop.
To prevent sagging of patient in to bed.
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Indication
Unconscious patients
Bedridden patients
Foot boards are often made in an L shaped – so that the base of L fits under foot of the
mattress.
Some foot boards can moved along the mattress to adjust to the clients foot drop from
their normal right angle to the legs and assume plantar flections position.
Foot drop:-is a condition of plantar flexions or a muscular which occurs from poor foot or leg
alignment.
Cause –when patient in bed for long time when the top sheet and blanket are tightly tucked.
Equipments
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adjustable, tuck a folded bath blanket between the board and the patient's feet.
8. Unless the footboard has side supports, place a sandbag, a folded bath blanket, or a pillow alongside
each foot to maintain 90-degree foot alignment.
9. Fold the top linens over the footboard, tuck them under the mattress, and miter the corners.
1. Wash hands
2. Document
4.3. Applying pillows
Objectives: at the end of this lesson leaner will be able to:-
Pillows
Pillows case
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Definition: Air rings are used to relieve pressure from the buttock and other bony prominent
areas. For application they should be filled with air and covered with
pillow case
Purpose
Used to lift the hip from bed to prevent bed sores or pressure sore or decubitus ulcer.
To relieve pressure from small bony prominent areas such as heel, Elbow, occipital.
Improves the circulation.
Indication
Bed ridden patients
Unconscious patients
Equipments:
1. Plastic air rings
2. Covering towel or pillow case
3. Chart showing body‘s prominent areas
Procedure
1. Explain the procedure to the patient
2. Wash hands
3. Assemble the necessary equipment.
4. Support the appropriate site
5. Applying air ring to body prominent area.
6. Observe patient comfort status
7. Wash hands.
8. Document
4.5. Applying bed cradle
Objectives:- at the end of this lesson leaner will be able to:-
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Definition: Bed cradle is sometimes called an Anderson frame. It is a device designed to keep
the top bed clothes off the feet, leg, abdomen and chest of a client
Types: there are several types of bed cradles; the most commonly used is curved metal rod.
Purpose
To keep bed top linen off the injured part of the body.
To prevent the weight of the bedding from resting on some part of the body.
To apply heat in case of drying plaster casts.
In case of electronic bed cradles are used to supply the desired warm in the case of
shock.
Indication Equipments:
Client with fracture or soft tissue
1. Bed cradle
injury.
2. Roll gauze/bandage
Client with burn.
3. Small size blanket
Client with some skin lesions.
Procedure:
2. Wash hands
6. Secure it in place.
9. Wash hands.
10. Document
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Types: they can be of various shapes and sizes usually made of metal
Purpose
Indication:
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Procedure
Definition: Sand bags are canvas, rubber or plastic bags filled with sand and sewed.
Purpose
To relive discomfort
Sand bags are used for supporting or immobilizing limbs
Used to support as in fractures bone
They should be covered with towel and placed on either side of the limb
To prevent foot drop or wrist drope
To prevent contracture
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Indication
Fractured limb
Amputated limb.
Equipments:
1. Bag
2. Rope
Sand
Covering towel
Weight scale
Adhesive plaster for labeling
Procedure
2.Wash hands
9. Wash hands.
1. Explain Splint
2. Mention the purpose of Splint
3. List the indications of Splint
4. Perform application of Splint
Definition: splints are devices applied to the arms, legs, or trunk to immobilize the injured
part of the body when it is needed.
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Purpose
Nursing consideration
1. Choice:-The splint chosen should be sufficiently strong and of suitable length and width.
2. Padding:-The splint should be covered with cotton wool to prevent discomfort or damage.
3. Molding:-Choose one which is most suitable mould to fit the natural curvature of the limb.
4. Fixation:-Splints must be fixed to the insured fracture limbs by bandage placed above and
below the injured part. Do not apply bandage directly on the injured part.
Equipment
Splints (wooden,metallic)
Dressing material (if there is open wound)
Glove
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Procedure
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Purpose
To maintain good body alignment.
To prevent bed from sagging.
To support the injured part when the patient has fractured spine, hips, lower limps.
Equipment
1. Fracture board
2. Thin foam mattress
Procedure
When back rest is used for the patient is liable to slip down to the foot of the bed,
therefore a foot board might be used.
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CHAPTER FIVE
BODY MECHANICS AND MOVING
4.1. Maintaining body alignment
Objective: At the end of the lesson learner will be able to :-
Body alignment (posture) refers to the relative position of body parts in relation to each other when
lying down, standing, sitting, or any other activity results in balance, which is an individual‘s ability
to maintain equilibrium
Purpose
To promote client comfort
To prevent contractures
To promote circulation
To lessen stress on muscle, tendons, nerves, and joints
To Prevent foot drop (plantar flexion)
Gives an appearance of confidence and health
4.1.1. Checking proper/normal alignment of spine
Objective: At the end of the lesson, leaner will be able to:
1. Proper/normal alignment of the spine refers to cervical concavity, a thoracic convexity, and a
lumbar concavity in standing patients ( Figure.-----)
Purpose
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Equipment
1. Pen
2. Documentation/charting format
Procedure
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forward with the center of gravity in the middle of the pelvis( about halfway between the umbilicus and
the symphysis pubis) (figure.5)
Purpose
Pen
Documentation/charting format
Procedure
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Definition
Proper/normal alignment on sitting posture has similar characteristics with standing posture
except the hips and knees are flexed ( Figure 6)
Purpose
1. Pen
2. Documentation/charting format
3. Chair
Procedure
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4. Proper/normal alignment on sitting posture has similar characteristics with standing posture
except that the patient is in supine position
Purpose
1. Pen
2. Documentation/charting format
3. Bed or examination couch
Procedure
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Definition
Body mechanics is the coordinated use of the body parts to produce motion and to maintain balance
Propose
1. Define dangling
2. Identify purpose of dangling
3. Mention indication and contraindication
4. Demonstrate proper dangling
Definition: Dangling is sitting on the side of the bed with the feet hanging down
Purpose
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Indication
Uncurious patient
Spinal injury
Precaution
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Purpose
Spinal injury
Note: logrolling is accomplished by two or three nurses working in a coordinated fashion (Figure8 and 9)
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Equipment
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Moving patients up in bed refers to returning the patient to previous correct position in
bed if he/she slides to the foot side of the bed.
Purpose
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Procedure Steps
Definition
Positioning is turning or putting the patients in a proper body alignment for the purpose of preventive,
promotive ,curative and rehabilitative aspects of health
Purpose of positioning
To relief pressure on various parts or lessen possible stress on pressure points
To prevent formation of deformity
To Improve circulation
Preserve muscle function as different muscle group‘s contract and relax.
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Indication
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Semi-prone position putting or assisting patients with upper arm flexed at shoulder and elbow;
lower arm positioned behind client and both legs flexed in front of client with more flexion in
upper leg either of body side (Figure.--) .
Purpose
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Contraindication
o lumbar lordosis
o Foot drop
o client with leg injuries or arthritis
Equipment
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Promote comfort
To help healing after certain abdominal operations
Indication
Spinal injury
Cardiac patient (CHF)
Breathing impairments
Pressure sore (buttock, scrum, heal and shoulder )
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Equipments
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Purpose
Promote comfort
For visualize the perineum
To insert urinary catheter
To relief pressure from ileum, knee and ankle
Indication
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Procedure
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Purpose
1.
2. Pillow of different size (4) 4. Draw sheet or turn sheet
3. Bed with side rails 5. Documentation format
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Procedure
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Purpose
1. Sigmoidoscopic examination
2. Vaginal and rectal examination
3. Cord Prolapse
4. Retoverted uterus
Contraindication
Cardio-pulmonary problem
Upper arm, spine and ribs fracture
Increased intra-cranial pressure (IICP)
Equipments
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Procedure
5.3.7. Fowler's position (semi-upright with back and knee rests elevated)
Objective: At the end of this lesson learner will be able to::
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Type
1. High Fowler's position is when the patient's head is raised 80-90 degrees,
2. Semi-Fowler's position is when the patient's head is elevated 30-45 degrees.
3. Low Fowler's position is when the head of bed is elevated 15-30 degrees
4. Fowler's which is 45-60 degrees
Purpose
1. To relive dyspnea
2. To improve circulation
3. To prevent thrombosis
4. To prevent aspiration during the introduction of feeding tubes
5. To facilitate drainage from abdomen and pelvic cavity post operatively
6. To relax the muscle of the abdomen, back and thighs
7. To relive tension on abdominal suture
8. To promote comfort
9. Increase comfort during eating
10. To relieve edema of the chest and abdomen
Indication
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Contraindication
1. Comatose/unconscious patients
2. Spinal injury
3. Foot drop
4. Head injury
5. Shoulder dislocation
Equipment
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Hypotension/shock
Abdominal and gynecologic surgery
Placing central venous line
Surgical reduction of hernea
Contraindication
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Contraindication
Spinal injury
Cardiac patient (CHF)
Breathing impairments
Pressure sore (buttock, scrum, heal and shoulder )
Equipments
1.
2. Bed block(if necessary 4. Screen
3. Drape 5. Documentation format
Procedure
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Definition: Lithotomy position is positioning the client feet above or the same level as hips with
perineum positioned at the edge of examination table ( Figure….).
Purpose
Spinal injury
Breathing impairments
Equipments
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9. Flex the feet above or the same level as hips and support with knee rest over a couch ( if
available)
10. Wash your hand
11. Note the patient reaction
12. Document the procedure
5.4.Patient ambulation
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Objective: At the end of this lesson, learner will be able to prepare patient/clients for ambulation
considering the necessary precaution
Determine the client‘s activity level and tolerance for physical exertion ( strength, endurance,
general status and mobility status)
Assess for factors that may negatively affect ambulation (e.g., mental status, fatigue, pain,
medications).
Evaluate the environment for safety (e.g., presence of obstacles in walkway, adequate lighting,
nonslip floor, handrails).
Check assistive devices for safety hazards
Check client‘s clothing (e.g., nonslip shoes, adequate covering for privacy and warmth).
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Procedure
1. Inform client about the purposes and distance of the walking exercise
2. Elevate the head of the bed and wait several minutes to prevents orthostatic hypotension
3. Lower the bed height
4. With one arm under the client‘s back and one arm under the client‘s upper legs, move the client
into the dangling position
5. Encourage client to dangle at side of bed for several minutes
6. Stand in front of client with your knees touching client‘s knees
7. Place arms under client‘s axilla
8. Assist client to a standing position, allowing client time to balance
9. Help client ambulate desired distance or distance of tolerance by placing your hand under the
client‘s forearm and ambulating close to the client
5.4.2. Assisting patient with assistive devices
Objective: At the end of this session students will be able to assist patient in ambulation using
appropriate assistive devices
Definition: Assistive device is a material used to support client/patient who unable to walk
independently
Common types
1. Gait belt 3. Walker
2. Cane 4. Crutch
5.4.2.1. Gait belt
Objective: At the end of this lesson learner will be able to:
1. Define client gait belt
2. Identify the purpose of gait belt
3. Indentify the indications and contraindications
4. Assist patient in ambulation using gait belt appropriately
Definition: Gate belt is an assistive used during simple assisted ambulation (Figure…..)
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Purpose
To aid patient/client in ambulation
Indication
One body part weakness
Equipment
Gait belt
Procedure
1. Wash your hands.
2. Explain what you are going to do.
3. Assist the client to sit on the edge of the bed.
4. Pause and allow the client to sit on the edge of the bed for a few moments to regain balance.
5. Assist the client in putting on socks and nonskid shoes.
6. Put a gait belt around the client's waist.
7. Stand in position of good body mechanics.
8. Assist the client to a standing position by straightening your legs as you lift with the gait belt and the
client pushes down with his hands on the mattress.
9. Pause to allow the client to regain balance.
10. Walk with the client by placing one hand on the gait belt in front of his waist and your other hand in
back under the gait belt.
11. Walk in the same pattern as the client (both step with left foot at the same time).
12. Assist the client to step forward with strong foot first.
13. Walk the client the distance instructed by supervisor or as indicated by the service plan
14. Return the client to the bed/chair.
15. Make sure the client is comfortable.
16. Remove the gait belt.
17. Wash your hands.
18. Record observations.
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5.4.2.2. Cane
Type
1. Standard Cane
2. T-handle Cane
3. Tripod Cane
4. Quad (Quadruped) Cane
Indication
Some weakness in one leg or hip
Purpose
To support the patient during walking
Equipment
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Procedure
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Purpose
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Equipment
1. Walker
2. Gait belt
3. Documentation format
Procedures
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1. Define crutch
2. Identify the purpose of crutch
3. Explain the types of crutch
4. Indentify the indications and contraindications
5. Assist patient in ambulation using crutch with different gates accordingly
Definitions
Crutch is walking aids made of wood or metal in the form of a shaft which reaches from the ground
to the client‘s axilla.
Crutch walking; is one of the patient ambulation techniques which helps the client to stand and
walk with the help of Crutch
Purpose
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Types of Crutch
Axillary:
Fits under the axilla with the weight being placed on the handgrips
Forearm:
It has a handgrip and a metal cuff that fits around the arm
More convenient but provides less stability than the axillary crutch
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Purpose
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Procedure
Purpose
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Indication
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Purpose
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Purpose
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Contraindication
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Definition: Crutch walking gait in which the pattern of crutches forward, then legs swing
forward together through the crutch
Purpose
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9. Help the client practice the gait by repeating step 8 until the client independently practice it
10. Assess the client‘s progress, and correct any mistakes as they occur.
11. Observe the patient condition
12. Record the procedure
5.4.2.6. Up and down stair gait
Purpose
Musculo-skeletal injury
Contraindication
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Procedure
a) Start with weight on uninjured leg and crutches on the same level.
b) Put crutches on the first step
c) Put weight on the crutch handles and transfers unaffected extremity to the step where
crutches are placed
9. Help the client practice the gait by repeating step 8 until the client independently practice it
10. Assess the client‘s progress, and correct any mistakes as they occur.
11. Observe the patient condition
12. Record the procedure
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Purpose
Contraindication
Unconscious patients
Equipment
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Purposes
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Indication
For patients unable to move from bed to areas where procedures performed
Equipment
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1. Stretcher 4. Glove
2. Pillow 5. Documentation format
3. Lift sheet
Procedure
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Definition
Range of motion exercise refers to activities aimed at improving movement of specific or group
of joints
Purpose
1. Wash hands
2. Explain the procedure to the client
3. Adjust the bed to a comfortable height.
4. Select one side of the bed to begin PROM exercises.
5. Uncover only the limb to be exercised.
6. Support all joints during exercise activity.
7. Use slow, gentle movements when performing exercises.
8. Repeat each exercise three times.
9. Stop if the client complains of pain or discomfort.
10. Begin exercise with the client‘s neck and work down ward.
11. Exercise the neck
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CHAPTER SIX
ESSENTIAL ASSESSMENT COMPONENTS
General objective: At the end of this chapter, the learner will be able to
1. Measure patient body temperature
2. Measure patient blood pressure
3. Take patient pulse with acceptable technique
4. Characterize patient respiration
5. Collect urine specimen and apply reservation skill
6. Collect body fluid specimen
7. Collect blood specimen through vein, capillary and artery puncture
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Definition: The body temperature is the difference between the amount of heat produced by
body process and the amount of heat lost to the external environment.
Purpose
1. To determine body temperature
2. To assist in diagnosis
3. To evaluate patient‘s recovery from illness
4. To determine if immediate measures should be implemented to reduce dangerously
elevated body temperature or converse body heat when body temperature is dangerous
low
5. To evaluate patient‘s response once heat conserving or heal reducing measures have been
implemented
6.1.1.1. Measuring oral temperature
Contraindication
Procedure
1. Explain the procedure
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2. Wash hands
3. Assemble the necessary equipment
4. Remove thermometer from storage container and cleanse under cool water.
5. Wipe thermometer dry with a tissue from bulb‘s end toward fingertips.
6. Read thermometer by locating mercury level. It should read 35.5°C (96°F).
7. If thermometer is not below a normal body temperature reading, grasp thermometer
with thumb and forefinger and shake vigorously by snapping the wrist in a downward
motion to move mercury to a level below normal.
8. Assist the client to assume semi fowlers position
9. Place thermometer in mouth under the tongue and along the gum line to the posterior
sublingual pocket. Instruct client to hold lips closed.
10. Leave in place as specified by agency policy, usually 3–5 minutes.
11. Remove thermometer and wipe with a tissue away from fingers toward the bulb‘s
end.
12. Read at eye level and rotate slowly until mercury level is visualized.
13. Shake thermometer down, and cleanse glass thermometer with soapy water, rinse
under cold water, and return to storage container.
14. Remove and dispose of gloves in receptacle.
15. Comfort the patient
16. Return used equipment and wash your hand
17. Record reading and indicate site as ―OT.‖(oral temperature)
6.1.1.2.Taking patient body temperature (axilary)
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Procedure
1) Explain the procedure
2) Wash hands
3) Assemble the necessary equipment
4) Maintain privacy if necessary
5) Remove client‘s arm and shoulder from one sleeve of gown. Avoid exposing
chest.
6) assist the client assume supine or semi sitting position
7) Make sure axillary skin is dry; if necessary, pat dry
8) Prepare thermometer (If thermometer is not below a normal body
temperature reading, grasp thermometer with thumb and forefinger and shake
vigorously by snapping the wrist in a downward motion to move mercury to
a level below normal).
9) Place thermometer or probe into center of axilla .
10) Fold client‘s upper arm straight down and place arm across client‘s chest.
11) Leave glass thermometer in place as specified by agency policy (usually 6–8
minutes). Leave an electronic thermometer in place until signal is heard.
12) Remove and read thermometer.
13) Inform client of temperature reading.
14) Cleanse glass thermometer (Remove thermometer and wipe with a tissue
away from fingers toward the bulb’s end) and return to storage container.
15) Assist client with replacing gown.
16) Comfort the patient
17) Return used equipment and wash your hand
18) Record reading and indicate site as ―AT.‖(Axillary temperature)
6.1.1.3. Measuring rectal temperature
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Precaution:
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8. Turn client‘s head to one side. For an adult, pull pinna upward and back; for a child, pull down and
back.
9. Gently insert probe with firm pressure into ear canal.
10. Remove probe after the reading is displayed on digital unit (usually 2 seconds).
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pencil and pen
Procedure
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Inform client of the site(s) at which you will measure pulse.
5. If supine, place client‘s forearm straight alongside body or Flex client‘s elbow and
place lower part of arm across chest.
6. Support client‘s wrist by grasping outer aspect with thumb.
7. Place your index and middle finger on inner aspect of client‘s wrist over the radial
artery or thumb side and apply light but firm pressure until pulse is palpated
8. Identify pulse rhythm and then Determine pulse volume.
9. Count pulse rate by using second hand on a watch:
For a regular rhythm, count number of beats for 30 seconds and multiply by 2.
For an irregular rhythm, count number of beats for a full minute, noting number
of irregular beats.
10. Comfort the client
11. Return equipment and wash hand
12. Record reading and indicate site as ―PR.‖(pulse rate)
Apical pulse
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Raise client‘s gown to expose sternum and left side of chest.
5. Cleanse earpiece and diaphragm of stethoscope with an alcohol swab.
6. Put stethoscope around your neck.
7. Apex of heart:
With client lying on left side, locate suprasternal notch.
Palpate second intercostal space to left of sternum.
Place index finger in intercostal space, counting downward until fifth
intercostals space is located.
Move index finger along fourth intercostals space left of the sternal border and
to the fifth intercostal space, left of the midclavicular line to palpate the point
of maximal impulse (PMI) .
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watch.
Infants and children: count a full minute.
Adults: count for 30 seconds and multiply by 2.
If an irregular rate or rhythm is present, count for a full minute.
8. Observe depth of respirations by degree of chest wall movement and rhythm of
cycle (regular or interrupted).
12. Comfort the client
15. Return equipment and wash hand
13. Record reading and
6.1.4. Assessing patient blood pressure
Objective: At the end of this lesson, the learner will able to:
Identify common site of assessing blood pressure
Identify and assemble equipment routinely used to assess blood pressure
Demonstrate procedures used to assess blood pressure
Document and Interpret the finding.
Definition: is the method of recording force exerted on arterial wall by pulsing blood under
pressure from the heart.
Purpose:
To evaluate effect of some drugs affecting cardiovascular system
To have baseline vital sign of patient on admission
To diagnose hypertension and hypotension disorders of blood
Contraindications for brachial artery blood pressure measurement
When the client has any of the following, do not measure blood pressure on the involved side
Venous access devices, such as an intravenous infusion or arteriovenous fistula for renal
dialysis
Surgery involving the breast, axilla, shoulder, arm, or hand
Injury or disease to the shoulder, arm, or hand, such as trauma, burns, or application of a
cast or bandage
Equipment:
Alcohol swabs Pen and pencil
Sphygmomanometer with proper
size cuff
Stethoscope
Tray
Vital sign sheet
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Procedure
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Determine which extremity is most appropriate for reading.
5. Have the client rest at least 5 minute before measurement.
6. Use appropriate size cuff
7. Move clothing away from upper aspect of arm.
8. Position arm at heart level, extend elbow with palm turned upward and for thigh, position
with knee slightly flexed.
9. Make sure bladder cuff is fully deflated and pump valve moves freely.
10. Locate brachial artery in the antecubital space.
11. Apply cuff comfortably and smoothly over upper arm, 2.5 cm (1 in.) above antecubital
space with center of cuff over brachial artery.
12. Connect bladder tubing to manometer tubing. If using a portable mercury-filled manometer,
position vertically at eye level.
13. Palpate brachial artery ,turn valve clockwise to close and compress bulb to inflate cuff to 30
mm Hg above point where palpated pulse disappears, then slowly release valve (deflating
cuff), noting reading when pulse is felt again .
14. Insert earpiece of stethoscope in ears with a forward tilt, ensuring diaphragm hangs freely
15. Relocate brachial pulse with your non dominant hand and place bell or diaphragm chest
piece directly over pulse. Chest piece should be in direct contact with skin and not touch
cuff
16. With dominant hand, turn valve clockwise to close. Compress pump to inflate cuff until
manometer registers 30 mm Hg above diminished pulse point identified in step 13.
17. Slowly turn valve counterclockwise so that mercury falls at a rate of 2–3 mm Hg per
second. Listen for five phases of Korotkoff‘s sounds while noting manometer reading:
18. Deflate cuff rapidly and completely.
19. Remove cuff or wait 2 minutes before taking a second reading.
20. Inform client of reading
21. Lower bed, raise side rails, place call light in easy reach.
22. Put all equipment in proper place.
23. Comfort the client
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Definition: Routine Urinalysis/screening in which the components of urine are identified and can be
collected at any time of the day
Purpose
To diagnose illness
To monitor the disease process
To evaluate the efficacy of treatment
Precaution
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Definition: is method of collecting urine specimen for specified period. Some tests of renal
function and urine composition require urine to be collected over 2 to 72 hr. The 24 hour timed
collection is most common.
Purpose:
The test allow for the measurement of elements such as amino acids, crearinin, hormones,
glucose and adrenocorticosteroids, whose levels change over time.
A timed urine collection can also provide a means to measure the concentration or
dilution of urine.
Used to monitor input and output
Equipment
Large bottle or container
Funnel if available and necessary
format for recording
Label for bottle
Glove
Procedures
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Label container with correct information
5. Take a clean chamber with a cover or a large bottle.
6. Attach the label with patient's name and keep it in a safe place, marked-"24 hours specimen."
Or prescribed duration .
7. Instruct the sweeper and patient's relative not to empty it.
8. Tell the patient that all urine for the full 24 hours/prescribed duration must be saved, after
passing it separate from stool.
9. If at any time the urine is not saved the procedure must be started all over again.
10. Preferably Start at 6 a.m. by having the patient void and throw the first specimen away,
because it was secreted during the night.
11. After that each time the patient voids, pour the urine into the same container and keep it
covered.
12. After 6 a.m. the next morning‘s has the patient again void and add this as the last specimen
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Definition: Mead stream urine specimen is method of collecting part of urine stream by avoiding
first and last part of urine in receptor.
Purpose
To take the specimen for culture and sensitivity
To identify possible microorganism in the urine
To detect and measure the presence of abnormalities in the urine like RBC,WBC,PH and
albumine
Equipment
A. Commercial kit for clean –voided B. Soap, water, washcloth and towel
urine containing: Bedpan(for non ambulatory
Sterile cotton balls and/or 2X2 client),specimen hat(if all urine
inch gauze pads. needs to be measured),potty-chair
Antiseptic solution (for young child )
Sterile water or saline C. Completed specimen identification
Sterile specimen collection label
container and sterile glove D. Completed laboratory requisition
form
Procedures
1) Explain the procedure
2) Wash hands
3) Assemble the necessary equipment
4) Provide privacy for client around the bed or closing room door. Allow mobile client to
collect specimen in bathroom or toilet
5) Give client cleansing towel, washcloth, and soap to cleanse perineum, or assist client with
cleansing perineum (if able)
6) Assist bedridden client onto bedpan
7) Using surgical asepsis, open sterile kit or prepare sterile tray.
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12. Create a sterile field and Drape the client with a sterile drape
13. Prepare the equipment and Put receiver for urine near the vulva.
14. Wash the outer skin folds then inner labia and urethral meatus with antiseptic solution from
front to back. (Starting from outer proceeding to inside)
15. Put forceps in the receiver kidney dish
16. Wash and Rinse the area well from outer skin folds then inner labia and urethral meatus
finally with distil water from front to back.
17. Put forceps in the receiver kidney dish
18. Dry with dry gauze the outer skin folds then inner labia and urethral meatus from front to
back
19. Put forceps in the receiver kidney dish
20. Lubricate the insertion tip of the catheter (5-7 cm in)
21. Expose the urinary meatus adequately by retracting the tissue or the labia minora in an
upward direction
22. Gently insert the catheter into meatus until urine is noted. Continue inserting for 2.5 to 5cm
additional.
23. Instruct the client to immediately report pain, discomfort or pressure if so discontinue the
procedure and investigate the cause
24. Take sterile specimen and cover it
25. Remove the catheter and discard it
26. Make patient comfortable by covering her up properly.
27. Label and send to laboratory room immediately
28. Return used equipment and wash hand
29. Proper documentation
6.2.1.5. Catheterized urine specimen for male client
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Equipment
Sterile
1. Kidney dish 7. Two Catheter
2. Galipot(2) 8. Syringe
3. Gauze 9. Distill Water
4. Forceps four 10. Specimen bottle
5. Four Towel 11. Two Gloves
6. Lubricant
Clean
1. Waste receiver 7. Antiseptic Solution
2. Rubber sheet 8. Two small basin
3. Flash light 9. Soap
4. Measuring jug 10. Request chart
5. Screen 11. Wash cloth(2)
6. Disposable glove
Procedures
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Keep patient privacy
5. Turn top bed linen upwards from the bottom to the patient‘s chest to protect her from
complete exposure.
6. Place patient in supine position, then put mackintosh under his buttocks.
7. Apply disposable glove
8. Clean starting from mid thigh with clean warm water and soap and dry the area
9. Open sterile filed
10. Done sterile gloving
11. Create a sterile field and Drape the client with a sterile drape
12. Prepare the equipment and Put receiver for urine near the genital area
13. Gently raise penis. If the client develops an erection, delay perineal care. Gently grasp
the shaft of the penis. If the client is uncircumcised, retract the foreskin
14. Take first forceps and wash with antiseptic solution starting from glans of penis to
down with circular manner.
15. Put forceps in the receiver kidney dish
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16. Take second forceps and wash with distil water starting from glans of penis to down
with circular manner.
17. Put forceps in the receiver kidney dish
18. Dry with dry gauze from up to down with circular manner
19. Put forceps in the receiver kidney dish
20. Lubricate the insertion tip of the catheter (5-7 cm in)
21. Hold the shaft of penis in 90 degree
22. Gently insert the catheter into meatus until urine is noted or 20 cm
23. Instruct the client to immediately report pain, discomfort or pressure if so discontinue
the procedure and investigate the cause
24. Take sterile specimen and cover it
25. Remove the catheter and discard it
26. Make patient comfortable by covering her up properly.
27. Label and send to laboratory room immediately
30. Return used equipment and wash hand
31. Proper documentation
6.2.2. Collecting stool specimen
Objective: At the end of this lesson, the learner will able to:
1. Assemble necessary equipment
2. Demonstrate proper technique of taking stool specimen
3. Interpret the result after taking the stool specimen
4. Demonstrate proper handling of stool sample
Definition: Taking small pieces of stool from patient for chemical, bacteriological or
parasiotological analysis
Purpose:
To identify specific pathogens
To determine presence of ova and parasites
To determine presence of blood and fat
To examine for stool characteristics such as color, consistency and odor
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Equipment
1. Clean disposable glove 7. Specimen bottle
2. Tongue depressor 8. Labeling tape
3. Bed pan 9. Lab request
4. Screen 10. Glove
5. Air fresher as needed 11. Request chart
6. Tissue paper
Procedures
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Keep patient privacy
5. Offer clean bed pan to the patient
6. Take bed pan to the utility room
7. Take a portion of feaces from different area of stool specimen
8. Throw tongue depressor into the waste can
9. Spray air fresher as necessary
10. Label bottle properly
11. Send to the laboratory
12. Return used equipment and wash hand
13. Proper documentation
NB:
Stool from a Client with Hepatitis:- When collecting a stool specimen from a client
with hepatitis, write on the lab requisition form that the client has hepatitis. This increases
the laboratory personnel‘s awareness to be extra careful when handling the specimen..
Send fresh stool immediately to the lab
6.2.3. Taking blood specimen
Objective: At the end of this lesson, the learner will able to:
Assemble necessary equipment
Demonstrate proper technique of taking blood specimen
Interpret the result after taking the blood specimen
Demonstrate proper handling of blood sample
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6.2.3.1.Vein puncture
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16. With draw the needle and apply pressure with dray cotton
17. Withdraw the needle from the syringe and bend the test tube then transfer the blood
to the test tube slowly.
18. Send to the laboratory room
19. Return used equipment and wash hand
20. Proper documentation
21. Return used equipment and wash hand
Definition: it is method of taking small drop of blood from capillary by pricking the skin.
Site for pricking
Tip of the finger (ring finger of the left hand)
Lobe of the ear
Infants plantar surface of the heal and the plantar surface of the big toe
Purpose
To detect hemo-parasite
To detect blood cell abnormalities
Equipment
1. Antiseptic swab 6. Lancet
2. Glove 7. pen and pencil
3. Tray 8. capillary tube
4. Safety box 9. record chart
5. West receiver 10. Glass of slide
dry cotton
Procedures
1. Explain the procedure
2. Wash hands
3. Assemble the necessary equipment
4. Put on glove
5. Clean the site with antiseptic swab
6. Prick the site with lancet
7. Collect a drop of blood on the glass slide
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Objective: At the end of this lesson, the learner will able to:
Arterial Puncture is an invasive procedure using a needle to withdraw blood from a peripheral
artery (e.g., radial or femoral) or from an arterial line in a 5-ml heparinized syringe
Purpose
Done for blood gas analysis to determine Oxygenation, Ventilation and the effectiveness of
respiratory therapy and Acid-base level of the blood
Contraindication
Anticoagulant therapy
Clotting disorders
Symptomatic peripheral vascular disease
Negative Allen test
If the client is hyperthermic
Immediately after breathing and suctioning treatments
If there have been changes on ventilator settings
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Complications o Infection
o Hematoma o Hemorrhage
o Arteriospasm o Trauma to the vessel
o Air or clotted-blood emboli o Arterial occlusion
o Anaphylaxis from local o Vasovagal response
anesthetic o Pain
Equipment
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3. Maintain privacy
4. Assemble the necessary equipments
5. Remove any moist outer dressing that cover the wound
A. Put on clean gloves
B. Remove the outer dressing and observe any drainage on the dressing. Hold the
dressing so that the client does not see the drainage
C. Determine the amount of drainage, for example ‗one 2x2 gauze saturated with pale
yellow drainage
D. Discard the dressing in the moisture proof bag. Handle it carefully so that the
dressing does not touch the outside of the bag.
E. Remove gloves and dispose of the properly
6. Open the sterile dressing set using sterile technique
7. Assess the wound
A. Put on sterile gloves
B. Assess the appearance of the tissues in and around the wound and the drainage.
Infection can cause reddened tissues with a thick discharge, which may be foul
smelling, whitish, or colored.
8. Cleanse the wound
A. Using gauze swabs or irrigation: cleanse the cleanse the wound with normal saline
until all exudates has been removed
B. After cleansing apply sterile gauze pad to the wound
C. If a topical antimicrobial ointment or cream is being used to treat the wound use a
swab to remove it.
D. Remove and discard sterile gloves
9. Obtain the aerobic culture
A. Open a specimen tube and place the cup upside down on a firm, dry surface so that
the inside will not become contaminated, or if the swab is attached to the lid, twist
the cap to loosen the swab. Hold the tube in one hand and take out the swab in the
other.
B. Rotate the swab back and forth over clean areas of granulation tissue from the sides
or base of the wound.
C. Do not use pus or pooled exudates to culture
D. Avoid touching the swab to intact skin at the wound edges.
E. Return the swab to the culture tube, taking care not to touch the top or outside of the
tube.
F. Crush the inner ampule containing the medium for organism growth at the bottom of
the tube.
G. Twist the cap to secure.
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H. If specimen is required from other site, repeat the steps. Specify the exact site(e.g.
inferior drain site or lower aspect of incision) on the label of each container. Be sure
to put swab in the appropriately labeled tube.
10. Dress the wound
A. Apply any ordered medication to the wound
B. Cover the wound with sterile wound dressing
11. Arrange for the specimen to be transported to the laboratory immediately. Be sure to
include the completed requisition.
12. Document all relevant information.
A. Record on the client‘s chart the taking of the specimen and source.
B. Include the date and time, the appearance of the wound; the color, consistency,
amount, and odor of any drainage; the type of culture collected; and any discomfort
experienced by the client.
6.2.6. Collecting Nose, Throat, and Sputum Specimens
Objective: at the end of this lesson learner will able to:-
Purpose: Examination of sputum may aid in the diagnosis and treatment of several conditions
ranging from simple Upper respiratory tract infections.
Equipment
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Important points
1. Standard precautions are used when collecting specimen involving any body fluids
2. Routine specimen collection is usually scheduled for early in the morning
3. Take sputum before brushing or rinsing the mouth and close the container without
touching inside of lid
4. Any specimen collected should be transported to the laboratory immediately to ensure
the most accurate results
5. Sputum specimen collection requires the client to expectorate or cough up secretions
from lower in the respiratory tract. The early morning the most accurate
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CHAPTER SEVEN
MAKING AND MAINTAINING BED
General objective: At the end of this chapter students will able to apply the correct steps in
preparing different types of bed
Bed making - is a technique, which provides enough area to the patient on which s/he can be
comfortable.
General instruction
1. Put bed coverings in order of use
Order of Beddings
1. Mattress cover 5. Top sheet
2. Bottom sheet 6. Blanket
3. Rubber sheet 7. Pillow case
4. Cotton (cloth) draw sheet 8. Bed spread
2. Wash hands thoroughly after handling a patient's bed linen
3. Linens and equipment soiled with secretions and excretions harbor micro-organisms that can
be transmitted directly or by hand‘s uniforms
4. Hold soiled linen away from uniform
5. Linen for one client is never (even momentarily) placed on another client‘s bed.
6. Soiled linen is placed directly in a portable linen hamper or a pillow case before it is gathered
for disposal.
7. Soiled linen is never shaken in the air because shaking can disseminate secretions and
excretions and the microorganisms they contain.
8. When stripping and making a bed, conserve time and energy by stripping and making up one
side as completely as possible before working on the other side.
9. To avoid unnecessary trips to the linen supply area, gather all needed linen before starting to
strip bed.
10. Make a vertical or horizontal toe pleat in the sheet to provide additional room for the client‘s
feet.
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11. While tucking bedding under the mattress the palm of the hand should face down to protect
your nails.
Note
Pillow should not be used for babies
The mattress should be turned as often as necessary to prevent sagging, which will cause
discomfort to the patient.
7.1. Stripping of a Bed
Objective: At the end of this lesson learner will be able to:
1. Define Stripping of a bed
2. Explain the purpose and precautions of bed stripping
3. Identify necessary equipments for stripping of a bed
4. Demonstrate Stripping of a bed
Definition: Stripping of a bed is removing the bed linen from a bed which had been
previously made-up.
Purpose:
To prevent cross contamination
Ventilate the bed and bedding, and
Prepare the bed for remaking
To prevent damage of bedding
Precautions
1. No bedding, either clean or soiled, should ever be put on the floor. It should be discarded
in hamper.
2. Do not let your uniform touch the bedding. Woollen blankets are never discarded in
soiled clothes hamper. If soiled, they should be dry-cleaned or washed carefully or
treated with direct sunlight.
3. Use glove it the bed soiled or used by patient
Equipment
Bedside chair
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Hamper
Glove as necessary
Procedure
1. wash hand
2. Place chair conveniently at the foot of the bed
3. place pillow on seat of chair
4. Loosen the bedding all around, starting from the right
5. Fold bedspread twice, bring top hem (edge) to bottom hem, pick up from the centre.
6. Fold the blanket and the top sheet in similar manner
7. Place soiled linen in the hamper
8. Place other soiled bedding on chair, and place that which is to be used again, over back of
chair
9. Fold the draw sheet in two and place it over the chair if clean or on the- chair if soiled.
10. Do likewise with mackintosh.
11. Remove and fold the bottom sheet in the same manner as the bedding
12. Turn mattress from top to bottom or from side to side.
13. Wash hands
14. Recording and documenting
7.2. Making Unoccupied Bed
Definition: Closed bed is a smooth, comfortable and clean bed, which is prepared for a newly
admitted patient.
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In closed bed: the top sheet, blanket and bed spread are drawn up to the top of the bed and
under the pillows.
Purpose:
To receive new patient
To keep the bed neat and clean until a new patient is admitted
Equipment Blanket (1)
Savlon water or Dettol water in basin.
Mattress (1)
Sponge cloth (4): to wipe with solution
Bed sheets(2): Bottom sheet (1), Top
(1) to dry (1)
sheet (1)
When bed make is done by two nurses,
Pillow (1)
sponge cloth is needed two each.
Pillow cover (1)
Laundry bag or hamper (1)
Mackintosh/ Rubber sheet (1)
Trolley(1)
Draw sheet (1)
Clean glove
Procedure
1. Wash hands and collect necessary materials
2. Place the materials to be used on the chair. Turn mattress and clean the mattress.
3. Move the chair and bed side locker.
4. Clean Bed-side locker, chair: Wipe with wet and dry.
5. Clean the mattress:
Stand in right side.
A. Start wet wiping from top to center and from center to bottom in right side of mattress.
B. Gather the dust and debris to the bottom.
C. Give wiping as same as procedure 2
Move to left side.
Wipe with wet and dry the left side.
6. Move to right side. Start making the bed, Place bottom sheet with correct side up, center of
sheet on center of bed and then at the head of the bed.
7. Tuck sheet under mattress at the head of bed and miter the corner.
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Mitering steps:
A. Face the side of bed and lift and lay the top edge of the sheet onto the bed to form a
triangular fold.
B. With your palms down, tuck lower edge of sheet (hanging free at side of mattress) under
mattress.
C. Grasp the triangular fold, bring it down over the side of the mattress and tuck the sheet
smoothly under the mattress Straighten the free hanging sheet on mattress side.
8. Remain on one side of bed until you have completed making the bed on that side.
9. Tuck sheet on the sides and foot of bed, mitering the corners.
10. Tuck sheets smoothly under the mattress, there should be no wrinkles.
11. Place rubber and draw sheet at the center of the bed and tuck smoothly and tightly.
12. Place cotton draw sheet on top of rubber draw sheet and tuck. The rubber draw sheet should
be covered completely.
13. Place top sheet with wrong side up, center fold of sheet on center of bed and wide it at head
of bed.
14. Tuck sheet of foot of bed, mitering the corner.
15. Place blankets with center of blanket on center of bed, tuck at the foot of beds and miter the
corner.
16. Fold top sheet over blanket
17. Place bed spread with right side up and tuck it.
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Definition: 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 of a client to get in.
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Procedure
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Definition: An occupied bed is a bed prepared for a weak patient (bed ridden) who is unable to
get out of bed.
Purposes
To provide comfort and to facilitate circulation of the patient
To provide cleanliness and facilitate position of the patients bed
To conserve patient‘s energy and maintain current health status
To comfort the patient
Equipment
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12. Put on clean bottom sheet on used top sheet center, fold at center of bed, rolling the top half
close to the patient, tucking top and bottom ends tightly and mitering the corner
13. Put on rubber sheet and draw sheet if needed.
14. Turn patient towards you on to the clean sheets and make comfortable on the edge of bed.
15. Go to the opposite side of bed. Taking basin and wash cloths with you, give patient back
care.
16. Remove dirty sheet gently and place in dirty pillow case, but not on the floor.
17. Remove dirty bottom sheet and unroll clean linen.
18. Tuck in tightly at ends and miter corners.
19. Turn patient and make position comfortable.
20. Back rub should be given before the patient is turned on his /her back
21. Place clean sheet over top sheet and ask the patient to hold it if she/he is conscious. Go to
foot of bed and pull the dirty top sheet out
22. Replace the blanket and bed spread
23. Miter the corners
24. Tuck in along sides for low beds
25. Leave sides hanging on high beds
26. Turn the top of the bed spread under the blanket
27. Turn top sheet back over the blanket and bed spread
28. Change pillowcase, lift patient‘s head to replace pillow. Loosen top bedding over patient‘s
toes and chest.
29. Be sure the patient is comfortable
30. Clean bedside table
31. Remove dirty linen, leaving room in order
32. Wash hands.
33. Recording and documentation
NB: If a full bath is not given at this time, the patient‘s back should be washed and cared for
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Definition: Cardiac bed is a bed prepared for a patient with heart disease or dyspnea and to
provide easy breathing for patient with minimum strain.
Purpose
To relieve dyspnea
To prevent complication
EQUIPMENT
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Definition: Anesthetic bed is a bed especially prepared to receive a patient after surgery and
major recovery from general anesthesia.
Purposes
To facilitate easy transfer of the patient from stretcher to bed.
To facilitate removal of secretion
To protect the mattress and bedding from bleeding, vomiting, drainage or discharges.
To protect the patient from becoming chilled or give warmth.
Equipment
A. For bed making
1. Two large sheets. 7. Small towel.
2. Draw sheet(two) 8. Pillow case
3. Bath blanket 9. Spread sheet
4. Woolen blanket 10. Additional Sheets and blanket
5. Rubber sheet (Mackintosh) 11. bed blocks as needed
6. Two tongue blades or a mouth gag.
12. An extra rubber sheet & draw sheet for operated areas
B. For first aid activity
1. Emergency drug 6. Sterile Suction catheter
2. Minor set 7. Sterile glove
3. Vital sign equipment 8. Examination lamp (at hand if
4. Suction machine needed).
5. Oxygen cylinder 9. Airway tube
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8. Then fold the bottom of the linens up so that the fold is even with the bottom of the
mattress. Do not tuck the linen in. Unfold the top linens to the side so that they lay opposite
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from where you will place the client‘s stretcher. Alternatively, you may fanfold the linens
to the foot of the bed. Leave a tab on top for easy grasping.
9. In cold season, place hot water bottles in middle of the bed, and cover with fanfold top
bedding temperature of hot water is never to exceed 50°C (122°F).
10. Have two or more pillows available, but do not put them on the bed. Rationale: A pillow
may be contraindicated for a client; usually the physician or charge nurse will determine
when it is safe for the client to have one.
11. Place pillow at the head of the bed between bed & mattress and tie it back with a piece of
bandage to protect had of Patient.
12. Place all necessary materials at the side of the bed opposite to the stretcher on which the
patient will come
13. Arrange emergency equipment{ B/P apparatus ,suction machine, Drug}
14. Close the windows. Leave the room clean and in order
15. Receiving the patient from operation room
A. Remove folded to cover of the bed
B. Place the patient on bed and cover quickly
C. See that patient is properly placed in bed with head to the left side and comfortable
D. Check patient s condition operated area, urine, vital sign, colour of patient etc.
E. Do after care and Comfort the patient after procedure
16. Return used equipment to utility room and wash your hand
17. Proper documentation
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Definition
A. Amputation: - is the surgical removal of a part of the body or a limb, performed to treat
recurrent infections or gangrene in peripheral vascular disease, to remove malignant tumors,
& in severe trauma.
B. Amputation bed/ stump bed is a regular bed with cradle, which is prepared for amputated
patient.
Purpose
To give extra warmth
To prepare for emergency, to have easy access and economy of time and energy
Equipment
1. Linens (3) 9. Draw sheet
2. Pillow 10. face &bath towel
3. Blanket(2) 11. Tourniquet
4. Pillow case 12. Rubber sheet
5. Bed cradle 13. Mackintosh
6. Trolly 14. Small rubber sheet with cover
7. sponge 15. Dressing set
8. safety pin 16. Sand bags with cover
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Procedure
Definition: Fracture bed is a hard firm bed designed for a patient with fracture.
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Purpose
1. Place the fracture board directly over the bed springs and the mattress on it. If the mattress is
thin, an extra mattress must be added to prevent pressure sore due to pressures on the head
surface.
2. Make the bottom bed as usual, and then place the small rubber sheet covered with draw sheet
at the place where the injured part will be resting. The small rubber and draw sheet are easier
to change then the whole bed. This applies specially to an arm or a leg, which is bleeding or
has discharge.
3. Fold back the bed cloths at foot of the bed for leg fracture. Cover the uninjured limb with a
small blanket. On draw sheet placed the cradle over the linen to adjust the cover over it.
Extra blanket and spreads may be necessary. Be sure that the covers come high enough on
the shoulder
4. Do after care and Comfort the patient after procedure
5. Return used equipment to utility room and wash your hand
6. proper documentation
N.B:
Never cover a plaster cast until it is thoroughly dry.
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The fracture board keeps the bed with no danger of sagging. It is also used for
fracture of the spine. A bed cradles are a frame made of wire wood or iron .it is used
to keep the top cover from touching the injured part.
7.8. Baby crib
Definition: A the bed that prepare for paediatric case with bed side safety
Purpose
To make comfort for baby with safety
Equipment
The same with closed bed
Procedure
1. Place baby at the foot of bed
2. Loosen bottom sheet at head
3. Place clean bottom sheet and tuck in
4. Place small rubber sheet or water proof pad on top
5. Place baby at the head of bed
6. Remove soiled linen and tuck clean bottom sheet mitring corners
7. Place clean top sheet and tuck at the bottom
8. Place blanket and tuck, and place baby bed spread
9. Complete making bed on both sides
10. Raise side rails of bed and leave baby comfortable in bed.
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CHAPTER EIGHT
HYGIENE CARE AND GROOMING
Objective: At the end of the Lesson, the learner will be able to demonstrate basic hygienic skills such as
bathing, shampooing hair, perineal care, foot care, back massage, toileting and bed making.
8.1. Bed bath
Objective: At the end of the lesson, the learner will be able to
1. Define bed bath
2. Identify necessary equipment for bath
3. Perform bed bath
Definition: Is a bath given to a patient who is unable to give care for him/her self.
Purposes
To promote comfort relaxation and mobility
cleanliness To improve self image
To stimulate circulation To give an opportunity for the nurse
To prevent bad body odors to assess patients
To prevent pressure sores To prevent multiplication of
To relax and refresh the patient pathogenic micro organisms on the
Maintain muscle tone & joint skin surface.
Indication:
becomes cool, too soapy, dirty or after washing the genital area
Always wash from clean to dirty.
Determine allergies to soap and other cream lotion.
Clean the eyes with water from the inner to the outer cantus.
Equipment
Washcloth (2) Bed making materials
Washbasin (2) air freshener
Bath towels (2) Face towel
Basin and jug with warm water Lotion thermometer
Pajama Bed pan or urinal
Oil, cream, lotion/powder Comp and brush
Soap with soap dish Gloves disposable
Nail cutter Screen
Bath blanket Deodorant
Trays for nail care or mouth Humber for soiled cloths
care if necessary Trolley
Procedure
soiled gown in it and place it on chair or foot of bed between matters and foot of bed.
8. Wash eyes with clean water only and face of patient before the other parts of the body.
9. Do not expose patient unnecessary.
10. Work quickly and smoothly. Watch for signs of fatigue during bath; report and chart any
reddened spots, rash, sores or swelling. Change water as often as necessary. Never use
dirty or soapy water.
11. Remember to protect the bed from dampness by placing bath towel
each part of body during bath.
12. Place one hand under each part to support it while washing and
drying the extremities.
13. Using long, firm, even strokes, wash from wrist to shoulder. Place basin on towel on side
of bed and allow patient to put hands in water. Wash, take basin away, dry thoroughly.
14. Bath chest, dry and cover with towel, then bath abdomen.
15. Flex knee on far side, uncover leg and thigh and drape to protect bed. Wash and dry leg.
Do the same for the other leg.
16. Get clean, warm water and turn patient on side. Spread towel close to body, wash back
and hips well. Rinse and dry carefully.
17. Rub back with alcohol and talcum powder or soapy water using whole flat of hand and
long smooth strokes. Use a circular movement around the reddened areas or over boney
prominences. If soap is used, clean it off after the rub.
18. Place towel under hips. Put basin and soap within easy reach of the patient. Give him the
washcloth if he is able to wash the genital area so that he may finish his bath. If the
patient is unable to do so, the nurse should finish the bath by cleaning the genital area of
the patient by wearing the glove.
19. Put on clean gown protect the pillow or bed with face towel and comb patient‘s hair. Cut
and clean finger nails and toe nails.
20. Make the bed and leave patient comfortable.
21. Wash bedside table and take dirty linen, bath basins, soap and alcohol to utility room.
Wash basin well, dry and return to cupboard. Return other equipment to proper place.
22. Before you leave patient, ask patient if there is anything else you may do for him within
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Definition: Type of bath that allow direct washing and rinsing by using shower
Shower: - The pt is assisted to the bathroom, sits or stands and spray of water is usually directed
on to the body.
Purpose
Precautions
o Adjust temperature and flow of the water
o Avoid chilling
o Always keep bath room un locked
o Check pt frequently for sign of exhaustion.
o Make sure that the tub shower clean and functioning
o Place disposable rubber or plastic materials on the floor of the shower
o Instruct patient not to use oil during bath
o If sensation is normal, ask client to test water, and adjust temperature if water is
too warm
o
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Equipment
a. Soap and soap dish f. Chair
2. Comb & Brush
b. Washcloth 3. Wheel chair ( optional)
4. Bed pan/Urinal
c. Bath towel 5. Nail cutter
6. Oil/cream/lotion
d. Gown 7. Pajama
e. Sleeper
Procedure
1. Check the bath room temperature, which should be warmer than the normal room
temperature
2. Make sure the tub is clean. Scour it carefully with disinfectant. Unless using a long-handled
swab, wear glove when cleaning the tub.
3. Rinse the tab well
4. Place a chair near the tub, with a bath blanket opened over it
5. Place towels, washcloth and soap where the client can reach them easily
6. Fill the tub about halfway(less for a child)
7. Test the water with a bath thermometer. Water temperature should be warm to very warm,
but never over 40.60c (1050F).
8. Bringing the client to the bathroom and assist patient to undress
9. Assist patient into the tub and avoid falling.
10.Allow patient to bath himself or assist as necessary.
11.Assist patient out of tub and dry his body and put on gown.
12.Return patient to room and put to bed.
13.Clean bathtub and leave room in order.
14.Discard soiled linen.
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Purpose
Provide psychological & physical comfort (reduce tension, anxiety stress,
stimulate and relax muscles)
Increase general and local circulation
Improves muscle and skin functioning
Prevent bedsore.
To relieve insomnia(inability to sleep)
It provides opportunity for the nurse to assess the patient condition.
Precautions
1 Massage pressure areas gently massage the back by using appropriate technique.-
duration of massage should not exceed 20 minutes
2 Apply the all four patterns of stroke at least three times
Pertissage (kneading): press on muscle groups or single muscle, picking them up
and squeezing them gently. Use the palms of the hand for the large muscle; use
finger and thumbs for single muscle. Use this for outer aspect of back.
Effeurage (stroking): massaging upward and down ward from vertebral column,
and back again in the direction of heart.
Friction: rub around the bony prominence of the clients bony, such as at the end of
the spine and along each shoulder blade.
Tapping (tapotement): use light tapping with the edge of the hands (the edge
farthest from the thumb) at times to stimulate circulation.
3 Repeated back massage may possibly cause subcutaneous tissue degeneration.
4 Frequent positioning is preferable to back massage
5 Inspect skin areas of pressure points for whitened or reddened areas that do not disappear
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after rubbing.
6 Covering areas not being massaged & prevent unnecessary exposure
7 Lubricating palms to decreases friction on skin during massage.
8 Identify location of bony prominences to avoid direct pressure
Equipment
1. Soap and soap dish 8. Screen
2. Draw sheet 9. Basin with water
3. Wash cloth 10. Rubber sheet with its cover
4. Lotion 11. Other medication as ordered
5. Bath towel 12. Air ring, cotton ring as
6. Powder necessary
7. Alcohol 13. Pillow
Procedure
1. Assess and explain procedure to patient
2. Wash your hands
3. Assemble the equipment
4. Assist the client to assume either a prone, Sim‘s, supine, or sitting position,
depending on client‘s condition
5. Place towel under patient‘s side
6. Wash with soap and water
7. Apply powder or lotion and rub back. pay special attention to bony Prominences
8. Choose stroke technique based on desired effects
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Mouth care: - Care of the mouth which includes brushing the teeth, mouth and tongue with
mouth wash solution and rinse it with water
Routine mouth care:- is providing oral care at least three times a day for hygienic purpose.
Special mouth care: - Is a care given to entire mouth, teeth, tongue and gum in an increased
frequency using mouthwash solution for helpless patient.
Purpose
Keep the mouth clean and fresh, which provide the pt sense of well being.
Stimulate appetite
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Is un conscious
Is not taking oral food or fluid
Has mouth infection or inflammation e.t.c.
Equipment
Solutions
Sodium bicarbonate solution ½ Tsp in 250 ml, of water
Hydrogen per oxide solution
Glass of Clean water
Normal saline solution
Lemon juice
Other mouth wash solution if a specially ordered.
Mouth gag Toothbrush and paste
Emesis basin
Glycerin/petrolatum Forceps
Cotton tipped application
Receiver Sputum mug
Towel Tongue depressor wrapped with
Tissue paper or piece of gauze gauze bandage
Lubricate (liquid paraffin or mineral
Denture care cup oil, cold cream, glycerin , Vaseline)
Drinking tube (straw)
Procedure
1. Explain procedure to the patient and wash your hands
2. Have all equipment read on the bed side table
3. Set on the semi sitting position and up the head of the bed
4. Place towel under patient‘s chin across his/her chest
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5. Turn patient‘s head to the side and arrange basin at corner of the mouth.
6. Dip applicator in mouth washes solution and cleans the inside of the mouth, the tongue, and
the teeth gently and carefully.
7. Discard the swab.
8. If the teeth are difficult to clean, a larger swab can be used. This is done by Wrapping several
turns of cotton around a tongue depressor.
9. If the tongue or lips are dry and cracked, moisten an applicator with lubricant and gently
wipe them with mineral oil, liquid paraffin, Vaseline or any suitable cream. A mixture of
lemon and glycerin is also good.
10. If he/she is unconscious, hold the mouth open with a tongue depressor padded with gauze.
11. This care should be done in the morning, at night and after each meal if possible.
12. Wait at least ten minutes after patient has eaten to prevent nausea. Do not go far back on the
patient‘s tongue as it may gag him.
13. Chart – procedure, time and observation.
8.5. Care of dentures
Objectives: - At the end of the lesson, the learner will be able
Purpose
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Procedures
Objectives: - At the end of the session the student will be able to:-
Purpose
To provide receptacle for elimination of waste material for clients confined to bed.
To obtain specimen of urine or stool for laboratory examination.
To obtain an accurate measurement or assessment of the client‘s urine or stool.
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Indication
Equipment
Procedure
1. explain the procedure
2. wash hand
3. assemble equipment
4. keep privacy
5. Obtain a bedpan, if one is not available in the bed side cabinet
6. Put on glove
7. Raise the bed to a comfortable height. Lower the near side rail
8. Fold the bed linen away from the client, exposing as little of his or her body as possible.
9. Place an incontinence pad on the bed if the client is confused or if using a fracture pan
10. Warm and dry the outer of the bedpan and carry to bed side and place in on a chair
11. Assist the client on to pan. If the client is able to help, encourage him/her to flex the knee
and lift the hips:
Place the bedpan under the buttocks, with the round curved end toward the clients
back and the narrower opened end toward the feet.
Turn back covers at the side. Place free hand under patient‘s buttocks and have
him flex knees and help in lifting his body. With the other hand adjust bedpan
under him.
If the patient unable to use regular bed pan use a fracture bedpan. Place it under
the buttocks with the flat end toward the client‘s back.
12. If the client is immobile, roll the client onto his or her side away from you. Position the
bedpan against the client‘s buttocks, hold it firmly in place and turn the client onto his or
her back. Check the pans location
13. Replace the bed linen over the client
14. Elevate the head of the bed to semi-fowler‘s position if the client can tolerate it. Raise the
side rail again.
15. Place the call light and toilet tissue within the client‘s reach and leave him or her alone if
possible. Tell the client to call if he or she needs help and also when finished. If leaving
the bedside, remove gloves and wash hands.
16. To remove the bedpan:
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Purpose Indication
Infection on the genital and
To remove normal perinea
perineum
secretions and odors
Surgery of the genitalia and
To prevent infection
perineum
To promote client comfort
Post delivery
To facilitate healing
Incontinent patients
To prevent irritation and
pts with indwelling catheter
ulceration of the genitalia.
Abnormal or un pleasant
discharge from the genitalia.
Equipment
1. Pitcher or container with warm water 6. Sterile Perineal pad
2. Prescribed solution 7. Bowl or kidney basin
3. Sterile forceps or glove 8. Bed pan/urinals
4. Protecting materials ,draw sheet 9. Screen
5. Gauze swabs
Procedure
1. Prepare tray or trolley with the above equipment, cover & take to patient‘s room.
2. Explain procedure to patient.
3. Assist patient to use bedpan.
4. Remove soiled pad and place in bowel or kidney basin.
5. Move tray or trolley near bed.
6. Fold the blanket to foot of the bed
7. Flex patient‘s knees and cover with top sheet.
8. Take the sterile cotton swabs with forceps, pour solution on the cotton and clean
perineum using downward strokes. Use only one cotton swab for each strokes.
9. Repeat cleansing the perineum pouring the solution over the genitalia.
10. Avoid hurting the perineum with the forceps. Be careful with episiotomies stitches
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11. Dry perineum and genitalia thoroughly using cotton swabs. If patient has episiotomy
observed for any signs of infection – swelling, discharge etc. medicated powder or
solution may be applied according to the orders.
12. Remove bedpan
13. Turn patient on one side and dry anal area.
14. Place perineal pad across perineum.
15. Avoid contaminating the inner side of pad
16. Apply T – Binder ( as needed)
17. Straighten bed and leave patient comfortable
18. Remove soiled article, clean and return to their proper places. Perinea swabbing should
be done at least three times daily and each time following bowl movement.
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Contraindication
DM and Peripheral vascular function
Impaired peripheral sensory function
Immediate post hemorroidioctomy
Equipment
1. Large Basin 5. Tissue paper or towel
2. Fenestrated chair (sitz bath chair) 6. Common Medication (Common salt
3. Glove ,KMnO4, Betadine solution)
4. Bath thermometer
Procedure
1. Check for specific order
2. Assemble equipment and take to the bath room ( may be given in the room in mobile
sitz bath chair if available)
3. Clean tub and fill half – full.
4. Check temperature of water (must be as patient can bear).
5. Close windows and explain procedure to patient
6. Take patient to the bathroom and assist to undress as necessary.
7. Assist patient to sit in a big bowl of warm water or in a tub.
8. Observe patient‘s condition and check pulse. Discontinue treatment if patient feels
dizzy.
9. Avoid chilling, drape shoulders with bath towel.
10. Allow pt to stay in the water for about 20 – 30 minutes, check patient frequently.
11. Assist patient to dry, dress and return to room.
12. Clean bowl or tub and discard used linen.
13. Apply dressing if needed.
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Definition: Feet and nail often need special attention. Assess the appearance of feet & nail
to identify existing problems or clients at risk of developing foot or nail problems.
Purpose:
To prevent the client‘s hands and feet odour
To soft, hydrated skin.
To maximized functional ability of hands and feet.
To make client comfort and relax.
Indication:
Paralyzed client and geriatric .
People with diabetic mellitus and clients with poor circulation are at high risk for
foot difficulties/ problems.
Equipment
1. Gloves
2. Bath/washbasin (plastic dishpan, bucket, or wastebasket will work as well)
3. Warm water
4. Towels (1–2)
5. Washcloth (soft but textured)
6. Soap (liquid preferable) or Cetaphil
7. Nail brush (soft)
8. Cotton-tip applicators
9. Nail clippers: one for fingernails, plier-type for toenails
10. Nail scissors (for cutting hangnails)
11. Talcum powder (water absorbent without cornstarch)
12. Body cream, petrolatum, or oil
13. cotton or lamb‘s wool pieces
14. bath thermometer
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Procedure
For feet:
Note any areas where toenails may be injuring adjacent toes. Trim to prevent
further damage.
Cut toenails straight across.
Trim fingernails according to client taste. If the client is confused or comatose,
trim to prevent the client from injuring self or others.
17. Lightly apply cream (not lotion), massaging into the hand/foot. Pay special attention
to dry areas. Avoid between and under fingers/toes.
18. ―Towel‖ off any excess cream.
19. Perform range of motion (ROM) exercises (repeat each movement 3–10 times): flex,
extend, rotate clockwise. Place lamb‘s wool or cotton to protect areas that are
rubbing or irritated. Put on clean, dry, absorbent (cotton) socks after foot care.
20. Run your hand around the interior of shoes and slippers to be sure there are no
foreign objects or scratchy edges prior to putting them on.
21. Remove, clean, and/or replace equipment/ supplies.
22. Dispose of gloves and wash hands.
Definition: facial hair removal of male client that un able to complete self-care.
Purpose :
6. After-shave lotion (if the client has no skin irritation and if the client prefers lotion)
7. Mirror
8. Sharp scissors and comb
9. Gloves
procedure
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Purpose:
Equipment
1. Suitable clothes
2. Mirror
3. Screen
Procedure
1. Assist the client to select suitable clothes. This may be their own personal clothing or
clothing from the clinical area‘s supplies.
2. Ensure privacy
3. Assist client to remove soiled clothing, outer garments first. If necessary assist in
cleansing prior to redressing.
4. Have clothing available and ready to use. If client has limited mobility or limb
injuries as identified during their mobility assessment remove clothing from
unaffected side first.
5. Be aware of wounds, drains and indwelling catheters when removing clothing and
re-dressing client.
6. Give the client time, and encourage them to
7. perform as much of the activity as possible. Remove clothing in a systematic way,
e.g. top to bottom, replacing with clean clothing as each item is removed.
8. Choose clothing with easy fitting fastenings.
9. Give client access to mirror to check overall appearance
10. Ensure client is left comfortable. Record any changed care needs in Nursing record.
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Definition: - Hair care is an important part of daily hygiene care it includes brushing and
combing of the hair.
Purpose
To stimulate scalp circulation
To maintain cleanliness of the hair & scalp
To prevent the presence of lice & nits
To provide pleasure and feeling of self-stem.
Equipment
Brush and comb
Towel & oil or Vaseline
Procedure
1. Place patient in comfortable position
2. Place towel on top of pillow under patient‘s head and shoulder.
3. If hair is badly tangled, comb small part at a time. Oil or Vaseline may be
applied to untangle the hair.
4. If the hair is long, it should be braided and fastened with rubber band.
5. Observe carefully for pedicli or nits
6. Remove towel and leave patient comfortable.
7. Remove hair from comb & brush, wash and dry.
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Purpose
To remove dirty
To prevent offensive odour
To stimulate circulation of the scalp
To keep the hair and scalp cleaned and healthy
To treat condition of the hair and scalp
To provide comfort and good appearance
Figure 26: shampooing
Precaution
Determine the facilities available for the procedure and the pts condition (pt may
have their hair shampoo during a bath or a shower. If pt is bed ridden the
shampoo may be performed with the pt in bed or lying on a trolley)
Use devices to protect neatness of the bed and pts gown
Observe condition of the pt. throughout the procedure.
Equipment
1. Bowel with Vaseline
2. Cotton
3. Mackintosh
4. Dustbin
5. Shampoo
6. Kidney tray
7. Comb or fine-toothed comb.
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Procedure
1. Carry equipment to the bedside arrange it.
2. Remove all but one pillow and place on foot of bed.
3. Loosen gown, and cover patient‘s shoulder with a towel.
Move patient to the edge of bed. Place him on the side with his back towards you.
5. Roll the two sides of the large rubber sheet towards each other. Slip one end of
rubber sheet under patient‘s head and the lower end in the basin or pail.
6. Give patient the washcloth to protect his eyes. Cotton may be used in the ears if
desired.
7. Moisten hair, pour on shampoo or soap solution and rub into scalp; wash head
thoroughly, rinse well, and repeat procedure if necessary. Hold pitcher so it will not
be suspended over patient‘s face while pouring. Avoid pouring water over fore head.
Dry hair as much as possible after rinsing thoroughly.
8. Draw rubber sheet out from under patient‘s head and drop it in basin. Straighten
pillow under head and dry with towel, rubbing briskly. Avoid tangling hair more
than necessary. Dry thoroughly and avoid chilling. Arrange hair according to
patient‘s desire.
9. Comb hair using clean comb and brush. Use oil or hair cream as desired by the
patient.
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1. Define pediculosis
2. Identify necessary equipments
3. Perform pediculosis treatment
Definition: - Pediculosis is a condition in which the hair is infested with lice or pedicles.
pediculosis treatment: - is an application of pesticides such as gamma benzene
hexachord (BHC)
Purpose
To kill and remove pedicles and nits from head and hair
To prevent transmission of pedicles.
To make patient comfortable
Precaution
Avoid treatment from interring the eyes, nose and throat
Apply Vaseline on the fore head to prevent irritation
Instruct the pt not to wash before 12 – 24 hrs
Contact family member of the pt and treat then as well.
Teach the pt and pts relative the importance of keeping the hair and the body
clean.
Hands must be washed after scratching the hair.
Equipment
1. Gown and cap (for the nurse)
2. Rubber sheet and cover
3. Bowel with swabs -
4. Gauze or cotton
5. Bowel with Vaseline
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Procedure
1. Position patient conveniently
2. Wear gown and cap to protect yourself.
3. Place towel and rubber sheet over pillow.
4. Apply Vaseline to forehead and around the edges of hair to prevent skin
reaction.
5. Apply medication on entire head
6. Wrap head with head cover or clean scarf and leave for several hours (12-
24hrs) wash hair.
7. Comb hair with fine tooth comb to remove dead lice.
8. Chart – treatment, time and observation
9. Repeat treatment as needed.
10. Collect used rubber and cover, Send to the laundry separately.
Purpose
To prevent infection
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15. Leave the client comfortable. Remove apron and wash hands
16. Evaluate care delivery, document and report any change in client‘s condition
17. Update care plan as necessary
8.16. Ear care/irrigatio
Objective: - At the end of the lesson, the learner will be able
Purpose
To remove ear wax or foreign object lodged in the ear canal. Less invasive than
using an instrument
Precautions
The ear canal should be examined with an otoscope prior to ear irrigation
Ear irrigation is contraindicated if the eardrum is ruptured, because the procedure
may force bacteria through the perforation into the inner ear
Ear irrigation is also contraindicated in patients with fever and ear pain, as these
symptoms may indicate an inner ear infection.
If a foreign object is made of vegetable matter (e.g., a bean or pea), irrigation is
contraindicated because the water will cause the object to swell and complicate
extraction of the object.
Equipments
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Procedure
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CHAPTER NINE
MEDICATION AND FLUID THERAPY
General objective: - At the end of the chapter learner will be able to:-
1. Perform medication withdrawing from a vial and ampoule
2. apply rights of medication administration
3. Identify necessary equipment for administering medication via SC, ID, IM and IV.
4. administer medication and fluid with acceptable technique
5. re-demonstrate how to administer drug via different routes
6. Apply the necessary steps to carry out the proper mixing of drugs
9.1. Medication preparation
Definition: Vials are often used to package multi-dose or single-dose parenteral medication. A
vial is a small glass bottle with a rubber seal at the top. Glass vials come with a protective plastic
or metal cap that prevents the rubber from being punctured prior to use.
Purpose
Equipment Needed:
1. Medication vial
Figure 27: Vials
2. Syringe with needle
3. Alcohol sponge pad
4. Gloves (optional)
5. Clean work space
6. Medication administration record (MAR)
Procedure
5. Determine the route of medication delivery and select the appropriate size syringe and
needle.
6. While holding the syringe at eye level, with-draw the plunger to the desired volume of
medication.
7. Clean the rubber top of the vial with a 70% alcohol pad. Use a circular motion starting at
the center and working out.
8. Using sterile technique, uncap the needle.
9. Lay the needle cap on a clean surface.
10. Placing the needle in the center of the vial, inject the air slowly. Do not cause turbulence.
11. Invert the vial and slowly; using gentle negative pressure, withdraw the medication. Keep
the needle tip in the liquid.
12. With the syringe at eye level determine that the appropriate dose has been reached by
volume
13. Slowly withdraw the needle from the vial. Follow the institution‘s policy regarding
recapping needles.
14. Using ink, mark the current date and time and initials on the vial.
15. Label the syringe with drug, dose, date, and time.
16. Wash hands.
9.1.2. Withdrawing Medication from an Ampoule
Objectives: At the end of this lesson, the learner will be able to
Purpose:
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1. Medication ampoule
2. Sterile gauze pad or alcohol pad
3. Syringe with filter needle
4. Replacement needle
5. Clean work space
6. Medication administration record (MAR)
Procedures
1. Wash hands.
2. Select appropriate ampoule
3. Select syringe with filter needle.
4. Obtain a sterile gauze pad.
5. Select and set aside the appropriate length of needle for planned injection.
6. Clear a work space.
7. Observe ampoule for location of the medication.
8. If the medication is trapped in the top, flick the neck of the ampoule repeatedly with your
fingernail while holding the ampoule upright
9. Wrap the sterile gauze pad around the neck and snap off the top in an outward motion.
10. Invert ampoule and place the needle into the liquid. Gently withdraw medication into the
syringe
11. Alternately, place the ampoule on the counter, hold and tilt slightly with the nondominant
hand. Insert the needle below the level of liquid and gently draw liquid into the syringe,
tilting the ampoule as needed to access all the liquid.
12. Remove the filter needle and replace with the injection needle.
13. Dispose of filter needle and glass ampoule (including lid) in appropriate container
14. Label the syringe with drug, dose, date, and time.
15. Wash hands.
9.1.3. Mixing medications from two vials into one syringe
Objectives: At the end of this session, students will be able to
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Purpose
9. Draw air into the syringe equal to the amount of medication to be drawn up from the first
vial. Inject air into the first vial. Keep the needle and syringe in the vial
10. Pulling back on the plunger, withdraw the correct amount (in milliliters) of medication
from the first vial.
11. Remove the syringe from the first vial and insert it into the second vial. Withdraw
medication from the second vial to the volume (in milliliters) total of both medications
summed together
12. Either leave the needle in the second vial until just prior to injecting the medication or
follow the institution‘s policy regarding recapping needles.
13. Wash hands.
9.1.4. Preparing an Intravenous Solution
Objectives: At the end of this lesson, the learner will be able to
1. Identify the indications for iv solution
2. List equipments to prepare an iv solutions
Definition: An IV solution preparation is a method of correcting or preventing a fluid and
electrolyte disturbance.
Indications
Clients who are acutely ill
Clients who are NPO after surgery, or
Have severe burns
Equipment
1. IV solution (bag or bottle)
2. Administration set (vented or nonvented)
3. Extension set IV pole
4. IV line filter
Procedures
1. Wash hands before preparing IV equipment.
2. Check the health care practitioner‘s order for the type and amount of solution.
3. Check integrity of the IV solution and equipment.
4. Select IV tubing in accord with agency policy.
5. Prepare IV solution label with client‘s name, date, time, additives, and your initials.
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to the open position, open all the tubing regulator clamps, and clear the tubing of air;
close the regulator clamp and replace the cap on the end of the tubing.
15. Tag tubing with date and time and your own initials.
16. Explain to the client what you are doing before taking the IV equipment into the client‘s
room.
9.1.4.2. Glass Bottle
17. Repeat steps 1–5.
- Vented tubing is used for glass bottles that are not vented.
18. Prepare the IV solution for administration.
- Check bottle for cracks or leaks.
- Remove metal cap, metal disk, and rubber diaphragm from top of glass bottle, or
remove protective additive cap if pharmacy has added medications to the IV bottle.
- Listen for the escape of air when the rubber diaphragm is removed.
19. Close the roller clamp on the IV tubing.
20. Remove the protective cap from the IV tubing spike and maintain the sterility of the
spike.
21. Place the glass bottle on a firm surface, and, using firm downward pressure, insert the
spike through designated port on the bottle cap.
22. Invert IV bottle (if the bottle is vented, the fluid inside the vent tube will escape), and
hang the bottle on an IV pole.
23. Continue steps 11–16.
9.2. Medication administration
Medication: - is any substance which may be administered in a variety of forms and by different
routes for the purpose of preventing, diagnosing or treating a disease or condition.
Purpose
A trolley containing
1. A bowl of water for used medication 6. Kidney dish and paper bag to discard
cup. the waste
2. Towel 7. Chart and medication card.
3. Measuring spoon. 8. Ordered medication.
4. A jag of water (bed side water). 9. Straw if necessary.
5. Mortar and pestle to crush and 10. Glass
powder the tablet if necessary
Producer
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Purpose
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Precaution
Tell the patient not to drink liquid and smoke for an hour because some tablets take up to an
hour to dissolve.
Tell the patient to keep the medication in place until it dissolves completely to insure
absorption
Tell the patient to avoid chewing the tablet or touching the tablet with the tongue to prevent
accidental swallowing.
When the client is receiving repeated doses of a buccal medication, the nurse should indicate
the site, such as right buccal cavity, to prevent irritation of the same site.
Equipments
A trolley containing
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12. Remove the towel and wipe the face with it if necessary
13. Position the patient for good body alignment
14. Take all articles to the utility room. /wash dry all articles and put
them in their proper place.
15. Wash hands
16. Recode the medication given, reaction observed, refused or
omitted immediately
Purpose
Precautions
Never point tip of dropper towards eye always hold dropper parallel to the eye
Never exert pressure on post- operative cases
Never use a broken dropper
The patient should be instructed not to touch the eye
Never apply expired medication maintain strict aseptic technique and use separate supply
for each eye
Always see the eyes are absolutely clean before application of medication.
Equipment
1. Explain the procedure to the patient and assess the client‘s knowledge of the drug and
its action
2. Wash hands
3. Prepare the equipments
4. Begin by checking the order.(Read the label 3 times)
5. The patient is placed supine or sitting position with head tilted back
6. Hold the lower eyelids open with thumb and index finger, pressing against bones of
socket. Tell pt to look up
(In case of eye ointment open eyelids and gently apply ointment from inner to outer
cantus of the lower lid of both eyes )
7. Apply prescribed amount of medication in to the conjunctiva sac or lower central eyelid
8. Instruct the patient close the eye and roll the eyeball w/c helps to spread the medication
over the entire conjunctiva
9. Use cotton balls to wipe excess medication with from inner cantus to outer cantus
10. Clean and return used equipments to its proper place
11. Make the patient to the comfortable position
12. Wash your hands very carefully and chart procedure and observations.
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Purpose
1. Explain the procedure to the patient and assess the client‘s knowledge of the drug and
its action
2. Wash hands
3. Prepare the equipments
4. Begin by checking the order.(Read the label 3 times)
5. The patient is placed supine or sitting position with head to side and the affected ear up
6. Pull the pinna up and back in case of adult and down and back in case children.
7. Apply prescribed amount of medication directly in to the ear canal.
8. Place a loose cotton in the outer ear to absorb any excess medicine
9. Keep the patient head turned to the un affected side 10-15 minutes
10. Clean and return used equipments to its proper place
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Objectives:-At the end of this lesson, the learners are expected to:
Purpose:
- Do not rub the area where medication is applied vigorously as absorption can
be altered.
Equipment
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Procedures
1. Wash hands.
2. Obtain order for medication with physician or qualified practitioner.
3. Ascertain client‘s allergic status.
4. If unfamiliar with medication, read label and read insert or seek appropriate information.
5. Select medication and verify medication with orders (first medication verification).
6. Check expiration date.
7. Read medication label again before leaving medication room or cart as available in
facilities (second medication verification).
8. Take medication to client‘s room and introduce self. In some facilities topical
medication used for skin irritations are kept in the client‘s room and therefore
verification may be done at the bedside.
9. Ask the client if he or she has had the medication before and its effect and ascertain if
the client has any drug allergies or untoward reactions.
10. Explain the purpose of the medication.
11. Read the label for the third time (third medication verification) and check the client‘s
identification band.
12. Position the client appropriately for administration of medication. Keep client draped for
privacy.
13. Put on gloves. If dressing is over area to be treated, remove, discard, and change gloves.
14. If an open wound, clean area to be treated with mild soap (if no allergies or reactions to
soap) and water. If skin is irritated, use only warm water. If administering a systemically
absorbed topical medication, clean the skin surface thoroughly and pat skin dry, leaving no
residues of soap.
14. Assess the client‘s skin condition, making notation of circulation, drainage color,
temperature, or any altered skin integrity.
15. Change gloves.
16. Apply medication according to label. If lotion or ointment, apply a thin layer and smooth
into skin as indicated.
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17. If an aerosol spray is used, shake the container and administer according to direction.
Spray evenly over affected area and avoid spraying close to client‘s or caregiver‘s face.
18. If gels or pastes are used, applicators may be needed. Apply evenly. If applying over an
area with hair growth, follow direction of hair.
19. If powders are used, dust lightly and avoid inhalation by client and caregiver.
20. If nitroglycerin ointment or pastes are used, follow instructions and orders carefully to
administer correct dosage.
- Remove the old ointment strip and clean the old site thoroughly. New ointment
will be applied in different area.
- Cleanse the new site with the appropriate cleaner.
- Squeeze the dose out onto the enclosed. Medication measuring strip Nitroglycerin
paste dosages are measured in inches and applied to the paper measuring strip
before being applied to the client.
Fig squeeze the correct dose out onto the enclosed medication measuring strip
- Flatten the roll of nitroglycerin so the ointment will be spread over a wider area
when applied to the client.
- Apply the measuring paper, ointment side down, to no hair portion of the client‘s
body.
- Tape the paper in place.
21. If a transdermal patch is used, follow the manufacturer‘s directions and apply the patch
to a smooth, cleaned skin surface.
- Remove the old patch and wash the site of the old patch.
- Wash and prepare the skin at a new site.
- Remove the protective covering over the
- Transdermal portion of the patch and apply the new patch
22. Remove gloves; wash hands.
23. Document the medication given, the site it was applied to, and the client‘s response to
the medication.
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Purpose
Avoid touching the tip of the nose with dropper since it may contaminate
Avoid touching the inner surface of the nose with dropper since it cause the patient to
sneeze
Do not use oily solutions as nasal drops since it interferes with the normal cilary‘s action
Do not use decongestants excessively or frequently as they became ineffective and may
actually worsen the patients nasal congestion
Equipment
1. Explain the procedure to the patient and assess the client‘s knowledge of the drug and its
action
2. Wash hands
3. Prepare the equipments
4. Begin by checking the order.(Read the label 3 times)
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Purpose:
1. Explain the procedure to the patient and assess the client‘s knowledge of the drug and its
action
2. Wash hands
3. Prepare the equipments
4. Begin by checking the order.(Read the label 3 times)
5. Screen the patient and put on gloves
6. Assist the client to the sim‘s position or the left lateral position with the upper leg flexed
7. Fold back the bed linen to expose the rectum
8. Apply small amount of lubricant to the smooth rounded end of the suppository to reduce
mucosal irritation. Lubricate the gloved index finger
9. Instruct the client to breathe through the mouth.
10. Insert the suppository in to the client‘s anal canal at least 4 inches (10 cm) for an adult and
5cm (2 inches) for a child. This position ensures placement of the suppository above the
client‘s internal sphincter and maximizes medication absorption (lubrication makes the
insertion easier)
11. Ask the client to maintain the position for 15-20 minutes to resist urge to defecate and
maintaining the position allows time for the medication to melt.
12. Press the folded tissue against anus for a few minutes until the pt‘s urge to expel the
suppository has passed.
13. Clean the anus with a toilet paper
14. Dispose of gloves and wash hands
15. Document the time, type, or given medication. Indicate the strength or dosage of the drug
Follow up phase
Check on the client 20-30 minutes and document client‘s response or result of the Rx and
the reaction of the pt to the Rx.
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Purpose
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Procedures
1. Check with the client and the chart for known allergies or medical conditions that would
contraindicate the use of the drug.
2. Gather necessary equipment.
3. Check the MAR against written health care practitioner orders.
4. Wash your hands.
5. Follow the five rights of medication administration. Check the client‘s identification
band.
6. Ask the client to void.
7. Position the client in a dorsal recumbent position with knees flexed and hips rotated
laterally or in a Sims‘ position if the client cannot maintain the dorsal recumbent position.
8. Don non-sterile gloves.
9. Explain procedure to patient. If client plans to self-administer, be very specific with
instructions. Provide for privacy.
10. Assess perineal area, inspect vaginal orifice, note any odor or discharge from the vagina,
and inquire about any problems such as itching or discomfort.
11. If secretion or discharge is present, cleanse the perineal area with soap and water.
12. Remove suppository from the foil wrapper and, if applicable, insert into applicator tip.
Apply a small amount of lubricant to rounded tip of suppository. If not using an
applicator, apply a small amount of lubricant to gloved index finger.
13. With non-dominant hand, spread labial folds. Insert the suppository into the vaginal canal
at least 2 inches (5 cm) along the posterior wall of the vagina or as far as it will go. If
using an applicator, insert as described above and depress plunger to release suppository.
Figure 31: Administering a vaginal suppository along the posterior wall of the vagina.
14. Wipe the perineum with clean, dry tissue
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Purpose
In patients who can't form an airtight seal around the device
In patients who lack the coordination or clear vision necessary to assemble a turbo-
inhaler.
Inhalant drugs may also be contraindicated. For example, bronchodilators are
contraindicated if the patient has tachycardia or a history of cardiac arrhythmias
associated with tachycardia.
Equipment
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Procedure
1. Check with the client and the chart for known allergies or medical conditions that would
contraindicate the use of the drug.
2. Gather necessary equipment.
3. Check the MAR against written health care practitioner orders.
4. Wash your hands.
5. Follow the five rights of medication administration. Check the client‘s identification band.
6. Review with the client the purpose of each prescribed medication.
7. Allow the client to hold and manipulate the canister. Explain how the canister fits into the
inhaler. Have the client demonstrate insertion of the canister.
8. Explain metered-dose concept to client, and discuss frequency of prescribed medications.
9. Explain that the inhaler must be shaken before each use.
10. Remove the mouthpiece and cap from the bottle and insert the stem into the small hole on the
flattened portion of the mouthpiece.
- Client should grasp the inhaler with thumb and first two fingers.
11. Instruct the client to exhale, place the mouth piece into the mouth, and ensure that the lips
form a tight seal around the mouthpiece.
9.2.9.2.Insert mouthpiece into mouth, forming a tight seal with the lips.
12. Instruct the client to firmly push the cylinder down against the mouthpiece only once
while slowly inhaling until the lungs feel full.
13. Ask the client to remove the mouthpiece while holding breath for about 10 seconds and then
to exhale slowly through pursed lips.
- If the client had difficulty coordinating the inhalation and medication
dispensing,aerochanber may be added
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Types
Intradermal (ID)
Subcutaneous (SC)
Intramuscular (IM)
Intravenous (IV)
Definition: - The introduction of medication, using hypodermic needle in the dermis. (corneum)
Purpose
Figure 34: Intra dermal injection sites: A. inner aspect of the fore arm, B. Upper chest.
C. Upper back.
Equipments
A tray containing
1. Medication administration record 5. Cotton balls
(MAR) 6. Disposable glove
2. Syringe & needle(sterile) (25- 7. Safety box
27gauge) 8. Marking pen
3. Receiver 9. Medication
4. Alcohol
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Procedures
1. Check with the client and the chart for any known allergies
2. Explain procedure to patient
3. Follow the five rights
4. Prepare the medication from an ampoule or vial
5. Explain the procedure to the client
6. Place the client in a comfortable position; provide privacy
7. Wash hands and don sterile gloves
8. Select and clean the site
Assess the client‘s skin for bruises, redness, or broken tissue
Select an appropriate site using appropriate anatomic landmarks
Cleanse the site with an alcohol wipe using a firm circular motion; cleanse from
inside to outside; allow alcohol to dry
9. Prepare the syringe for injection
Remove the needle guard
Express any air bubbles from the syringe
Check the amount of solution in the syringe
10. Inject the medication.
Hold the syringe in dominant hand
With nondominant hand, grasp the client‘s dorsal forearm and gently pull the
skin taut on ventral forearm(Figure 29-20)
Place the needle close to the skin, bevel side up.
Insert the needle at a 10° to 15° angle until resistance is felt, and
advance the needle approximately 3 mm below the skin surface;
the needle‘s tip should be visible under the skin.
Administer the medication slowly; observe the development of a bleb (large
flaccid vesicle that resembles a mosquito bite). If none appears, withdraw the
needle slightly.
Withdraw the needle.
Pat area gently with a dry 2 ×2 sterile gauze pad.
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Purpose:
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Figure 36: Subcutaneous injection sites: A. Abdomen; B. Lateral and anterior aspect of
upper arm and thigh; C. Scapular area on back; D. Upper ventrodorsal gluteal
area
Equipment
1. Tray 6. File
2. Sterile syringe & needle 7. Safety box
3. Sterile forceps in a container 8. Medication chart
4. Alcohol swabs 9. Disposable gloves
5. Medication
Procedure
1. Check with client and the chart for any known allergies.
2. Wash your hands
3. Follow the five rights
4. Prepare the medication from an ampule or vial; refer to Procedure 29-2 or 29-3 as
appropriate.
5. Take medication to the client‘s room and place on a clean surface
6. Check the client‘s identification armband
7. Explain the procedure to the client
8. Place the client in a comfortable position; pro-vide for privacy
9. Don nonsterile gloves
10. Select and clean the site.
A. Assess the client‘s skin for bruises, redness, hard tissue, or broken skin.
B. Cleanse the site with an alcohol swab; cleanse from inside outward.
11. Prepare for the injection.
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A. Remove the needle guard and express any air bubbles from the syringe; check the
dosage in the syringe.
B. With dominant hand, hold the syringe like a dart between your thumb and
forefingers.
C. Pinch the subcutaneous tissue between the thumb and forefinger with the non
dominant hand.
D. If the client has substantial sub-cutaneous tissue, spread the tissue taut.
E. Administer the injection.
F. Insert the needle quickly at a 45° or 90° angle.
G. Release the subcutaneous tissue and grasp the barrel of the syringe with
nondominant hand.
H. With dominant hand, aspirate by pulling back on the plunger gently, except when
administering an anticoagulant injection.
I. If blood appears, remove needle and discard in a sharps container.
J. Inject medication slowly if there is no blood present.
K. Remove the needle quickly and lightly mas-sage area with alcohol swab; do not
massage the injection site after the administration of an anticoagulant.
L. Do not recap the needle; discard the needle in a sharps container.
12. Position client for comfort.
13. Remove gloves and wash hands.
14. Record on the MAR the route, site, and time of injection.
15. Observe the client for any side or adverse
16. Effects and assess the effectiveness of the medication at the appropriate time
Equipments
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If blood does not appear, inject the medication slowly, about 10 sec/ml.
Wait 10 seconds after the medication has been injected, then smoothly withdraw
the needle at the same angle of insertion.
Apply gentle pressure at the site with a dry, sterile 2 ×2 gauze; do not massage
the injec-tion site. Swab using gentle pressure.
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Discard the needle and syringe in a sharps container; do not recap the needle
12. Position client for comfort; encourage client receiving ventrogluteal injections to perform
leg exercises (flexion and extension)
13. Remove gloves, wash hands
14. Record on the MAR the dosage, route, site, and time
15. Inspect the injection site within 2 to 4 hours and evaluate the client‘s response to the
medication
9.2.10.4.Intravenous Injections
Objectives:-At the end of the lesson, the learner will be able to:
1. define intravenous injection
2. describe the purposes of intravenous infusion
3. assemble the necessary equipments
4. demonstrate intravenous injections
Purpose:-
When the given drug is irritating to the body tissue if given through other routes.
When quick action is desired.
When blood drawing is needed.
Site of IV injection
Children Adult
Tray containing
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Procedures
1. Gather prepared equipment (medication labeled with the client‘s name, and time tape for
fluids to infuse per hour)
2. Wash hands
3. Check the client‘s armband
4. Explain the procedure to the client
5. Assess the puncture site
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Figure 36: Connect locking cannula to a Y-site injection port of primary infusion set.
16. Observe client for any signs of adverse reactions to the medication.
17. When secondary bag and drip chamber are empty, close the clamp on secondary system,
readjust drip rate of primary solution as indicated, and remove the secondary system.
18. Record medication infusion on the MAR and note any client responses in the nurses‘
notes
9.2.10.5.Intravenous infusion
Objectives:-At the end of the lesson, the learner will be able to:
Definition:-
1. IV infusion is the administration of a large amount of fluid (50-500 even more) into the
system through a vein.
Purpose
When the giving drug is irritating to the body tissue if given through other routes.
When quick action is desired.
When it is particularly desirable to eliminate the variability of absorption.
When blood drawing is needed ( exsanguinations)
2. An I.V. injection is the introduction of a drug in solution from into a vein. Often the
amount is not more than 50 ml. at a time.
Purpose:
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Administration Sets
1. Piercing pin: A hollow spike that is inserted into the administration port of the IV bag. It
is important this remains sterile when inserted.
2. Drip chamber : This is where the solution flows prior to its entry into the tubing; it acts
as a pressurizing chamber for non-vented bags.
3. Roller clamp: This is used to regulate the flow of fluids through the IV tubing.
4. IV cannula or catheter : A flexible tube that is used to insert medication within body
cavity or blood vessel. It has a trocar (a sharp-pointed needle) attached to it that punctures
the skin to get the catheter within the vein.
5. Slide clamp: This is used to restrict fluid flow and act as a quick on/off control of the IV
tubing. The tubing ends in a sterile-capped adapter, which is attached to the cannula.
Equipment
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1. Define an IV therapy
2. Assemble the necessary equipments
3. Mention the purposes of intravenous therapy
4. Practice the recommended intravenous therapy procedures
Definition: It is administration of a large amount of fluid into the system through a vein.
Medications are administered IV by the following:-
Indication
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Remove IV container from the pole and lower the container below the level of
infusion site.
Observe for backflow of blood into the hub of the venous access device.
Replace container on IV pole.
9.2.10.6.1. Adding Solution to a Continuous Infusion Line
7. Check the date on the tubing tag.
8. Hang the new bag of fluids on the IV pole and remove the cover from the port.
9. Remove the current infusion bag of fluids from the IV pole.
10. While maintaining aseptic technique, remove the tubing spike from the port of the infusing
bag of fluids and reinsert the tubing spike into the port on the new bag of fluids; push the full
length of the spike into the port.
11. Set the infusion rate.
Manual Rate Regulation
A. Open regulator clamp; close slowly while observing the drip chamber until the fluid
is dripping at a slow, steady pace.
B. Count the number of drops for a 15-second interval and multiply by 4; for example,
if the drop factor of tubing is 10 drops/ml then the drop rate should be 21
drops/minute to infuse 1000 ml/8 hours.
C. Open the regulator clamp slowly to increase the drip flow rate; close the regulator
clamp to decrease the drip rate to achieve 21 drops/minute.
D. Recount the drop rate after 5 and 15 minutes.
E. Proceed to steps 12–19.
Dial-a-Flo Regulation
1. Turn Dial-a-Flo regulator until arrow is aligned with desired volume of fluid to infuse
over 1 hour.
2. Check drip rate over 15 seconds, and multiply by 4.
3. Adjust height of IV pole if necessary.
4. Recount drip rate after 5 minutes and again after 15 minutes.
5. Proceed to steps 12–19.
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28. Dispose of equipment and gloves in proper receptacle and wash hands.
29. Record fluid administration on MAR and client response in nurses‘ notes
9.3. Blood transfusions
Objectives: At the end of this lesson, the learner will be able to
Purpose:
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Equipment
1. Check prescriber‘s orders for number of units and client‘s signed consent form.
2. Check with the blood laboratory or blood bank that type and cross match have been
completed and that blood is ready.
3. Gather equipment and check integrity of the equipment.
4. Check client‘s arm for an identification band (special band that contains essential data,
blood group and type).
5. Explain procedure to client and his relatives, and answer questions to get co-operation.
6. Assess IV site for patency, gauge size of needle or catheter and verify that IV is in place.
7. Check vital signs.
8. Obtain whole blood unit or packed cells from the blood laboratory or blood bank.
Check requisition form with laboratory personnel.
Check blood label against blood unit for client‘s name and identaband number,
blood group (ABO) and type (Rh), blood unit num-ber, and expiration date of
blood unit.
9. Check requisition form and blood label with another RN and sign form with another RN
in accord with agency protocol
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10. Check blood unit for bubbles, cloudiness, dark color, or sediment; if any of these signs is
present, return blood unit to laboratory and process a written report of actions in accord
with agency protocol.
11. Check label on blood unit against client‘s identaband: name, identification number, blood
group, blood type, and blood unit number.
12. Hang one bag of normal saline on IV pole, pull back tab, and spike with regular
administration set; prime tubing, replace protective cap on distal end of tubing.
13. Prepare Y-set tubing with in-line filter:
Hang second bag of normal saline and blood bag on pole.
Remove Y-tubing from package and close roller clamp. Note red and white caps
of tubing spikes.
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31. Discard Y-set tubing and blood bag in a biohazard bag and follow protocol regarding
disposition.
32. Remove gloves, wash hands.
33. Obtain post infusion vital signs.
34. Document to transfusion record:
Date and time of starting and completing the transfusion
Type of blood transfused
Vital signs
Absence or presence of any reaction or complications
Status of the IV site
Disposition of the blood bag and tubing
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CHAPTER TEN
SKIN INTEGRITY AND WOUND CARE
Objective: At the end of the chapter, the learner will be able to
1. Define wound
2. Explain the purpose of wound care.
3. Identify important equipment needed to provide wound care.
4. Perform dressing of clean and septic wounds.
5. Provide care for the patient with draining wound.
6. Demonstrate skill of wound suturing and irrigation.
7. Apply clip and remove it when indicated.
Definitions: Wound is a disruption in the integrity of body tissue which may be intentional or
unintentional
10.1. Wound dressing
Objectives: At the end of the lesson, the learner will be able to
1. Define wound dressing
2. List the types of wound dressings
3. Collect necessary material
4. Demonstrate the different types of wound dressing techniques
Definitions: Dressing: Any of various materials used for covering and protecting a wound
Wound dressing is process of covering wound or applying sterile protective covering using
aseptic technique
Types of wound dressing
1. Clean wound dressing
2. Septic wound dressing
3. Wound dressing with drainage tube
Purpose of wound dressing
To Keep the wound moist and To keep locally applied drugs in
therefore enhance epithelialization position
To Keep the wound clean To keep edges of the wound together
by immobilization
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To relief pain and comfort the patient To protect the wound from
Provide physical, psychological, and mechanical injury.
aesthetic comfort To protect the wound from microbial
Remove necrotic tissue contamination.
Prevent, eliminate, or control To absorb drainage
infection To prevent hemorrhage.
Maintain a moist wound environment To splint or immobilize the wound
Protect wound from further injury site and there by facilitate healing and
Protect skin surrounding wound prevent injury
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18. Using aseptic technique open the packed sterile instruments, sterile dressings, the irrigation and
cleaning solution, and the instrument set to provide a sterile field, Pour cleaning solution to galipot,
gauze and cotton from a drum.
19. Don sterile gloves.
20. Apply fenestrated towel to the wound to increase the sterile field
21. If sample is needed, take the sample first then clean.
22. Take the second sterile forceps, and clean wound with cotton balls soaked in antiseptic solution
starting from inside to the outside.
23. Use one gauze square for each wipe, discard each square by dropping in to plastic bag, do not touch
bag with forceps.
24. Again use the second forceps to dry wound using gauze sponge and same motion by another new
forceps then discard.
25. Apply medication if any and dress the wound with sterile gauze with sterile another dressing forceps
o Ointment and paste must be smeared with spatula on gauze and then applied on the wound.
o Solutions or powder can be applied direct on the wound.
26. Make sure that the wound is properly covered
27. Fix dressing in place using adhesive tape or bandage.
28. Remove fenestrated towel, rubber and draw sheet.
29. Remove gloves from inside out, and discard them in plastic waste bag.
30. Provide patient comfort measures.
31. Clean and return equipment to proper place.
32. Wash your hands
33. Document the procedure
10.1.2. Dressing septic wound
Objective: At the end of this lesson, the learner should able to
1. Define septic wound dressing
2. Identify the purpose of septic wound dressings
3. Collect the necessary equipments for septic wound dressing
4. Demonstrate clean wound dressing procedures
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Definition: Dressing septic wound is method of covering infected wound that generally contain purulent
material (pus) draining from the wound site .
Purposes:-
Absorb materials being discharged from the wound.
Apply pressure to the area.
Apply local medication.
Prevent pain, swelling & injury.
Percussions
If sterile forceps are not available use sterile gloves.
Immerse used forceps, scissors and other instrument in strong antiseptic solution before
cleansing and discard soiled dressing properly.
In a big ward it is best to give priorities to clean wounds and then to septic wounds when
changing dressings as this might lessen the risk of cross infection.
Wounds should not be too tightly packed in effort to absorb discharge as this may delay
healing.
Equipment
Sterile Dressing set
1. Sterile galipot 5. Sterile cotton tipped application
2. Sterile kidney dish 6. Sterile pair of gloves if needed in
3. Sterile gauze case of gas gangrene rabies etc
4. terile forceps (3)Sterile test tube or
slide if necessary
Clean try
1. Clean glove 7. Bucket to put in soiled
2. Surgical glove dressing/water proof disposable bag
3. Cleaning solution (normal saline, 8. Rubber and cotton draw sheet
H2O2) /Mackintosh with its cover
4. Ordered medication 9. Spatula if ointment
5. Plaster 10. Receiver with strong disinfectant to
6. Bandage scissors or surgical blade immerse used instrument
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11. Probe and director if required 13. Bandage or adhesive tape and
12. Benzene or ether Bucket to put in soiled dressing
Procedure
1. Check order for changing dressings/dressing
2. Great the patient and explain procedure to the patient.
3. Wash your hands
4. Clean trolley or tray, assemble sterile equipment on one side & clean items on the other
side and make sure that the sterile equipments are properly covered.
5. Put on single use examination glove
6. Apply screen (close door and curtain), drape, & put patient in comfortable position
7. Place rubber sheet and its cover under the patient to prevent soiling the linen.
8. Place a clean towel or draw sheet underneath the working area to minimize
contamination.
9. First remove the outer layer of the dressing.
10. Remove the outer layer of dressing and dispose with glove
11. Wear sterile gloves
12. Use forceps to remove the inner layer of the dressing smoothly & discard forceps
13. Observe wound and check if there is drainage rubber or tube.
14. Take specimen for culture or slide if ordered (do not cleanse wound with antiseptic
before you obtain the specimen).
15. Take the sterile cleaning forceps
16. Start cleaning wound from the cleanest part of the wound to the most contaminated part
using antiseptic solution (Hydrogen per oxide 3% is commonly used for septic wound).
17. Deberide dead tissue as needed
18. Discard cotton ball used for cleaning after each stroke over the wound.
19. Cleanse the skin around the wound to remove the plaster gum with benzene
20. Use gauze for drying the skin around properly.
21. Use third forceps for dressing the wound
22. Dress the wound and make sure that the wound is covered completely.
23. Make sure that the wound is properly covered
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Clean tray
1. Antiseptic solution as ordered 6. Dressing scissors
2. Cotton wool or absorbent 7. Ointment paste or paraffin gauze
3. Receiver 8. Spatula if needed
4. Rubber sheet and its cover 9. One pair sterile gloves if
5. Adhesive tape or bandage available
Procedure
1. Check order for dressing / changing dressing
2. Great the patient
3. Check the order and the site of dressing drainage tube
4. Explain procedure to the patient.
5. Perform hand hygiene
6. Clean trolley or tray, assemble sterile equipment on one side & clean items on the other
side and make sure that the sterile equipments are properly covered.
7. Put on single use examination glove
8. Apply screen or close door and curtain
9. Drape and position the patient according to the need and put rubber sheet and its cover
under the part to be dressed.
10. Remove the outer layer of the dressing.
11. Use sterile forceps and remove the inner layer of the dressing (pay attention so that the
drainage tube is not pulled out with the old dressing).
12. Observe the wound for the type and amount of discharge.
13. Clean the wound with cotton balls soaked in antiseptic solution.
14. Grasp the top of drainage tube with sterile forceps. Pull it up a short distance while using
gentle rotation and cut off the tip of the drain with sterile scissors (the length to be cut
depends on the instruction or order).
15. Place sterile safety pin through the drainage tube close to the wound using sterile gloves
or sterile gauze, if it is in the abdomen to stop the drainage tube slipping down out of
sight.
16. Make sure the wound and the skin around are properly cleaned.
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17. Apply ointment or paste to the skin with spatula directly around to prevent irritation and
excoriation (if the excoriation exist use paraffin gauze to prevent further complications).
18. Cut the gauze towards its center to fit around rubber drainage tube so that it fits properly
around the tube thus preventing discomfort.
19. Use adhesive tape or bandage to secure the dressing in place.
20. Record state of wound and the drainage.
10.2. Wound Irrigation
Objective: At the end of this lesson, the learner should able to
1. Define wound irrigation
2. Describe the purpose and precaution consideration of wound irrigation
3. Assemble the necessary equipments for wound irrigation
4. Practice wound irrigation
Definition: Wound irrigation is the process of washing debris, drainage, or exudates out of the
wound to promote healing.
Purpose
1. To clean the area from pathogens and 5. To remove and monitor drainage from
debris wounds.
2. To apply local heat 6. To manage wounds while preventing
3. To irrigate with antiseptic solutions infection
4. To promote wound healing from the
deepest area of a wound to the skin
surface.
Precaution
Keep patient in convenient position.
According to the need the solution will flow from wound down to the receiver.
Use sterile technique and warn solution for irrigating the wound.
. Equipment
Sterile Field Set
1. Sterile gauze 6. Sterile galipot or kidney dish
2. Sterile gloves 7. Sterile catheter
3. Sterile forceps (3) 8. Sterile syringe 20 cc
4. Sterile test tube or slide 9. Gown
5. Sterile cotton tipped application 10. Goggles
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11. Mask
Clean tray
1. Clean glove 6. Solution (hydrogen per oxide or
2. Bandage scissors or surgical blade normal saline commonly used)
3. Bandage or adhesive tape and 7. Adhesive tape or bandage
Bucket to put in soiled dressing 8. Bandage scissors
4. Receiver (2) 9. Receiver for soiled dressing
5. Rubber sheet and its cover
Procedure
1. Check order for irrigation
2. Great the patient
3. Check the order for irrigation and dressing
4. Explain procedure to the patient.
5. Wash your hands
6. Clean trolley or tray, assemble sterile equipment on one side & clean items on the other
side and make sure that the sterile equipments are properly covered.
7. Put on single use examination glove
8. Apply screen (close door and curtain) and drape
9. Position patient comfortably to permit gravitational flow of irrigation solution wound and
into collection receptacle
10. .Put rubber sheet and its cover under the part to be irrigated.
11. Check temperature of solution
12. Apply gown and goggle if needed
13. Remove the outer layer of the dressing by disposable glove and dispose the glove
14. Open sterile field
15. Put on sterile glove
16. Remove the inner layer of the dressing using the first sterile forceps.
17. Put the sterile receiver under patient to receive the out flow( may be sterile basin)
18. Use syringe with desired amount of solution fitted with the catheter.
19. Use forceps to direct the catheter into the wound.
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20. First inject the solution such as hydrogen per oxide at body temperature gently and wait
for the flow. This must be followed by normal saline for rinsing.
21. Make sure the wound is cleaned and dried properly with gauze.
22. Dress the wound and check if it is covered completely.
23. Secure dressing in place with adhesive tape or bandage.
24. Leave patient comfortable and tidy.
25. Clean and return equipment to proper place.
26. Wash your hands
27. Record the state of the wound.
10.3. Suturing
Objective: At the end of this lesson, the learner will be able to
1. Define suturing and suture
2. Describe the purpose of the different types of sutures
3. Re-demonstrate suturing
Definitions
Suturing is the technique of uniting parts of the body by stitching them together.
Sutures are threads used to sew body tissue together which can be absorbable
(Chromic Cat gut) and non absorbable (silk, cotton, linen, clips and wire nylon).
Purpose
To approximate wound edges until healing occurs.
To speed up healing of wound.
To minimize the chance of infection
For aesthetic purpose
Indication
Open intentional and unintentional wound
Contraindication
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Purpose
To prevent further contamination
To comfort the patient
To relieve tension from wound site.
Precaution
Keep wound clean and dry for the first 24 hours.
Bathing is allowed after 48 hours.
Stick to the day stitches should be removed.
Keep wound clean and make dry dressing if no discharge.
Change bandages often.
Equipment
Sterile field set
1. Sterile gauze 5. Toothed tissue /pick up/pin forceps
2. Sterile cotton balls (1)
3. Sterile kidney dish 6. Sterile stitch scissors/surgical blade
4. Sterile forceps (2)
Clean tray
1. Rubber sheet and its cover
2. Antiseptic solution
3. Receiver/ waste container
4. Adhesive tape/ bandage
5. Plaster scissor
Procedure
1. Check the order for stitch removal
2. Greet the patient and Explain the purpose oe procedure.
3. Wash your hands
4. Clean trolley or tray, assemble sterile equipment on one side & clean items on the other
side and make sure that the sterile equipments are properly covered.
5. Adjust light
6. Position the patient and protect bedding with rubber sheet and its cover.
7. Wear sterile glove
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8. Remove the old dressing and discard it in the receiver.
9. Cleanse the wound using the 1st forceps with antiseptic solution starting from the
cleanest part of wound to the most contaminated part.
10. Place sterile gauze to receiver pieces of sutures.
11. Take a scissor in the right hand/ surgical blade.
12. Take pick up/pin set/ toothed tissue forceps in the left hand.
13. Pull 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.
14. Receiver pieces of stitches on sterile gauze and count number of stitches removed.
15. Inspect the wound for healing and apply iodine on suture site.
16. Apply dressing accordingly.
17. Keep patient comfortable and tidy.
18. Perform hand hygiene
19. Clean and return equipment to their proper place
20. Record the state of the wound.
10.5. Clips Application
Objective: At the end of this lesson, the learner will be able to
1. Define clips
2. Describe the purpose and indication of clips
3. Assemble the necessary equipments of clips
4. Practice application of clips following the steps
Definition
Clips are metal sutures used to stitch the skin
Clip application is the process of applying clips .
Purpose
To approximate wound edges until healing occurs
To promote wound healing
To minimize the chance of infection
For aesthetic (cosmetics) purpose
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Equipment
1.
2. Tray or trolley covered with a 7. Mitchell‘s clip applier
sterile towel 8. Tissue forceps (Tooth dissecting
3. Sterile hole towel (fenestrated forceps)
towel) 9. Sets of clip
4. Sterile kidney dish 10. Sterile cotton swabs in gallipots
5. Sterile needle and syringe 11. Sterile Gauze
6. Sterile gloves
Clean tray
1. Antiseptic solution with its 3. Adhesive plaster
container 4. Local anesthesia (Lidocaine)
2. Transferring with its container
Procedure
1. Check the order for clips application
2. Great the patient and explain the purpose of clips application to the patient.
3. Wash your hands
4. Wear clean glove
5. Clean trolley or tray, assemble sterile equipment on one side & clean items on the
other side and make sure that the sterile equipments are properly covered.
6. Adjust light
7. Wash your hand again
8. Wear sterile glove
9. Clean the wound thoroughly.
10. Drape the wound with the hold sheet
11. Infiltrate the edge of the wound to be sutured with local anesthesia.
12. Approximate the edge of skin with the help of the tissue forceps and apply clip to the
wound edge using the Mitchell‘s clip applier.
13. Clean the wound and cover it with sterile gauze.
14. Remove the fenestrated/window towel .
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15. Make the patient comfortable.
16. Remove all equipment wash and return to its proper place or send for sterilization.
17. Wash your hands
18. Record the state of the wound.
10.6. Removal of clips
Objective: At the end of this lesson, the learner should able to
1. Define removal of clips
2. Assemble the necessary equipments for clip removal
3. Demonstrate clips removal
Definition:-
Removal of clips is removal of clips from sutured area.
Purpose
To prevent further contamination.
Precaution
Stick to the day clips should be removed.
Use aseptic technique
Keep wound clean and make dry dressing if no discharge.
Change bandages often.
Equipment
Sterile field set
1. Sterile gauze 4. Sterile forceps (3)
2. Sterile cotton balls 5. Sterile clip removal forceps
3. Sterile kidney dish
Clean tray
1. Rubber sheet and its cover 5. Antiseptic solution (Savalon 1%
2. Receiver/ waste container and iodine)
3. Adhesive tape/ bandage 6. Benzene or ether
4. Plaster scissor
Procedure
1. Check the order for clips application
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2. Great the patient and explain the procedure.
3. Wash your hands
4. Wear clean glove
5. Clean trolley or tray, assemble sterile equipment on one side & clean items on the other
side and make sure that the sterile equipments are properly covered.
6. Adjust light
7. Wash your hand again
8. Position and drape the patient.
9. Protect the bedding with rubber sheet and its cover.
10. Wear sterile glove
11. Remove old dressing and discard.
12. Cleanse wound with antiseptic solution starting from cleanest part of the wound to the
most contaminated part and discard the cotton ball.
13. Place sterile gauze to receive removed clips.
14. Take clip remove with the right hand and dissecting forceps with the left hand.
15. Insert the lower blade of the clip remove below the middle of clip using the dissecting
forceps as a support of old the clips in place, and close the blade firmly as this will cause
disagreement of the clips from the skin.
16. Receive clips on sterile gauze and count the number of clips.
17. Apply iodine on the skin puncture in place with adhesive tape.
18. Leave patient comfortable and tidy.
19. Record the state of scar.
20. Clean and return used equipment to its proper place
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CHAPTER ELEVEN
COLD AND HEAT APPLICATION
Objective: At the end of this chapter, the learner will be able to :
1. List purpose of applying cold and heat
2. Identify and assemble necessary equipment to apply cold and heat
3. Demonstrate how to apply cold and heat with acceptable technique
11.1. Application of cold
Definition: sponging of the skin with alcohol or cool water for reducing body temperature
(fever).
Purpose
To relieve pain To relieve headache
To reduce swelling and inflammation
Reduce raised body temperature
Equipments
1. Basin 8. Recording format
2. Towel 9. Bed pan
3. Syringe 10. Screen
4. Water at recommended temperature 11. West receiver
5. Lotion thermometer 12. Roll bandage
6. Body thermometer 13. Alcohol
7. Glove 14. Grycline
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Procedure:
1.Explain the procedure
2.Wash hands properly
3.Assemble the necessary equipments
4.Give opportunity to use bed pans or urinals before tipped sponging
5.Take temperature and record
6.Note whether patient has antipyretic to reduce fever
7.Add tepid water to the bath basin (21.1oC to 29.4 oC) use lotion thermometer to measure
Mix 3 parts water+ 1 part alcohol with 1% grycline.
8.Place moist, cool cloths wrung out just enough to prevent dripping in the client axillae and the groin
9. Perform the procedure for at least 25-30minute and Monitor the client‘s body temperature throughout
the procedure to determine the treatment effects.
10. Sponge each limb for at least 5 minute and the back and buttocks for at least 10-15minute.
11. Stop the procedure if the client become very chilled or begins to shiver.
12. Stop sponging as soon as the client‘s temperature approaches the normal range (38.7 oC).give the
patient bath blanket.
13.Comfort the patient
14.Return equipments
13. Washhand.
14.document the procedure with patient reaction pre and post temperature
15. Take the temperature 30minute after you complete the bath.
11.1.2. Cold compress
Objective: at the end of this practical session the learner will be able to:-
Define cold compress
List purposes of cold compress
Assemble necessary equipments required for the procedure
Apply cold compress
Document the procedure
Definition: Cold compress is application of face towel or gauze wet in cold water to be applied
on specific body part.
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Purpose
To relieve pain To relieve headache
To reduce swelling and inflammation
Reduce raised body temperature
Equipments 7. Glove
8. Recording format
1. Basin
9. Bed pan
2. Towel
10. Screen
3. Ice pack
11. West receiver
4. Water at recommended temperature
12. Roll bandage
5. Lotion thermometer
6. Body thermometer
Procedure:
1.Explain the procedure
2.Wash hands properly
3.Assemble the necessary equipments
4.Give opportunity to use bed pans or urinals before tipped sponging
5.measure client‘s body temperature
5.Wear gloves if patient has open wound or has had surgery
6. Put the compresses in a basin containing pieces of ice and small amount of water.
7.Wring the compresses thoroughly and apply
8.Change the compresses frequently
9.Wrap the area with roll bandage if continuous compress needed
10. Continue the treatment as ordered, usually for 15-20 minutes. Repeat the treatment 2-4 hours as
ordered
13.Comfort the patient
14.Return equipments
13. Wash hand.
14.Document the procedure with patient reaction and pre and post temperature
15. Take the temperature 30minute after you complete the compress.
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Objective: at the end of this practical session the learner will be ableto
Define application of ice pack Assemble necessary equipments
explain purposes of ice pack required for the procedure
Describe contraindication for the Demonstrate application of ice pack
procedure Document the procedure
Definition: application of dry cold by using ice in rubber bag /padded towel/bag or container
Purpose
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Objective: at the end of this practical session the learner will be able to
1. Define application of ice collar
2. List purposes of ice collar
3. Describe contraindication for the procedure
4. Assemble necessary equipments required for the procedure
5. Demonstrate application of ice collar
6. Document the procedure
Definition: application of dry cold by using ice in rubber bag /padded bowel/bag or container.
Purpose
Equipment
Ice collar
Ice in bowel Towel and mackintosh
Water in bowel Kidney dish
Salt Steel tray
Tablespoon
Procedure
1.Explain the procedure
2.Wash hands properly
3.Assemble the necessary equipments
4.Give opportunity to use bed pans or urinals before tipped sponging
5.Measure client‘s body temperature
5.Wear gloves if patient has open wound or has had surgery
6.Add salt to ice chips to prevent fast melting of ice
7. Fill the collar threefourthsfull with ice and remove the remainingair from the collar before
closing the collar.
8. Check for leaks. Place the collar in a protectivecover and place it around the client‘s neck.
9. Apply ice collar to area as ordered.
9.Comfort the patient
10.Return equipments
11. Wash hand.
12.Document the procedure with patient reaction and pre and post temperature
13. Take the temperature 30minute after you complete the compress.
11.2. Application of heat
11.2.1. Applying warm soak
Objective: at the end of this practical session the learner will be able to
Define application of warm soak
List purposes of warm soak
Describe indication/contraindication for warm soak application
Assemble necessary equipments required for the procedure
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17. Lower the head of the bed and make the patient comfortable.
18. Return equipment to the utility room.
19. Wash hand.
20. Document the procedure with patient reaction
11.2.2. Applying Hot Compress
Objective: at the end of this practical session the learner will be able to:-
Define application of hot compress
List purposes of hot compress
Assemble necessary equipments required for the procedure
Demonstrate application of hot compress
Document the procedure
Definition: Hot compress is application of face towel or gauze wet in warm water to be applied
on specific body part.
Purpose
To relieve stasis of blood To relieve distention and congestion
To relax muscle To provide warmth to the body
To relieve pain To promote healing
To increase blood circulation To soften the exudate
To promote suppuration To decrease joint stiffness
Equipment:
Disposable gloves Lotion thermometer
Syringe Binder or towel
Bed protector K pad as necessary
Compresses
Pins or bandageProcedure
1. Explain the procedure
2. Wash hands properly
3. Assemble the necessary equipments
4. Protect the bed and the patient‘s clothing with a bed protector.
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5. Check the temperature of the solution. Moisten the compresses; remove excess liquid.
6. Done clean glove
7. Expose only the area to be hot compressed.
8. Apply the hot compress to the specific body part.
9. Secure the compresses with a bandage or binder if long term compress needed
10. The compress must be in contact with the patient‘s skin.
11. Help the patient to maintain a comfortable position throughout the procedure.
12. Un screen the unit. Leave the unit neat and tidy, with the signal cord within easy reach.
13. Maintain proper temperature and moisture.
14. If the compresses are to be kept warm, a K-Pad may be applied.
15. A syringe may be used to apply more solution to keep the compresses wet.
16. Remove the compresses when ordered. Change as ordered or once in 24 hours. Check skin
several times each day.
17. Discard the compresses.
18. Remove gloves
19. Comfort the patient.
20. Return equipment t.
21. Wash hands
22. Document the procedure with patient reaction
11.2.3. Hot Water Bag Application
Objective: at the end of this practical session the learner will be ableto
Define application of hot water bag
List purposes of hot water bag
Assemble necessary equipments required for the procedure
Apply hot water bag
Document the procedure
Definition: - Hot water bag application is a process of applying dry heat by means of a rubber
bag on specific body part.
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Purpose
Equipment
9.The temperature should be 105 to 115 oF for children and 115 to 125 oF for adults
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12.Expel excess air by permitting water to come to mouth of bag and then close
14.Wipe outside with duster cover with towel and apply to body part
15. Expose only the part that needs treatment and apply on it.
16.Provide warmth by covering all non-treatment area with bath blanket or bed covers
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CHAPTER TEWELVE
NUTRITON AND METABOLISM
Objectives: At the end of this chapter the learner will be able to:-
1. Demonstrate how to feed a helpless patient
2. Demonstrate proper practice of Gastrostomy feeding
3. properly administer parental feeding
4. properly check placement of NG tube
5. accurately washout gastric mucosa
6. monitor input and output of patient
12.1. Feeding a helpless patient
Objectives: At the end of this lesson, the learner will be able to:
1. Define feeding a helpless patient
2. List the indication of feeding a helpless patient
3. Describe the purpose of feeding a helpless patient
4. Assemble the necessary equipments for feeding a helpless patient
5. Demonstrate how to feed a helpless patient
Definition: Feeding a helpless patient is providing nutritional intake for a pt that is unable
to feed him/her self.
Purpose
To assist the patient to eat meal To prevent dehydration
To meet the nutritional need To improve appetite
To promote healthy
Indication
General weakness or critically ill patient
Paralysis or limitation of movement E.g. Presence of arm splints casts and traction.
Small children.
12.2. Feeding the Helpless Patient General Instruction
Check the diet ordered
Make surrounding neat and clean.
Prepare pt and over – bed table
Hot food should be served hot and cold food cold.
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The tray should be complete, clean and neat. The food, no matter how simple, should
be attractive and appetizing.
Precaution
Control odors noise and unpleasant sights at meal equipment.
Remove solid equipments & linens
Patient - Provide oral hygiene
Hand washing
Position comfortable preferable sitting up position
Meal tray: - Ensure correct tray for correct pt
Equipment
1. Extra – pillow, if not a patch bedNap kin
2. Food on a clean tray
3. Towel
4. Glass of water
5. Meal tray
6. Drinking tube or feeding cup
7. Over bed table
8. Oral hygiene equipment
9. Feeding spoon
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Procedure
1. Make patient comfortable. Elevate head and shoulder if permissible.
2. Protect patient‘s gown and bed with a towel.
3. Arrange tray conventionally. Place tray where it can be reached easily.
4. Feed patient as indicated.
12.3. Gastrostomy feeding
Objectives: At the end of this lesson, the learner will be able to:
Purpose
Purpose:
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4. Provide parentral nutritional support to clients who have excess metabolic needs due to
trauma , cancer, or hyper metabolic state
Indication
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Procedure
1. Schedule and assist client with chest x-ray after central catheter insertion
2. Confirm correct solution is running at order rate.
3. Check solutions expiration date .
4. Use infusion controller to monitor and regulate flow rate
5. Inspect tubing and catheter connection for leaks or kinks. Tape all connections. Change
tubing every 24 hours accordingly to agency policy
6. Inspect insertion site for infiltration thrombophelibits or drainage. If present, notify
physician. Note the physician may order removal of the catheter and culture of the catheter
tip
7. Monitor vital signs , including temperature every 4 hours
8. Assess for symptoms of air embolism (i.e., decrease level of consciousness, tachycardia,
dyspnoea, anxiety, ‖feeling of impending doom‖, chest pain, cyanosis, hypotension) Note :
if suspected ,lay clients on left side with head in trendelenburg position.
9. Use the TPN line only for administration of TPN and lipids. Don‘t use the line for any other
reason
10. Perform test for g glucose every 6 hours. Notify the physician if abnormal
11. Monitor laboratory test of electrolyte, BUN, glucose as order and report abnormal finding
12. Maintain accurate record of intake and output to monitor fluid balance
13. Weigh client daily and record
14. Inspect dressing once shift for drainage and intactness. Change whenever loose or moist and
at least every 48 hours.
15. Wash hands and document procedure in the client‘s medical record
12.5. Nasogastric tube insertion
Objectives: On the completion of the lesson learners will be :
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Apply proper checking of NG tube placement.
Definition: Passing a tube through a nasal cavity down the nasopharynx and oesophagus in to
the stomach
Purpose
To administer tube feeding and medication to clients unable to eat by mouth or swallow
a sufficient diet without aspirating food or fluids in to the lungs.
To establish a means for suctioning stomach contents to prevent gastric distension,
before and after surgery ,nausea and vomiting
To remove stomach contents for laboratory analysis
To decompress abdominal distension.
To lavage (wash) the stomach in case of poisoning or overdose of medications
Indication
Surgery Unconscious
Abdominal distension Severe dehydration
Poison Diagnostic analysis
Equipment
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Procedure
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10. Lubricate about 15-20 cm of the tube with a water soluble lubricant using a swab
11. Insert the rounded end of the tube in hyper extend the neck in to the cleanest nostril and
slide it backwards and in wards along the floor of the nose to the nasopharynx.
a. If any obstruction is felt, withdraw the tube and try again in a slightly different
direction or use the other nostril.
12. As the tube passes down in the nasopharynx, ask the patient to start swallowing and
sipping water this will close the glottis, enabling the tube to pass in to the oesophagus.
a. Slight pressure is sometimes necessary to pass tube but never forced against
resistance, because of the danger of injury
13. Advance the tube through the pharynx, as the patient swallow‘s until the predetermined
mark has been reached.
While inserting the tube observe for patient condition for Coils in the mouth by
opening the mouth by tongue depressor
If Client gag, stop passing the tube momentarily with each wall insert 5 to 10 cm
with each swallow.
If client continues to gag and the tube does not advance with each swallow,
withdraw it slightly.
If the patient shows signs of distress like gasping or cyanosis, remove the tube
immediately and try again the procedures.
14. Continue in advancing the tube until the mark on and the tube reach his/her nostril.
15. Taping a tube to the bridge of the nose
16. Check the position of the tube to confirm that it is in the stomach by:-
A. Introducing 10-20ml of air in to the stomach via the tube and check for a whooshing
sound using a stethoscope placed over the epigastrium.
B. Aspirating the contents of the stomach with a syringe. The aspirate turns blue litmus
paper to red, due to HCI.
C. Insert/immerse the tip of tube in the glass of water and if you see bubble that show
you are in the lung.
17. Clamp the end of the tube with clamper or forceps or spigot
18. Secure the tube to the nostril and attach to forehead with adhesive tape. Ensure patient
is comfortable.
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19. Attach the tube to a suction source or feeding apparatus as ordered
20. Assist the patient into position and comfort
21. Remove and clean the used equipment return it in to proper place
22. Wash hands and dry
23. Document relevant information
12.6. Nasogastric tube medication administration
The nurse checks the patency and placement of a nasogastric tube before adding any water
or medications by performing the following actions:
When different types of medications are administered, each type is given separately,
using a cccccbolus method that is compatible with the medication‘s preparation.
The tube is flushed with 20 to 30 mL of water after each dose.
If a liquid form of a medication is not available and the medication can be crushed, it
must first be reduced to a fine powder or the tube will become clogged
For clients who have an NG tube for decompression (removal) of gastric contents, turn off
the suction for 20 to 30 minutes after the instillation of the medication to allow time for the
gastric contents to be emptied into the intestines, where most drugs are absorbed
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Definition: Aspiration is the withdrawal of fluid or gas from gastric cavity by sectioning.
Gastric content analysis is examination of the contents of the stomach, primarily to determine
the quantity of acid present and incidentally to ascertain the presence of blood, bile, bacteria,
and abnormal cells.
Purpose
1. To relieve stomach or intestinal distension following abdominal surgery.
2. In case of gastrointestinal obstruction to remove the stomach content,
3. To keep the stomach empty before an emergency abdominal operation is done.
4. To aspirate the stomach contents for diagnostic purpose ,like detect acid-fast bacillus
in a client with undiagnosed tuberculosis, total absence of hydrochloric acid is
diagnostic of pernicious anaemia.
Equipments
11. Tray
21. Spatula
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Procedure
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Or aspirate 20-30ml of the content of the stomach with syringe then test the content by
using Litmus paper. Gastric content is yellow to green in colour and usually presents in
amounts greater than 10 ml.
Take 20 cc syringe aspirate air and administer the air through NG tube, place
stethoscope on epigastric area then listen to a gurgling sound. If you hear the sound it
means that the tube is wit in the stomach.
Chest x- ray
15. After being sure that the tube is in the right position secure the tube by taping to bridge of the
client's nose
16. Aspirate gastric fluid using 20-50 ml syringe and collect specimen if needed, or aspirate with
suction machine or attach with bag or clamp end of tubing as ordered.
17. Histamine will be given subcutaneously to stimulate gastric secretions.
18. Continuously monitor the blood pressure to detect hypotension.
19. Collect gastric specimen every 15 minutes for 1 hour.
20. Label the specimen to indicate specimen before and after histamine injection
21. Comfort the patient
22. Clean or discard used equipments.
23. Record
12.8. Gastric lavage
Objective: On the completion of the lesson learners will be:
1. Define gastric lavage.
2. List the purpose of gastric lavage.
3. Collect the necessary equipment for gastric lavage.
4. Perform the gastric lavage according to the steps.
Definition: Gastric lavage is the introduction of solution into the stomach and removing gastric
contents through nasogastric tube for washing out the stomach.
Purpose
To remove inserted poison, other than corrosive substances like ammonia and mineral
substances.
To introduce ice water or normal saline solution in tackling bleeding.
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Pyloric stenosis
Poisoning
Preoperative care
Equipments
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7. Select the appropriate distances mark on the tube by measuring the distance on the tube from
the client‘s bridge of the nose to ear lobe plus the distance form ear lobe the to the bottom of
the xiphistemu(xyphoid process).
8. Lubricate the tube.
9. Gently insert and pass the tube, the tongue, the mouth forward the posterior pharynx (If the
client is unconscious, mouth gag may be used)
If air bubbles, cough and cyanosis are noticed withdraw the tube and recommence the
procedure.
10. Advance the tube slowly to prevent injury until the pre measured mark,
11. Assess the correct placement by aspirating stomach contents, or by listening gosh of air while
the client exhales.
12. After the NG tube is in place, allow the stomach contents to empty in to the drainage
container before instilling any irrigating solutions. This confirms proper placement of the
tube and decreases the risk of over filling of the stomach and inducing of vomiting.
13. Once you confirm proper placement of the tube, begin gastric lavage by instilling about
250ml of irrigating solution to assess the patient‘s tolerance and prevent vomiting.
If you are using simple rubber tube for the lavage
a. Fill the small jug with water/ solution, measure and pour gently until the funnel is
empty, then invent over the pail (the funnel is connected with the funnel end of
the oesophageal tube)
b. Take specimen, if required, and continue the process until the returned fluid
becomes clear and the prescribed solution had been used.
If you are using a tube with a bulb
a) Clamp the tube below the bulb,
b) With right hand, squeeze the bulb thus forcing the air out through the funnel.
c) With left hand, pinch tubing above the bulb/proximal to you/ and at the same time
with right hand, release the clamp. This creates a suction which will draw the
stomach contents into the bulb.
d) Lower funnel and allow excess gastric contents to drain into the pail.
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Contra indication
Diffused peritonitis
Intestinal obstruction that prohibits normal bowel functioning
Intractable vomiting; paralytic ileus
Severe diarrhea
Patient assessment
1. Assess the client for signs of gastric distress, such as nausea, vomiting, and cramping, to
determine the client‘s tolerance for the tube feeding.
2. Assess the feeding tube placement every 4 hours to confirm tube placement in the GI tract.
3. Assess the client‘s respiratory status to evaluate for pulmonary aspiration of gastric contents.
4. Assess the client‘s ongoing nutritional status to evaluate the effectiveness of the tube feeding.
5. Assess the client‘s intake and output to evaluate feeding impossible.
Equipment
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4. Assess the client for feelings of abdominal distension, blenching, loose stools, flatus or plain;
bowel sounds and allergies to foods.
5. If NG tube is not in place follow the NG tube insertion procedure and insert the tube and
secure it.
6. Confirm correct placement of the tube
7. Cover the patient‘s chest with the towel to protect him/her from spills of food.
8. Aspirate stomach contents to determine amount of residual and measure it.
If the residual is over 50-100 ml in adults and 10 ml or more infants, hold the
feeding until residual diminishes or subtract the withdrawn amount from the total
feeding and administer the rest. All these are based on the policy agency.
9. Reinstall the gastric contents to the stomach to prevent electrolyte imbalance.
10. Before the feeding solution has drained from the neck of the bottle, instil 50-60 ml of water
through the tube, to prevent tube feeding syndrome and further blockage.
11. Remove air from the feeding tubes and attach it to the nasogastric tubes and to prevent air
from entering to the stomach, never allow the syringe or the gavage bag to empty completely.
12. Hang bottle on IV stand beside patient and run the food through the giving set or if a syringe
is to be used remove plunger from barrel of syringe and attack barrel to nasogastric tube.
Deliver feeding over the desired length of time (as ordered). Usually 200-350 ml
over 10-15 minutes is given.
Replace any formula administered by an open system every 4 hours with fresh
formula. Formula should be at room temperature or cool (not cold).
13. After the administration of the appropriate amount of food, flush the tube by adding about
60ml of water to the syringe. This maintains the patency of the tube by removing excess food
particles which could block the tube.
14. If you are administering a continuous feeding, flush the tube every 4hours to help prevent
tube occlusion.
15. To discontinue the NG tube feeding disconnect the syringe from the feeding tube.
16. Close the tip of the NG tube with its plug cap before all of the rinse solution has run through
to prevent leakage and contamination.
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17. Leave the patient in semi sitting position of slightly elevated right lateral position for at least
30minutes.
18. Communicate with your patient.
19. Clean and return used equipments.
20. Wash your hand
21. Record the amount given and the patient‘s general condition.
Complications
Diarrhoea – due to hyper osmolar feeding, rapid infusion, bacteria contaminated feedings,
lactase deficiency and food allergies etc.
Nausea/ vomiting- due to Change in rate of feeding, offensive smell, in adequate gastric
emptying.
Cramping/ gas- due to air in tube.
Constipation- high milk content, low fiber intake, inadequate fluid intake.
Aspiration pneumonia- due to improper tube placement, flat in bed, too large tube etc.
Tube displacement- due to excessive coughing/ vomiting, tracheal suctioning etc.
Tube obstruction- due to inadequate flushing/ formula rate.
Nasopharengeal irritation- due to tube position and large tubes.
Hyperglycaemia- glucose intolerance and high carbohydrate feeding content.
12.10. Removal of a Nasogastric Tube
Objective: at the end of this lesson, the learner will be able to:-
When the physician determines that the client‘s nutritional status no longer warrants EN therapy
or the need to provide decompression of the gastric contents, the nasogastric tube is removed. If
the client is connected to suction for decompression, the physician may prescribe clamping the
tubing for several hours prior to removal, to ensure a functioning GI tract.
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Equipment:
1. Hand wash
2. Verify the physician‘s prescription.
3. Check the client‘s armband and explain the procedure.
4. Provide for privacy.
5. Wash hands and don gloves.
6. Place the client in a high Fowler‘s position and adjust the height of the bed to a
comfortable working position.
7. Place the towel across the client‘s chest.
8. Clamp or plug the tube and unpin the tube from client‘s gown.
9. Remove the tape securing the tube from the client‘s nose.
10. Hold the paper towel open in your non dominant hand under the client‘s chin; with your
dominant hand, grasp and pinch the tube near the nostril, and remove the tube with a
steady, continuous pull, allowing the tube to fall into the paper towel.
11. Dispose of the tube and paper towel in the receptacle.
12. Clean the client‘s nares and provide oral hygiene.
13. Position the client comfortably, place call light in easy reach, and return bed to a low
position.
14. Remove gloves, place in receptacle, and dispose of receptacle in accord with agency
policy.
15. Wash hands and document procedure in the client‘s medical record
12.11. Measuring Intake and Output
Objectives: At the end of this lesson, the learner will be able to:
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Oral Intake
7. Measure all oral fluids in accord with agency policy (e.g., cup = 150 ml, glass = 240 ml).
8. Record time and amount of all fluid intake in the designated space on bedside form (oral,
tube feedings, IV fluids).
9. Transfer 8-hour total fluid intake from bedside I&O record to graphic sheet or 24-hour
I&O record on client‘s chart.
10. Record all forms of intake, except blood and blood products, in the appropriate column of
the 24-hour record.
11. Complete 24-hour intake record by adding all 8-hour totals.
Output
Night total
day
day total
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evening
evening total
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CHAPTER THIRTEEN
ELIMINATION
Objective: At the end of the chapter, the learner will be able to:-
1. Insert indwelling and plain urinary catheter for male and female clients
2. Perform bladder irrigation
3. Provide care for client with supra-pubic catheter
4. Identify types of enema solution with possible advantage and disadvantage
5. Re-demonstrate proper technique of enema administration
6. Provide care for colostomy appliance
7. Manage colostomy irrigation
Definition- act of voiding or expelling waste material from the bowels
Urinary catheterization
Suprapubic catheterization
Definition: Urinary Catheterization- involves inserting a small tube/ catheter through the
urethra in to the bladder to allow urine to drain
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Catheters: are tubes commonly made of rubber or plastics, although certain types are
made of woven silk or metal.
Purpose
Purpose
To relieve discomfort due to bladder distention
To obtain a sterile urine specimen
To empty the bladder prior to surgery
Equipment
Sterile
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12. Cleanse penis using circular motion, starting over meatus and working down wards
glans, repeat procedure twice using new swabs always by the help of forceps.
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13. Pick up catheter, lubricated at least 7.5cm from distal end. Draw penis upwards and
forwards at 900 angle to the leg insert the catheter, lower penis when feeling resistance at
an angle of 60 degree
14. Insert catheter about 18-20cm till urine flow
15. Remove catheter, replace foreskin to avoid complication
16. Remove catheter measure urine, dry area with dry cotton swab, remove bed protection
position patient comfortable and cover
17. Remove and clean equipment
18. Send specimen to the laboratory
13.1.1.2. Insertions of indwelling Urinary catheter
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Procedure
23. Gently insert the catheter into meatus until urine is noted. Continue inserting for 2.5 to
5cm additional.
24. After catheter insertion, the balloon is inflated to hold the catheter in place within the
bladder.
25. Instruct the client to immediately report discomfort or pressure during balloon inflation;
if pain occurs, discontinue the procedure, deflate the balloon, and insert the catheter
further into the bladder.
26. Gently pull the catheter until the retention balloon is snuggled against the bladder neck
(resistance will be met) re-push back 2cm after the test
27. If laboratory test is prescribed, collect some amount of urine in the sterile specimen
bottle straight from the catheter
28. Secure the catheter to the abdomen or thigh and connect to drainage tube
29. Place the drainage bag below the level of the bladder.
30. Remove gloves, dispose of equipment, and wash hands.
31. Help client adjust position.
32. Assess and document
13.1.1.3. Applying a Condom Catheter
Objective- at the end of this lesson, the learner will be able to
Definition- The condom catheter is an external drainage system to collect urine from male
clients who have incontinence
Purpose
Provide a means of collecting urine and controlling incontinence without the risk of
infection that an indwelling urinary catheter imposes
Equipment
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Procedure
1. Wash hands and apply gloves.
2. Select an appropriate condom catheter.
3. Cleanse the penile shaft.
4. Inspect the penile shaft for excessive hair.
5. Inspect the penis for altered skin integrity.
6. Stretch the shaft of the penis and unroll the condom to the base of the penis.
7. Follow product directions for the application of the sealant
8. Attach the condom to the drainage apparatus,
9. either a leg bag or bedside drainage bag.
10. Remove gloves and wash hands.
11. Remove and reapply the condom catheter every 24 to 48 hours, or when leakage occurs.
13.1.2. Bladder Irrigation (open and closed method)
Objective: at the end of this lesson, the learner will able to :
1. Define bladder irrigation
2. Demonstrate bladder irrigation
Definition: it is the washing out of the bladder to clear the catheter and/or the bladder.
Purpose
To clean the bladder before operation depending on the surgeons order
To arrest bleeding from the bladder
To clean the catheter from mucous or blood clots
To clean bladder form pus
Precaution
Care should be taken not air into the balder as it may cause spasm
Not more than 100-300ml must be instilled at a time after bladder operation capacity may
be limited.
If the catheter is blocked by blood clots, a suction of the catheter must be proceed the
irrigation
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Equipment
a complete set to catheterization Receiver with plaster to put the catheter
end (open method)
A sterile bladder syringe for open
method Rubber and draw sheet
Closed method
2. Connect Y-place to the catheter and IV set to one end of the ―Y‖ and drainage tube to
the other end
3. Intermittent irrigation clamp the drainage tube and let irrigation solution run in the
bladder (100-200ml) then close the set and open the drainage tube empty the bladder.
4. Repeat this procedure as soften as necessary
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1. Define enema
2. Identify different types of enema
3. Demonstrate different types of enema
4. Demonstrate insertion of flatus tube
5. Perform colostomy care and irrigation
6. Demonstrate digital removal of fecal impaction
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13.2.1. Enema
Definition:
The term enema is used to refer to the process of instilling fluid through the anal
sphincter into the rectum and lower intestine for a therapeutic purpose.
Purpose:
Purpose
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Precautions
No need to use too much soap - this may produce sever irritation of the membrane of the
colon.
Tap water must be administered consciously for infants or adults who have altered kidney
or cardiac reserve this is to avoid water intoxication.
Contraindications
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12. Lubricate the tip of the tubing with water soluble lubricant
13. Gently insert tubing 3 to 4 inch (6-8cm) in to patients rectum pass the external and
internal sphincters
14. Raise the water container to a maximum height of 45cm
15. Allow solutions to flow slowly
16. Hold the tubing in place in the patient's rectum at all times. Keep abed pan near by
17. After you have instilled the solution, gently remove the tubing instruct patient to hold
solution for 10 to 15 minutes.
18. Elevate the head of the bed so that the patient can assume as squatting position on the
bedpan or assist to bathroom.
19. Provide privacy until the patient has expelled the total volume of the instilled solution
20. Removal and cover bed pan
21. Assist patient with perineal care and help patient to assume a comfortable position
22. If the patient is on strict input and out measure returns to make sure total volume of the
solution is expelled.
23. Clean all equipment and replace in both room or appropriate vocation
24. Wash your hands
13.2.1.2. Retention enema
Objectives:- At the end of this lesson, the learner will be able
Definition: - it is the injection of a liquid in to the rectum, to be retained in the rectum for some
period of time
Purpose:
Equipment
Procedure
1. Identify and prepare patient as for any enema
2. Fill the ordered solution to the enema can
3. Position patient
4. Expose anal opening and insert rectal tube tip of container 3-4 inches
5. Squeeze contents slowly and empty entire amount in to rectum
6. Remove rectal tube gently
7. Explain to patient that the solution should be retained for one to three hours
before it is expelled
8. A cleaning enema may need to be given to remove the solution (oil) and stimulate
defecation
9. Clean all equipment and wash your hand
13.2.1.3. Rectal wash out
Objectives:- At the end of this lesson, the learner will be able
Definition: - is the injection of a liquid in to the rectum to be wash out the rectum and colon
Purpose
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Precaution
The rectal wash out should not exceed for more than 2 hours
The rectal wash out should be finished one hour be for examination (e.g. x-ray,
sigmoidoscopy) this is to give time for the large intestine to absorb the rest of the fluid
Give cleansing enema half hour be for the rectal wash out.
Equipment
1. Pitcher 5. Bucket
2. Newspaper 6. Funnel
3. small jug 7. Bedpan
4. Large mug for fluid
8. Tubing and glass connecting
9. Rectal tube or catheter and clamp
10. lotion thermometer 13. Solution of (40 co)
11. Mackintosh and towel 14. glove
12. swab and Vaseline
Procedure
Definition: The insertion of a rectal tube is done to manage flatulence (gas) following abdominal
surgery and/or reduce abdominal distention due to flatulence.
Purpose
6. Position client in left lateral position with upper leg bent over lower leg
7. Place disposable pads (if not available, use towels).
8. Use odor eliminator per manufacturer (optional).
9. Apply gloves.
10. Apply lubricant to a gloved finger.
11. Insert lubricated finger into rectum to check for possible obstructions prior to insertion of
rectal tube.
12. Change gloves if soiled from rectal exam.
13. Lubricate end of catheter.
14. Gently insert catheter into anal canal approximately 10–15 cm (4–6 inches)
15. Attach plastic bag or drainage bag to end of catheter if needed to control odor or stool
16. Inflate balloon of catheter or tape tube to the lower buttock if rectal tube is not to be removed
within 30 minutes
17. Dispose of pad. Remove soiled gloves and place in appropriate receptacle.
18. Wash hands
1. Define colostomy
2. Explain the importance of colostomy irrigation
3. Collect necessary equipments
4. Perform colon irrigation
Definition: Colostomy: is an opening created as a permanent or temporary diversion of the
bowel at the level of the colon
Equipments
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Procedure
1. Wash hands.
2. Apply clean gloves.
3. Assemble irrigation kit: Attach cone or catheter to irrigation bag tubing.
4. Fill irrigation bag with 1000 cc tepid tap water
5. Open clamp and let water from the irrigation bag fill the tubing.
6. Hang bottom of irrigation bag at height of client‘s shoulder, or 18 inches above the stoma
if client is supine.
7. Check direction of intestine by inserting a gloved finger into orifice of stoma.
8. Place irrigation sleeve over stoma and hold in place with belt
9. Spray inside of irrigation sleeve and bathroom with odor eliminator (usual dose is two
sprays).
10. Cuff end of irrigation sleeve and place into toilet bowl (if client is in bathroom) or bedpan
(if client is in bed or chair).
11. Lubricate the cone end of the irrigation tubing and insert into orifice of stoma through the
top opening of irrigation sleeve
12. Close top of irrigation sleeve over the tubing.
13. Slowly run water through tubing into colon
14. Remove cone after all water has emptied out of irrigation bag.
15. Close end of irrigation sleeve by attaching it to the top of the sleeve.
16. Encourage client to ambulate to facilitate emptying of remaining stool from colon.
17. Remove irrigation sleeve after 20–30 minutes or when stool is no longer emptying from
colon.
18. Cleanse stoma and skin with warm tap water. Pat to dry.
19. Place gauze pad over stoma to absorb mucus from stoma.
20. Secure gauze with hypoallergenic tape.
21. Remove gloves and wash hands.
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Removal of hard and large fecal mass that cannot pass through the anus without tissue damage
by inserting one or two gloved fingers into the rectum.
Purpose
Equipment
Procedure
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5. Position client in the left lateral position (Sims‘) with upper leg bent over lower leg
6. Place disposable pads (if not available, use towels) underneath client. Position a bedpan near the
client.
7. Use odor eliminator per manufacturer (optional).
8. Apply gloves
9. Apply lubricant to a gloved finger.
10. Insert lubricated finger into rectum to check for fecal impaction.
11. Gently probe for stool by moving finger upward toward the umbilicus, moving finger back and
forth to dislodge stool
12. Once anus relaxes and opens, several fingers can be inserted into rectal canal to assist in removal
of stool. Be sure to lubricate additional fingers.
13. Manipulate the stool mass with the fingers, breaking it up into small pieces.
14. Move the stool pieces toward the anus and remove them. Place removed stool into appropriate
receptacle (i.e., bedpan or disposable bed pad).
15. Monitor the client for complications such as rectal bleeding or slowed heart rate.
16. With clean gloves, provide pericare
17. Dispose of stool in appropriate receptacle.
18. Assist client to use the bedpan or commode if he needs to defecate.
19. Remove gloves and wash hands
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CHAPTER FOURTEEN
PERI-OPERATIVE CARE
General objective: At the end of the chapter the learner will be able to
1. Perform preoperative patient assessment
2. Provide preoperative care
3. Apply principle of infection prevention in the intraoperative care
4. Position patient appropriately for the procedure
5. Assume responsibility of scrub nurse
6. Provide immediate post operative care
Definition: Perioperative care is a period of time that constitutes the surgical experience including
preoperative, intra-operative and post operative phases.
14.1. Pre-operative care
Objectives: At the end of the lesson, the learner will be able to:
Definition: preoperative care is a care given for a patient from the time the decision is made for
surgical intervention to the transfer of the patient to the operating room.
Purpose
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e. Information packets regarding g. Intravenous fluids, IV set ,syringe
surgery and needles, and equipment as
f. Informed consent forms needed
h. Preoperative medication
i. Transfer cart
Procedures
Objectives:-At the end of the lesson, the learner will be able to:
Definition: intra-operative care is a care given for a patient from when the patient is transferred to
operation room table to when the patient is admitted to the recovery room or post anesthesia care
unit.
Purpose
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Equipment
Procedures
1. Review chart for surgery to be performed and determine the exact area to be prepped.
2. Wash hands.
3. Assess client‘s level of consciousness and mobility
4. Explain the procedure to client.
5. Be sure that hairpins, jewelry, nail polish, con-tact lenses, prostheses, and dentures were re-moved
during the preoperative preparation.
6. Assist client with transfer from wheelchair or bed to the surgical table.
7. Position the client for optimal access to the surgical site according to institutional protocol
8. .Cover with blanket
9. Cover hair if required
10. Assemble equipment needed
11. \Remove ring(s) and watch. Wash hands and apply clean gloves.
12. The surgical prep sites follow, depending on the type of surgery to be performed.
Head and neck: The site extends from above the eyebrows, over the top of the head, and
includes the ears and both anterior and posterior areas of the neck. The face and eyebrows
are not shaved.
Lateral neck: Clean the external auditory canal with a cotton swab. Anteriorly, prepare the
side of the face, from above the ear to the upper thorax to just below the clavicle.
Posteriorly, prepare from the neck to the spine including the area above the scapula.
Chest surgery: The site extends from the neck to the bottom of the rib cage and to the
lateral midline. The shoulder and arm of the operative side should be included.
Abdominal surgery: The preparation site ex-tends from the axilla to the pubis extending
bilaterally to the lateral midline. All visible pubic hair should be shaved.
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Perineal surgery: Shave all pubic hair and the inner thighs to the midthigh. The area starts
above the pubic bone anteriorly and extends beyond the anus posteriorly.
Cervical spine surgery: Posteriorly from the top of the ears to the waist. The area extends
on each side to the midaxillary line.
Lumbar spine surgery :Posteriorly from the axilla down to the midgluteal level of the but-
tocks. The area extends on each side to the midaxillary line
Rectal surgery: Shave the buttocks from the iliac crest down to the upper third of the
thighs, including the anal region. The area ex-tends to the midline on each side.
Flank surgery: Extends anteriorly from the axilla, down to the upper thigh, including the
external genital area. Posteriorly the area ex-tends from the midscapular to the midgluteal
regions
Hand and forearm surgery: The area includes the full circumference of the affected arm,
from the axilla to the fingertips.
Lower extremity surgery: The area includes the entire leg, toes, and foot of the affected
leg from the umbilicus anteriorly and the top of the buttocks posteriorly.
Lower leg surgery: The area to be prepared includes the circumference of the entire region
from midthigh to the distal toes of the affected leg.
13. Arrange for adequate light on the area to be prepared.
14. Using warm water, hold the skin taut and hold the razor at a 45° angle. Shave the area care-fully by
stroking in the direction of hair growth. Rinse the razor carefully to remove ac cumulated hair from
the blade.
15. Dry the client‘s skin with a sterile towel.
16. Clear the shaving supplies from the preparation area.
17. Apply sterile gloves and gown.
18. Scrub the surgical site with an antibacterial cleaner. Using a rotary movement to clean the skin,
begin in the center and gradually enlarge the area with each rotation.
19. Continue this process for three to ten minutes as prescribed by institutional policy.
20. Clean any hidden areas in the surgical site (the ear canals, under the fingernails, the umbilicus)
using cotton swabs.
21. Rinse the area with sterile water. Wait for the site to dry or pat dry with a sterile towel.
22. .Cover the area with sterile drapes leaving the surgical site exposed
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13.3. Postoperative Care
Objective: At the end of the practical session, the students will be able to:
Definition: postoperative care is a care given for a patient which begins with the admission of the
patient to the post anesthesia care unit and ends after follow up evaluation in the clinical setting.
Purpose
Equipment
Procedures
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CHAPTER FITEEN
OXYGENATION
General objective: at the end of this chapter the learner will be able to:-
1. Utilize different oxygenation delivery system when necessary
2. Provide suctioning of airway
3. Give Nursing care to patient with tracheostomy
4. Provide CPR for Adult, children and infant
5. Monitor oxygenation level of client
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Purpose
Used primarily to reverse hypoxemia
To provide and maintain a normal supply of oxygen for blood, and tissues.
To provide adequate transport of oxygen in the blood while decreasing the work of breathing
and reducing stress on the myocardium.
Decrease work of the heart in clients with cardiac disease
To relieve dyspnea
Indication
Respiratory failure : • Cystic fibrosis
• Type 1 (hypoxemic): Saturation < • Chest injury
90%. PaO2 <60 mm Hg Blood disorders such as anemia
• Type 2 (hypercapnic): PCO2>50 Cardiac insufficiency
mmHg, pH<7.35 High metabolic demands
Lung diseases and injury Hypoxia
• COPD Hypoxemia
• Pneumonia Asphyxia
• Bronchial asthma Gas poisoning
Precautions
A “no smoking” sign must be posted in the client‘s room to prevent the risk of fire 3 meters
The catheter tip and the cylinder itself must not be lubricated with Vaseline, oil.
Never use alcohol on the patient‘s skin while the oxygen is run.
Never use an electrical facial shaver (razor) while the oxygen is in use.
The cylinder must be handling carefully as the oxygen is under pressure
The fine adjustment must always be closed when the main tap is turned on.
Check that if there is obstacle in the patient airway before giving oxygen in order to prevent
patient from suffocation.
The rate of flow will be ordered by the doctor.
Protect patient from asphyxiation by inspecting regularly the pressure gauge and flow
Monitor the vital signs, and mental status.
Transport oxygen cylinder always by the transport cart.
Never deliver more than 2-3 liters of oxygen to patients with chronic lung disease, e.g. COPD
Methods of oxygen administration
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1. Face mask
2. Nasal cannula
3. Nasal catheter
4. Oxygen tent/hood
15.2.1. Oxygen administration via face mask
Objectives: At the end of this lesson learner will be able to:
1. Define Oxygen administration via face mask
2. Describe the specific purposes of Oxygen administration via face mask
3. Collect necessary equipments
4. Demonstrate oxygen administration by using face mask
Definition
Oxygen administrations via face mask administering oxygen to the patient by means of face
mask according to requirement of patient ( Figur..).
Purpose
Used to administer higher concentration of oxygen.
Equipment
1. A cylinder of oxygen. 5. Humidifier with distil water
2. Face Mask of appropriate size 6. Gauzes
3. Regulator 7. No smoking sign
• Gauge 8. Equipments for V/S
• Flow meter 9. Receiver
4. Oxygen tube 10. Chart
Procedure
1. Determine need for oxygen therapy
2. Check order for rate, device to be used and concentration.
3. Greet the patient and explain the procedure (if conscious) to the relatives (if unconscious).
4. Wash hands.
5. Assemble equipment to the bedside
6. Perform an assessment of vital signs, level of consciousness, lab. Values etc and record.
7. Assess risk factors for oxygen administration in patient and environment like – hypoxia drive
in patient and faulty electrical connection.
8. Post ―No smoking‖ signs on patient‘s door ―oxygen in use‖ sign on the bed
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9. Place the patient on fowlers position unless contraindicated
10. Check for patency of air ways
11. Set up oxygen equipment and humidifier:
a. Attach regulator to source. Set flow meter in ―Off‖ position.
b. Open main tap while flow meter is closed then turn on fine adjustment to release small
amount of oxygen, to clean the inside of regulators
c. Read the gauges (or check the color in gauges) of the cylinder to determine the amount
of oxygen.
d. Fill humidifier with sterile water between the maximum and minimum mark on it.
e. Attach humidifier bottle to base of the flow meter.
f. Check the presence of bubbling in humidifier to confirm the flow of oxygen through.
g. Attach tubing and face mask to humidifier.
h. Adjust flow meter to prescribed level
12. Check the flow of oxygen through the tube and mask before applying to the patient (feel the
incoming air with your cheek).
13. Clean the mouth if there is visible soiled
14. Apply mask to patient face from nose to down ward
15. Secure elastic band around patient head.
16. Apply gauze behind ears as well as scalp where elastic band passes.
17. Ensure that safety precautions are followed.
18. Inspect patient and equipment frequently for flow rate, clinical condition, level of water in
humidifier etc.
19. Wash hands
20. Remove the mask and dry the skin every 2-3 hours if oxygen is administered continuously
21. Document relevant data in patient record
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Nonrebreather mask
Figure 40: Oxygen administration via face mask
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Purposes
To administer low concentration of oxygen to patients
To allow uninterrupted supply of oxygen during activities like eating, talking
Light weight, comfortable, continuous use with meals and activity
Equipments
1. A cylinder of oxygen. 5. Humidifier with distil water
2. Nasal cannula 6. Gauzes
3. Regulator 7. No smoking sign
Gauge 8. Equipments for V/S
Flow meter 9. Receiver
4. Oxygen tube 10. Chart
Procedure
1. Determine need for oxygen therapy
2. Check order for rate, device to be used and concentration.
3. Greet the patient and explain the procedure (if conscious) to the relatives (if unconscious).
4. Wash hands.
5. Assemble equipment to the bedside
6. Perform an assessment of vital signs, level of consciousness, lab. Values etc and record.
7. Assess risk factors for oxygen administration in patient and environment like – hypoxia drive
in patient and faulty electrical connection.
8. Post ―No smoking‖ signs on patient‘s door ―oxygen in use‖ sign on the bed
9. Place the patient on fowlers position unless contraindicated
10. Check for patency of air ways
11. Set up oxygen equipment and humidifier:
i. Attach regulator to source. Set flow meter in ―Off‖ position.
j. Open main tap while flow meter is closed then turn on fine adjustment to release small
amount of oxygen, to clean the inside of regulators
k. Read the gauges (or check the color in gauges) of the cylinder to determine the amount
of oxygen.
l. Fill humidifier with sterile water between the maximum and minimum mark on it.
m. Attach humidifier bottle to base of the flow meter.
n. Check the presence of bubbling in humidifier to confirm the flow of oxygen.
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o. Attach tubing to humidifier and then to the nasal cannula
p. Adjust flow meter to prescribed level
12. Check the flow of oxygen through the tube before applying to the patient (feel the incoming
air).
13. Place tips of cannula to patient‘s nares and adjust straps around ear for snug. The elastic band
may be fixed behind head or under chin. If nasal catheter it should be lubricated preferably
with water and passed backward into pharynx till the tip of the catheter is opposite the uvula.
14. Pad tubing with gauze pads over ear and inspect skin behind ear periodically for
irritation/break down.
15. Ensure that safety precautions are followed.
16. Inspect patient and equipment frequently for flow rate, clinical condition, level of water in
humidifier etc.
17. Wash hands
18. Remove the mask and dry the skin every 8 hours if oxygen is administered continuously
19. Document relevant data in patient record
NB: A patient receiving oxygen by catheter requires special mouth and nose care since the catheter
tends to irritate the mucous membrane.
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15.2.3. Giving oxygen by tent/hood
Objectives: At the end of this lesson, learner will be able to:
1. Define Oxygen administration via oxygen tent
2. Describe the specific purposes of Oxygen administration via oxygen tent
3. Collect necessary equipments
4. Demonstrate oxygen administration by using oxygen tent
Definition
Methods of administering oxygen via tent /hood
Purposes
To administer high concentration of oxygen to patients
To administer oxygen for infants
Equipments
1. A cylinder of oxygen. 5. Humidifier with distil water
2. Oxygen tent/hood 6. Gauzes
3. Regulator 7. No smoking sign
a. Gauge 8. Equipments for V/S
b. Flow meter 9. Receiver
4. Oxygen tube 10. Chart
Procedure
1. Determine need for oxygen therapy, check physicians order for rate, device to be used and
concentration.
2. Identify the patient
3. Explain the procedure to the relatives of the infant.
4. Wash hands.
5. Assemble equipment to the bedside
6. Perform an assessment of vital signs, level of consciousness, lab. Values etc and record.
7. Assess risk factors for oxygen administration in patient and environment like – hypoxia drive
in patient and faulty electrical connection.
8. Post ―No smoking‖ signals on patient‘s door in view of patient and visitors and explain to
them the danger of smoking when oxygen is on flow.
9. Place the patient on fowlers position unless contraindicated
10. Instruct him/her to clean his nostril to avoid obstruction (if well enough)
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11. Set up oxygen equipment and humidifier:
q. Attach regulator to source. Set flow meter in ―Off‖ position.
r. Open main tap while flow meter is closed then turn on fine adjustment to release small
amount of oxygen, to clean the inside of regulators
s. Read the gauges (or check the color in gauges) of the cylinder to determine the amount
of oxygen.
t. Fill humidifier with sterile water between the maximum and minimum mark on it.
u. Attach humidifier bottle to base of the flow meter.
v. Check the presence of bubbling in humidifier to confirm the flow of oxygen.
w. Attach tubing to humidifier and then to the oxygen tent
x. Adjust flow meter to prescribed level
12. Check the flow of oxygen through the tube before applying to the patient (feel the incoming
air).
13. Prepare tent and position over bed attach to oxygen source
14. Place client in tent observe all safety precautions
15. secure tent by folded towels
16. Change cloth and linens as necessary
17. Ensure that safety precautions are followed.
18. Inspect patient and equipment frequently for flow rate, clinical condition, level of water in
humidifier etc.
19. Wash hands
20. Oxygen catheter are removed every 8 hrs and a clean catheter is inserted into the other nostril.
21. Document relevant data in patient record
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15.3.Air way suctioning
15.3.1. Performing Nasopharyngeal and Oro pharyngeal Suctioning
Objectives: At the end of this practical session, the students will be able to:
1. Define nasopharyngeal and oropharyngeal suctioning
2. Describe the purposes of nasopharyngeal and oropharyngeal suctioning
3. List the indications and contraindications of suctioning
4. Collect necessary equipments
5. Demonstrate nasopharyngeal and oropharyngeal suctioning
Definition
The removal of secretion from the nasopharynx and oropharynx by using suction catheter and
suction machine
Purposes
To clear secretions the client cannot remove by coughing.
To relief dyspnea caused by secretion accumulation
To maintain patent air way
To collect sputum or secretions for diagnostic testing
To prevent aspiration
Indications
For nasopharyngeal suctioning
Post operative patient
Conscious patients who cannot maintain airway
Can be used with intact gag reflex
For oropharyngeal
o Unconscious patients
o Secretion in oral cavity
Precaution
Limit suctioning to 3 times per day for adult but if needed consult your physician
Never insert the catheter in to nares or mouth while the suction is on and the port is closed
Never suction more than 15 seconds for adult and 10 seconds for infant at a time to avoid
hypoxia.
Contraindication
For oropharyngeal suctioning
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o Mouth/buccal burn
o Conscious patient
For nasopharyngeal suctioning
o Head injuries
o Nosebleeds
Equipments
1. Suction machine: Wall suction/portable 5. Normal saline
suction with extension tubing connected 6. Sputum cup(if conscious)
to suction device 7. Sthetescope
2. Sterile glove 8. Pen light (if nasopharyngeal)
3. Sterile suction catheter 9. Gauze/soft tissue
o French of suction catheter 10. Waste receiver
For infant from 5-8 fr 11. Ambo bag
For child from 8-10 fr 12. Gown and mask and goggles or face
For Adult from 12-16 fr shield if indicated
4. Sterile solution container (or sterile 13. Sterile or clean towel/water proof/
kidney dish) 14. Mouth care set
Procedures
1. Determine the need for suctioning, check physicians order.
2. Identify the patient
3. Explain the procedure to the patient if conscious otherwise for his/her relatives. Advice that
suctioning may cause coughing or gagging but emphasize the importance of clearing the airway.
4. Wash hands.
5. Assemble equipment to the bedside
6. Assess the client‘s need for suctioning: inability to effectively clear the airway by coughing and
expectoration; coarse bubbling or gurgling noises with respiration.
7. Choose the most appropriate route (nasopharyngeal or oropharyngeal) for your client. If
nasopharyngeal approach is considered, inspect the nares with a penlight to determine patency.
Alternatively, you may assess patency by occluding each nare in turn with finger pressure while
asking the client to breathe through the remaining nare if conscious.
8. Position the client in a high Fowler‘s or semi- Fowler‘s position and apply clean water proof towel
over the chest of the patient.
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9. If the client is unconscious or otherwise unable to protect his or her airway, place in a side-lying
position.
10. Connect extension tubing to suction device if not already in place, and adjust suction control to: If
portable suction unit If wall unit suction machine
For infant from 2-5 mmHg -For infant from 50-95 mmHg
For child from 5-10 mmHg -For child from 95-110 mmHg
For Adult from 10-15 mmHg -For Adult from 100-120 mmHg
11. Open packed sterile instrument and prepare on a sterile field.
12. Pour about 100 ml of solution into the sterile container, unpack sterile suction catheter.
13. Oxygenate the patient with ambo bag 3-5 ventilation
14. Put on gown and mask and goggles or face shield if indicated.
15. Put on the gloves using sterile gloving technique
16. Using your sterile hand (Dominant hand), pick up the suction catheter. Grasp the plastic
connector end between your thumb and forefinger and coil the tip around your remaining fingers.
17. Pick up the extension tubing with your clean hand (Non-dominant). Connect the suction catheter
to the extension tubing, taking care not to contaminate the catheter.
18. Position your clean hand on the extension tube.
19. Dip the catheter tip into the sterile solution, and activate the suction with your non-dominant hand.
Observe as the solution is drawn into the catheter. It will also lubricate the catheter
20. For oropharyngeal suctioning, ask the client to open his or her mouth. Without activating the
suction, gently insert the catheter and advance it until you reach the pool of secretions or until the
client coughs or insert 4 inches (12 cm).
21. For nasopharyngeal suctioning, estimate the distance from the tip of the client‘s nose to the
earlobe and grasp the catheter between your thumb and forefinger at a point equal to this distance
from the catheter‘s tip.
22. Insert the catheter tip into the nare with the suction control port uncovered. Advance the catheter
gently with a slight downward slant. Slight rotation of the catheter may be used to ease insertion.
Advance the catheter to the point marked by your thumb and forefinger
23. If resistance is met, do not force the catheter. Withdraw it and attempt insertion via the opposite
nare.
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24. Apply suction intermittently by occluding then suction control port with your thumb; at the same
time, slowly rotate the catheter by rolling it between your thumb and fingers while slowly
withdrawing it. Apply suction for no longer than 15 seconds at a time.
25. Repeat step 23 until all secretions has been cleared, allowing 20-30 seconds brief rest periods
between suctioning episodes.
26. Give ambo bag between each single suctioning
27. Instruct the patient to have deep breathing and coughing exercise if conscious. Give sputum cup if
he/she needs to spit secretion then clean with soft tissue/gauze.
28. Withdraw the catheter by looping it around your fingers as you pull it out.
29. Dip the catheter tip into the sterile solution and apply suction after a brief rest.
30. Disconnect the catheter from the extension tubing, holding the coiled catheter in your gloved
hand.
31. Provide the client with oral hygiene if indicated or desired.
32. Return used supplies in the appropriate container.
33. Remove the glove by pulling it over the catheter; discard catheter and gloves in an appropriate
container.
34. Check the effectiveness of the procedure with Sthetescope
35. Wash your hands.
36. Document the procedure, noting the amount, color, and odor of secretions and the client‘s
response to the procedure.
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2. To improve oxygenation and reduce the work of breathing.
3. To remove accumulated trachea-bronchial secretions using sterile technique.
4. Stimulate the cough reflex.
5. Prevent pulmonary aspiration of blood and gastric fluids.
6. Prevent infection and atelectasis.
Equipment:
1. Sterile normal saline For infant from 5-8 fr
2. Suction machine: Wall suction/portable For child from 8-10 fr
suction with extension tubing connected to For Adult from 12-16 fr
suction device 8. Control port or In-line suction catheter
3. Ambu bag connected to 100% O2 9. Sterile solution container (or sterile kidney
4. Clear protective goggles/mask or face dish)
shield 10. Sthetescope
5. Sterile gloves for open suction 11. Gauze/soft tissue
6. Clean gloves for (in-line) closed suction 12. Waste receiver
7. Sterile catheter with intermittent suction 13. Sterile or clean towel/water proof/
o French/size/ of suction catheter 14. Normal saline
Procedures
1. Explain the procedure to the patient before beginning and offer reassurance during suctioning; the
patient may be apprehensive about choking and about an inability to communicate
2. Determine the need for suctioning, check physicians order.
3. Begin by carrying out hand hygiene.
4. Assess the client‘s need for suctioning: inability to effectively clear the airway by coughing and
expectoration; coarse bubbling or gurgling noises with respiration.
5. Assemble equipment to the bedside
6. Position the client in a high Fowler‘s or semi- Fowler‘s position and apply clean water proof towel
over the chest of the patient.
7. If the client is unconscious or otherwise unable to protect his or her airway, place in a side-lying
position.
8. Connect extension tubing to suction device if not already in place, and adjust suction control to:
If portable suction unit If wall unit suction machine
For infant from 2-5 mmHg -For infant from 50-95 mmHg
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For child from 5-10 mmHg -For child from 95-110 mmHg
For Adult from 10-15 mmHg -For Adult from 100-120 mmHg
9. Open packed sterile instrument and prepare on a sterile field.
10. Fill basin with sterile normal saline solution.
11. Ventilate the patient with manual resuscitation bag and high flow oxygen.
12. Put on sterile glove.
13. Pick up sterile suction catheter with gloved hand (Dominant hand) and connect to suction.
14. Hyper oxygenate the patient‘s lungs for several deep breaths.
15. Insert suction catheter at least as far as the end of the tube without applying suction, just far
enough to stimulate the cough reflex
16. Apply suction while withdrawing and gently rotating the catheter 360° (no longer than 10 to 15
seconds, because hypoxia and dysrhythmias may develop, leading to cardiac arrest).
17. Re oxygenates and inflates the patient‘s lungs for several breaths.
18. Repeat previous three steps until the airway is clear.
19. Rinse catheter in basin with sterile normal saline solution between suction attempts if necessary.
20. Suction oropharyngeal cavity after completing tracheal suctioning.
21. Rinse suction tubing.
22. Discard catheter, gloves, and basin appropriately.
23. Discard catheter, gloves, and basin appropriately.
15.4.Tracheostomy care
Objective: at the end of this practical session, the students will able to:
1. Define tracheostomy care
2. List the indications of tracheostomy care
3. Prepare equipment for tracheostomy care
4. Monitor the patient during and after the tracheostomy care
5. Demonstrate proper tracheostomy care
Definition:
Tracheostomy care is a care given to patient with tracheostomy.
Purpose
To prevent infection
To promote respiratory function.
To bypasses the upper airways
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To maintain a patent airway
Prevent pulmonary aspiration of blood and gastric fluids
To prevent pneumonia that may result from accumulated secretions
To allow removal of trachea-bronchial secretions
Indication
When adventitious breath sounds are detected
Whenever secretions are obviously present.
Equipment
1. Sterile Tracheal dilator 9. Sterile drapes/water proof pad
2. Sterile cotton-tip applicators 10. Sterile glove
3. Sterile Hydrogen peroxide solution 11. Clean glove
4. Sterile Normal saline (0.9% sodium 12. Suction kit and suction equipment
chloride solution ) 13. Tracheostomy ties
5. Sterile 0.9% sodium chloride solution 14. Ambo bag with 100% oxygen source
containers (2) 15. Mouth care set
a. 1 for suctioning 16. Personal protective devices: gown,
b. 1 for rinsing the inner cannula mask
6. Sterile nylon brush 17. Waste receiver/Plastic bag/
7. Sterile precut 4 × 4 dressing gauze 18. Chart
8. Sterile gauze for drying
Procedure
1. Determine the need for suctioning, check physicians order.
2. Identify the patient
3. Explain the procedure to the patient if conscious otherwise for his/her relatives.
4. Wash hands.
5. Assemble equipment to the bedside
6. Put on goggles and mask or face shield and gown and don sterile gloves
7. Position the client in a high Fowler‘s or semi- Fowler‘s position and apply clean water proof towel
over the chest of the patient; If the client is unconscious or otherwise unable to protect his or her
airway, place in a side-lying position.
8. Place plastic bag or disposal container within easy reach. Position in an area that does not require
crossing over the sterile field or stoma to discard soiled items.
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9. Prepare sterile equipments. Loosen the caps on the bottles of sterile saline and hydrogen peroxide
then pour in to each galipot (containers) to 0.5 inch
NB: pour hydrogen peroxide in to one galipot/container and normal saline in to the rest two
containers
10. Don clean glove then remove the soiled tracheostomy dressing. Note the amount, color, and odor
of any drainage around the stoma.
11. Gently loosen the inner cannula of the tracheostomy tube by twisting the outer ring
counterclockwise; then withdraw the inner cannula in a smooth motion. Place the inner cannula
into the basin of peroxide.
12. Remove the gloves by pulling them over the discarded dressing, and discard the gloves and
dressing.
13. Put on the gloves using sterile gloving technique
14. Place the sterile drape on the patient‘s chest, with its upper edge as near to the tracheostomy tube
as possible.
15. Using your sterile hand, pick up the cannula and pick up the nylon brush then scrub to remove
any visible crusts or secretions from inside and outside the cannula
16. Place the cannula into the container of sterile saline. Agitate so that all surfaces are bathed in
saline.
17. Inspect the inner cannula again to be sure it is clean; then remove excess saline from the lumen by
tapping the cannula against a sterile surface then place at dry sterile gauze.
18. Perform suctioning.
NB:
The pressure of tracheostomy suctioning is similar with nasopharyngeal suctioning
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Give 1 full minute rest between each single suctioning
Oxygenation with ambo bag must be given 3-5 times between each single suctioning
19. Using your sterile hand, pick up a sterile cotton swab and saturate the tip with hydrogen peroxide.
Swab the peristomal skin, including the area under the tracheostomy tube‘s faceplate. If you must
touch the tracheostomy tube or the client, do so with your clean hand
20. Gently replace the inner cannula, following the curve of the tube. When fully inserted, lock the
inner cannula in place by rotating the external ring clockwise until it clicks into place.
21. Place a new precut sterile gauze dressing around the stoma, between the faceplate and the skin.
22. Inspect the ties or strap securing the faceplate. If damp or soiled, carefully cut the ties (or loosen
the Velcro to remove a strap). Remove the ties or strap and inspect the underlying skin for redness
or breakdown. (Now no longer sterile procedure is needed)
23. To replace ties, cut a length of twill tape about as long as the circumference of the client‘s neck.
Fold over one end to 1 inch and cut a small (1/2 inch) slit into the folded end.
Thread the slit end of the tape through the eye of one side of the tracheostomy
faceplate from the underside of the faceplate. Thread the end of the tie through the cut
slit and secure it with a knot.
Slip the tape under the client‘s neck, keeping it smooth and flat against the skin.
Bring the loose end of the tape around to the other side of the faceplate. Ask the client
to flex his or her neck and slip one of your fingers under the tape as you measure the
desired tightness of the tie.
Fold the end of the tape and cut a slit as in step then tie the end. Trim off excess tape
from the end and knot the cut ends of the tape.
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Contraindication
All positions are contraindicated for:
Intracranial pressure (ICP) > 20 mm Hg Large pleural effusions
Head and neck injury until stabilized Pulmonary embolism
Active hemorrhage with hemodynamic Aged, confused, or anxious patients
instability who do not tolerate position changes
Recent spinal surgery Rib fracture, with or without flail chest
Acute spinal injury Surgical wound or healing tissue
Active hemoptysis Cyanosis, shortness of breath, difficulty
Empyema breathing, weakness, or very ill feeling
Bronchopleural fistula experienced.
Pulmonary edema associated with Unstable vital signs.
congestive heart failure
Trendelenburg position is contraindicated for:
Intracranial pressure (ICP) > 20 mm Hg
Uncontrolled hypertension
Distended abdomen
Esophageal surgery
Recent gross hemoptysis related to recent lung carcinoma
Uncontrolled airway at risk for aspiration (tube feeding or recent meal)
Reverse Trendelenburg is contraindicated in the presence of hypotension or vasoactive medication
Precaution
If sputum is foul-smelling, it is important to perform postural drainage in a room away from
other patients and/or family members.
Aware on the patient‘s diagnosis as well as the lung lobes or segments involved, cardiac status,
and any structural deformities of the chest wall and spine.
Auscultating the chest before and after the procedure helps to identify the areas needing
drainage and to assess the effectiveness of treatment.
Equipment
1. Pillow 4. Bed block
2. Sputum mug 5. Bronchodilator medications
3. Tissue paper 6. Stethoscope
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7. Specimen bottle and requisition 9. Hospital bed that can be
if required trenbelenburgs position
8. Mouth care set to clean and
freshen the mouth following the
treatment.
10.
Procedure
1. Great the patient and introduce your self
2. Explain the purpose of the procedure and the disease process to the patient.
3. Schedule the postural drainage treatments in to two or three times daily depending on the degree
of lung congestion especially best time before breakfast, before lunch, and late afternoon and
before bedtime.
4. Wash your hands
5. Clean trolley or tray and assemble the necessary equipments
6. Prepare nebulizer medication if necessary
7. Instruct the patient to inhale bronchodilators and mucolytic agents to improve bronchial tree
drainage
8. Assess the patients‘ tolerance for postural drainage by assessing vital sign, respiratory status and
fatigue.
9. Instructs the patient to remain in each position for 10 to 15 minutes and to breathe in slowly
through the nose and then breathe out slowly through pursed lips to help keep the airways open
so that secretions can drain while in each position.
Positions
A. Upper lobes
Apical segment
Client lies back at 300 angle.
Percussion/vibration area- b/n the clavicle and above the scapulae.
Posterior segment
Client sits upright in a chair or in bed with head bent slightly forward.
Percussion/vibration area – between the clavicle and the scapula.
Inferior segment
Position-Client lies on a flat bed with pillow under the knees to flex them.
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Percussion vibration area –upper chest below the clavicle down to the nipple line
except for women
B. Right middle lobe.
Right lateral and medial segments.
Client lies on left side and leans back slightly against pillows, extending at the back
from the should to the hip.
Elevate foot of bed about 150 or 400.
Percussion /vibration area
For male client: over the right side of the chest at the level of the nipple beween the
fourth and sixth ribs.
For female client beneath the breast, with the heel of the nurse‘s hand positioned
toward her axila, cupped fingers extending for ward beneath breast.
Lower division of left upper lobe ( lingual)
Position as above for right meddle lobe, but on the right side
Percussion/vibration area –as above right meddle lobe, but on the left side.
C. Lower lobes
Superior lung segment
Position lies on the abdomen on a flat bed, and place two pillows under the hips.
Percussion /vibration area -the middle area of the back (below the scapula) on both
sides of the spine.
Anterior basal segments
Lies on unaffected side with upper arm over the head and pillow between knees.
Elevated the foot of the bed about 3o0 or 450 or to height tolerate by the client.
Percussion /vibration area – over the lower ribs inferior to the axila on the affected side
of the chest.
Lateral basal lung segment
Lies partly on unaffected side and partly on the abdomen. Elevate the foot of bed
about 300 or 45 cm or height tolerated, or elevated client‘s hip with pillows.
Percussion /vibration area – the upper most side of the lower ribs.
Posterior basal lungs segment
Lies in prone position
Elevated foot of bed about 45 cm
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Elevated client‘s hip on two or three pillows.
Percussion /vibration area –over the lower ribs both sides closed to the spine.
20. The nurse should explain how to cough and remove secretions in each position. If the patient
cannot cough, the nurse may need to suction the secretions mechanically.
21. The nurse notes the amount, color, viscosity, and character of the expelled sputum.
22. Assess the patient‘s skin color and pulse in the first few times the procedure is performed.
23. Perform mouth care
24. Remove gloves from inside out, and discard them in plastic waste bag.
25. Provide patient comfort measures.
26. Clean and return equipment to proper place.
27. Wash your hands
28. Document the patient status and procedure
15.6. Deep breathing and coughing exercise
Definition
Cardio-Pulmonary Resuscitation is an emergency procedure consisting of external cardiac massage
and artificial respiration
Purpose
To squeeze blood manually out of the heart for victim‘s with cardiac arrest
To provide oxygenated blood to the brain and heart
To restore blood circulation
Indications
Respiratory Arrest: - Respiratory arrest refers to the absence of breathing.
Cardiac Arrest: When the heart stops, there is no pulse.
Precaution
The CPR Must begins within 4-6 minutes of collapse if not; the brain is sensitive to hypoxia
and will sustain irreversible damage after 4-6 minutes of no oxygen.
The cause of cardiac arrest is important BUT do not delay CPR to obtain history
Relative Contraindications
Ribs fractured
Burn of sternum( full thickness )
Equipments
No special equipments are needed at emergency situation- just hands and mouth & step by step
procedure.
At hospital level ( Ambu bag , firm board, stethoscope , spatula , air way )
Procedure
15.6.1. Adult CPR procedure
1. Check the Scene or Assessment of the Situation (Always Present if it is out of Health Centers)
Make sure it is safe for you to help.
Don't become another victim and assess the environment to know the cause of the problem
2. Check the Victim or Assessment of unresponsiveness
Tap or gently shake the victim and shout ―Are you ok‖.
To elicit a response a painful stimulus can be applied such as:
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Pinching the earlobe,
Pressing over the eyelid and observing for grimacing.
Other associations recommend rubbing on the sternum using the knuckles of the
fingers.
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Open the airway by the head tilt / chin lift maneuver for all victims and Remove foreign body.
We might also assess the breathing status of the victim
Health care personnel use:
o Head tilt- chin lift
o Jaw thrust in trauma patient
6. Breathing
Assessment of breathlessness and carotid pulse (5-10 seconds)
Place your ear just one inch above the mouth and the nose of the victim and perform the
following simultaneously: Use LLF methods
o LOOK: for the chest to rise and fall
o LISTEN: for air escaping during exhalation, and
o FEEL: for the flow of air on your cheek
NB: Count the number 1001,1002,1003,1004,1005,1006,1007,1008,1009,1010 to be sure you are
checking for 10 seconds because 1001 represents 1 second, and 1002 represents 2, and
continue others like this.
Figure 48: Listening (left) and giving rescue breathing (right) in CPR
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If breathing is not present, begin rescue breathing by giving two slow breaths: pinch nose and
cover the mouth with yours and blow until you see the chest rise. Give 2 breaths.
Time:
Each breath should take 1.5 sec to 2 sec and watch for chest rise and allow time for exhalation
(3-3.5 sec).
Volume:
o Sufficient volume
o No large volume or forceful breathing.
7. Circulation
If pulse is not definitely felt within 10 seconds, proceed with chest compression
Provides 30% (or less) of normal circulation
To locate the landmark for external chest compression
The technique of costal margin that is as follows:
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A. Run your index and middle fingers up the lower margin of the rib cage and locate the sternal
notch with your middle finger. The index finger is place next to the middle finger on the lower
and of the sternum.
B. The heel of the other hand (the one nearest the victim‘s head) is placed on the lower half of the
sternum, and the other hand is placed on the top of the hand on the sternum so that the hands
are parallel.
C. Your fingers may be either extended or interlaced but must be kept off the chest.
D. Lock your elbows into position, the arms are straightened and shoulders directly over the victim‘s
sternum. Keep the heel of your hand lightly in contact with the chest during the relaxation
phase of chest compression to maintain correct hand position.
Push hard- push fast: equal compression and relaxation allowing recoil of chest wall.
Chest compression – ventilation 30: 2, for 5 cycles (2 minutes rate of 100 per minute.
Depth of 1.5 to 2 inches for adults
Count compression in English in the sequence of:
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o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and 1,2,3,4,5,6,7,8,9,1= for 1st cycle
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and 1,2,3,4,5,6,7,8,9,2= for 2nd cycle
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and 1,2,3,4,5,6,7,8,9,3= for 3rd cycle
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and 1,2,3,4,5,6,7,8,9,4= for 4th cycle
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and 1,2,3,4,5,6,7,8,9,5= for 5th cycle
8. Reassessment
After 5 cycles of compressions and 6 cycle of ventilations (30:2), check for return of carotid
pulse/ and spontaneous breathing
According to the findings (after 2 minutes):
o There is pulse – place in the recovery position, monitor vital signs until EMS arrives.
o There is pulse but no breathing: continue rescue breathing every 5- 6 seconds (10-12
breaths). Recheck pulse every 2 minutes.
o No pulse or breathing continues CPR 30:2. Until provider arrives
Repeat A – B- C to 5 cycle of compression and 6 cycles of breathing. (150:12)
When to Stop CPR
1. if another trained person takes over CPR for you
2. if more advanced medical personnel take over
3. if you are exhausted and unable to continue
4. if the scene becomes unsafe
5. if the victim's heart starts beating
15.6.2. CPR for child below 8 years old
1. Check the Scene or Assessment of the Situation (Always Present if it is out of Health Centers)
Make sure it is safe for you to help.
Don't become another victim and assess the environment to know the cause of the problem
2. Check the Victim or Assessment of unresponsiveness
Tap or gently shake the victim and shout ―Are you ok‖.
To elicit a response a painful stimulus can be applied such as:
Pinching the earlobe,
Pressing over the eyelid and observing for grimacing.
Other associations recommend rubbing on the sternum using the knuckles of the
fingers.
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3. Call for Help or Activate EMS
Rescuer who is alone should alter sequence of rescue based on most likely cause.
Sudden witnessed collapse (likely VF) arrest activates EMS (Emergency medical service), do
CPR.
Hypoxic arrest (i.e., suffocation give 5 cycles of CPR (about 2 minutes) before alerting EMS.
If there is no response, Call ***** and return to the victim. In most locations the emergency
dispatcher can assist you with CPR instructions
4. Positioning the victim
Place the victim first on His/ Her back on hard surface. If the victim is lying face down, turn or
roll the victim as unit, supporting the head and neck
5. Airway
Open the airway: perform head-tilt, chin lift maneuver. If liquids turn the victim‘s head to side
and let it drain
6. Breathing
1. Assessment of breathlessness and pulse (carotid) together– (5-10 seconds)
2. Place your ear just one inch above the mouth and the nose of the victim and perform the following
simultaneously.
Look for the chest to rise and fall
Listen for air escaping during exhalation, and
Feel for the flow of air on your cheek
3. Assessment of pulselessness (5-10 seconds) check carotid
If breathing is not present, begin rescue breathing by giving two slow breaths: pinch nose and
cover the mouth with yours and blow until you see the chest rise. Give 2 breaths.
4. Time: each breath should take 1.5 sec and watch for chest rise and allow time for exhalation.
5. Volume – sufficient volume. No large volume or forceful breathing.
7. Circulation
If the pulse is absent begin external chest compressions
Land mark for compression is not to be used; that is as follows:
o Run your index and middle fingers along the lower rib cage until the middle finger
reaches the notch (xyphoid process). The index finger is placed next to the middle
finger.
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o The heel of the same hand is placed next hand is placed next to the point where the
index finger was located. (One hand can be used.)
Lock your elbows into position, the arms are straightened and shoulders directly over the
victim‘s sternum. Keep the heel of your hand lightly in contact with the chest during the
relaxation phase chest compression to maintain correct hand position.
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2. Check the Victim or Assessment of unresponsiveness
Tap the infant and shake to elicit a response, or palpate the sole of the feet
To elicit a response a painful stimulus can be applied such as:
o Pinching the earlobe,
o Pressing over the eyelid and observing for grimacing.
If unresponsive start CPR immediately. If second rescuer or someone is available, have him or
her activate the EMS system.
3. Call for Help or Activate EMS (if second rescuer is available otherwise call after 2 min.)
Sudden witnessed collapse (likely VF) arrest activates EMS (Emergency medical service), do
CPR.
Hypoxic arrest (i.e., suffocation give 5 cycles of CPR (about 2 minutes) before alerting EMS.
If there is no response, Call ***** and return to the victim. In most locations the emergency
dispatcher can assist you with CPR instructions
4. Position the victim in supine, firm and flat surface
5. Airway
Open the airway:
o Apply head tilt- chin lift to ‗sniffing‘ or neutral position.
o Jaw thrust maneuver in trauma patient
6. Breathing
Assessment of breathlessness and brachial pulse (5-10 seconds)
o Place your ear just one inch above the mouth and the nose of the infant and perform
the following.
Look for the chest to rise and fall
Listen for air escaping during exhalation
Feel for the flow of air on your check
Assessment of pulselessness: brachial pulse (5-10 seconds)
o Feel for the brachial pulse while maintaining head tilt with the other hand, Never
use carotid pulse for infants because you may interrupt circulation to brain if
present.
o The brachial pulse is located on the inside of the upper arm, between elbow and
shoulder.
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If the breathing is not present, make a tight seal over the mouth and the nose of the infant
and begin rescue breathing by giving two slow breaths.
Time: 1 second per breath and watch chest rises and allows time for exhalation.
Volume; enough to see the chest of the infant rise during ventilation (cheek)
7. Circulation
If pulse is absent give 5 cycles of external 30 chest compressions followed by 2 slow
breaths.
Figure 54: Giving chest compression infant in CPR
Land mark for external chest compressions
Nipple line technique
o The area of compression is just below the imaginary line, using the middle and ring
fingers. draw a line between your baby's nipples, and go 1 finger length lower than the
nipple line. hold your index finger up, and use your other 2 fingers to do chest
compressions.
Rate of compression: 100 per minute
Depth of compression: 1/3-1/2 the depth for the chest
Compression / ventilation ratio: 30:2
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Compression / relaxation cycle should be equal
8. Reassessment
Reassess the infant after every 5 cycles of 30 compressions and 6 cycles of 2 ventilations (2
minutes).
According to the findings:
o There is pulse and breathing, place the infant in the recovery position, monitors
vital signs until EMS arrives
o There is pulse but no breathing continues rescue breathing one breath every 3-5
seconds (12-20 per minute) and reassess.
o No pulse or breathing continues CPR 30:2. Ratio, assess for pulse and breathing
after 5 cycles (2minutes)
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CHAPTER SIXTEEN
THERAPEUTIC AND DIAGNOSTIC PROCEDURE
Objective: At the end of this chapter, the learner will be able to:-
1. Prepare patient for the procedure
2. Assemble necessary equipment
3. Monitor client after assistive procedure
4. Apply measures to reduce complication during and after assistive and diagnostic procedure
16.1. Assisting with thoracentesis
Objective: at the end of this lesson, learner will be able to:-
1. Define thoracentesis
2. prepare equipment for thoracentesis
3. prepare the patient for thoracentesis
4. monitor the patient during and after the procedure
Definition: thoracentesis is the procedure in which a puncture is made into the chest wall to withdraw
fluid or air from the pleural cavity for diagnostic or therapeutic purposes.
Indication
A. When unexplained fluid or air accumulates in the
chest cavity outside lung.
B. Pleural effusions
C. Compromised cardiovascular status due to air
fluid or blood outside the lung,
D. Pleural fluid analysis
E. Instillation of medication into the pleural space
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Purpose
Removal of fluid and air from the pleural cavity
Aspiration of pleural fluid for analysis
Pleural biopsy
Instillation of medication into the pleural space
Contraindication
1. Absolute contraindications.
Uncooperative patient
Coagulation disorders that cannot be corrected
2. Relative contraindications
the site of insertion has known bullous disease (e.g. emphysema)
use of positive end-expiratory pressure (PEEP, see mechanical ventilation)
Only one functioning lung (due to diminished reserve).
Precaution: The aspiration should not exceed 1L as there is a risk of development of
pulmonary edema.
Equipment
Sterile:
1. 2 Gallipots 8. Syringe and needle for local anaesthesia
2. 1 pair of dissecting forceps 9. Rubber tube which fit the opening of the
3. 1 pair of artery forceps two-way tap
4. Swabs and gauze in a receiver 10. 10 or 20 cc aspiration syringe and needle
5. towel with a hole((fenestrated towel) 11. two - way tap
6. hand towel 12. 2 glass tube for specimen
7. Gloves 13. Receiver to collect fluid specimen
Clean
1. Rubber sheet and towel 6. Cleaning lotion such as ether, tincture of
2. Receiver for used instrument iodine
3. Measuring jug 7. Plaster with scissor
4. Trolley 8. Sputum mug
5. Local anaesthesia 9. Lab request-form
Procedure:
1. Check clinical record for order and possible allergy
2. Alert physician if any abnormal lab result
3. Explain the procedure to the patient and inform them to try not to cough, not to breathe
deeply, and not to move suddenly during the procedure to avoid puncture of the visceral
pleura or lung
4. Verify informed written consent
5. Wash hands
6. Collect necessary equipment and bring to patient bedside
7. Take baseline vital sign including pulse oximetry
8. Screen the patient.
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9. Remove clothes to expose chest.
10. Position the patient as directed by the physician. The position may be either one of the
following or a similar position, as directed by the physician.
(a) Position the patient to sit on the side of the bed, facing away from the physician, with
feet supported on a chair and the head and arms resting on an over bed table padded
with pillows. The arms are elevated slightly to widen the intercostals spaces.
(b) If the patient is unable to sit, turn him on the unaffected side with the arm of the
affected side raised above his head. Elevate the head of the bed 300 to 450.
11. Place the thoracentesis tray on instrument table. Open sterile wrapper cover to provide a
sterile field.
12. Place other supplies on adjacent bedside stand or over bed table. Open glove wrapper.
13. Assist with handling of local anesthetic vial. Hold vial with label uppermost so that the
physician can personally check the label before withdrawing any of the solution. Cleanse
stopper with alcohol swab. Invert vial and hold firmly while the doctor, with gloved
hands, withdraws the required solution.
14. Support and help patient to avoid moving and coughing while the thoracentesis needle is
introduced.
15. Assist as directed with collection of specimens as the physician manipulates the syringe,
the stopcock, and drainage tubing. Use care not to contaminate the end of the tubing, the
cap, or the open end of the specimen tubes. Cap the tubes and place them upright in a
clean glass provided for this purpose. Label each tube as directed by the physician.
16. If drainage of a large amount of accumulated fluid is necessary, assist the doctor by
placing the free end of the tubing in the drainage bottle.
17. Watch the patient's color; check pulse and respiration. Immediately report any sudden
change, as this may indicate damage to the visceral pleura from a nick or puncture by the
needle.
18. After the needle is withdrawn, apply a sterile occlusive dressing over the puncture site.
19. Position patient comfortably (usually Fowler's position).
20. Complete entries on appropriate laboratory request forms as directed.
21. Send properly labeled specimens with completed request forms to laboratory immediately
if required
22. Measure and record amount of fluid withdrawn and discard this fluid unless directed
otherwise.
23. Return used equipment and wash hand
24. Proper documentation
Complications
Pneumothorax Infection
Hemorrhage into the pleural space or puncture of the spleen or liver,
chest wall, Re-expansion pulmonary edema due
Vasovagal syncope (fainting) to rapid removal of more than one
Air emboli liter of fluid
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16.2. Assisting with Water-seal chest drainage system
Objective: at the end of this lesson the learner will able to:-
Definition: Underwater-seal chest drainage is a closed (airtight) system for drainage of air and
fluid from the chest cavity.
Indication
Pneumothorax
Haemothorax
Empyema
Chest trauma
Flail ches
Purpose
To re-establish expansion of the pleural space
To remove the air or bloody fluid from pleural space and allow for expansion of the lung (or
to evacuate fluid & blood).
Uncontrolled bleeding
Pneumothorax: (AIR)
The best position is supine or with head elevated anywhere from low to high fowler‘s.
The chest tube will be inserted into the 2nd or 3rd intercostal space anterior chest at the
mid-clavicular line
Effusions: (FLUID)
If patient able, the best position is sitting on the side of the bed leaning over a pillow
placed on a bedside table.
The chest tube is inserted between the 7th to 8th intercostal space in the mid-axillary line
Precaution
To protect occlusion of tube use rolled towels.
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The patient should be encourage to cough and deep breath once hourly to prevent atelectasis
and assist in removing air and fluid.
Use aseptic technique when preparing equipment and changing the bottle.
Make sure that the system is air tight at any time
Keep a clamp with the pt for emergency.
Equipment
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Nursing intervention
1. If using a chest drainage system with a water seal, fill the water seal chamber with sterile
water to the level specified by the manufacturer.
2. When using suction in chest drainage systems with a water seal, fill the suction control
chamber with sterile water to the 20-cm level or as prescribed.
In systems without a water seal, set the regulator dial at the appropriate suction level.
3. Attach the drainage catheter exiting the thoracic cavity to the tubing coming from the
collection chamber. Tape securely with adhesive tape.
4. If suction is used, connect the suction control chamber tubing to the suction unit. If using a
wet suction system, turn on the suction unit and increase pressure until slow but steady
bubbling appears in the suction control chamber.
If using a chest drainage system with a dry suction control chamber, turn the regulator
dial to 20 cm H2O.
5. Mark the drainage from the collection chamber with tape on the outside of the drainage unit.
Mark hourly/daily increments (date and time) at the drainage level.
6. Ensure that the drainage tubing does not kink, loop, or interfere with the patient‘s
movements.
7. Encourage the patient to assume a comfortable position with good body alignment. With
the lateral position, make sure that the patient‘s body does not compress the tubing. The
patient should be turned and repositioned every 1.5 to 2 hours. Provide adequate analgesia.
8. Assist the patient with range-of-motion exercises for the affected arm and shoulder several
times daily. Provide adequate analgesia.
9. Gently ―milk‖ the tubing in the direction of the drainage chamber as needed.
10. Make sure there is fluctuation (―tidaling‖) of the fluid level in the water seal chamber (in
wet systems), or check the air leak indicator for leaks (in dry systems with a one-way valve).
Fluid fluctuations in the water seal chamber or air leak indicator area will stop when:
a. The lung has re-expanded
b. The tubing is obstructed by blood clots, fibrin, or kinks
c. A loop of tubing hangs below the rest of the tubing
d. Suction motor or wall suction is not working properly
11. Observe for air leaks in the drainage system; they are indicated by constant bubbling in the
water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Also,
assess the chest tube system for correctable external leaks. Notify the physician immediately
of excessive bubbling in the water seal chamber not due to external leaks.
12. When turning down the dry suction, depress the manual high negativity vent, and assess for
a rise in the water level of the water seal chamber.
13. Observe and immediately report rapid and shallow breathing, cyanosis, pressure in the
chest, subcutaneous emphysema, symptoms of hemorrhage, or significant changes in vital
signs.
14. Encourage the patient to breathe deeply and cough at frequent intervals. Provide adequate
analgesia. If needed, request an order for patient-controlled analgesia. Also teach the patient
how to perform incentive spirometry.
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15. If the patient is lying on a stretcher and must be transported to another area, place the
drainage system below the chest level. If the tubing disconnects, cut off the contaminated
tips of the chest tube and tubing, insert a sterile connector in the cut ends, and reattach to the
drainage system. Do not clamp the chest tube during transport.
16. When assisting in the chest tube‘s removal, instruct the patient to perform a gentle Valsalva
maneuver or to breathe quietly.
The chest tube is then clamped and quickly removed.
Simultaneously, a small bandage is applied and made airtight with petrolatum gauze
covered by a 4 × 4-inch gauze pad and thoroughly covered and sealed with nonporous
tape.
16.3. Assisting with Bronchoscopy
Objective: at the end of this lesson the learner will able to:-
1. Define Bronchoscopy
2. Explain the precuations of Bronchoscopy
3. Prepare equipment for Bronchoscopy
4. Prepare the patient for Bronchoscopy
5. Monitor the patient during and after the Bronchoscopy
Definition: Bronchoscopy is the direct inspection and examination of the larynx, trachea, and
bronchi through either a flexible fiberoptic bronchoscope or a rigid bronchoscope.
Purposes
A. Diagnostic:
To examine tissues or collect secretions
To determine the location and extent of the pathologic process and to obtain a tissue
sample for diagnosis (by biting or cutting forceps, curettage, or brush biopsy)
To determine if a tumor can be resected surgically, and
To diagnose bleeding sites (source of hemoptysis).
B. Therapeutic:
Remove foreign bodies from the tracheobronchial tree
Remove secretions obstructing the tracheobronchial tree when the patient cannot clear
them
Treat postoperative atelectasis, and
Destroy and excise lesions.
Indications
Abnormal chest x-ray: presence of a lesion, persistent atelectasis, infiltrates in the
lung fields.
Hemoptysis
Unexplained cough, localized wheeze, or stridor
Need to obtain lower respiratory tract secretions or tissue for diagnostic purposes
To assess and/or evaluate airways
To perform difficult intubations
To remove a foreign body
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Contraindications
Inability to adequately oxygenate the client during the bronchoscopy
Clients with severe obstructive lung disease
Unstable hemodynamic status
Lack of client consent
Recent myocardial infarction
Unstable angina
Hypoxemia or hypercarbia
Low platelet count
Precautions
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Procedure
Complications
Hypoxemia Penumothorax
Hypercarbia Hemoptysis
Hypotension Adverse effect of medication used
Laryngospasm before and during the bronchoscopy
Bradycardia
Definition: - Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a
small surgical incision or puncture made through the abdominal wall under sterile conditions.
Purpose:
1. For diagnostic purpose:- to obtain a specimen of fluid
2. For therapeutic purpose: - to relieve pressure on the organs of the abdomen and chest.
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Precaution
During and after the procedure watch patient carefully for signs of shock
If the puncture is done on the site, lay the patient on the unaffected site at the end of the
procedure
Make sure the abdomen binder is under the patient before the procedure
Equipment
Sterile set
1. Sterile trochar and cannula—small 6. Syringe and needle for local
pieces of tubing attached to the anaesthesia
cannula with clamp. 7. Dissecting forceps & artery forceps
2. Towel with hole/ fenestrated towel 8. Small scalpel if needed
3. Hand towel 9. 2 Test tubes
4. Gloves, swabs & gauze in a bowel 10. Cotton balls
5. 2 gallipots 11. Knife and small scalpel
Clean
1. Rubber sheet with cover 4. Pail or other receiver to collect fluid
2. Abdominal binder with safety pin 5. adhesive tape
3. Cleansing lotion and local anesthesia 6. Screen
Procedure
Definition: It is sterile procedure performed to aspirate a sample of liver tissue for laboratory diagnosis
Purpose
To evaluate diffuse disorders of the parenchyma
To diagnose space-occupying lesions.
Useful when clinical findings and laboratory tests are not diagnostic.
Site: between 6th and 7th ribs on right lower chest wall patient lay in supine position with right hand over
the head.
Equipment
Sterile
1. Gallipot 6. Syringes for needle for local anaesthesia
2. Fenestrated towel 7. Dressing forceps, scissors and scalpel if
3. Swabs and gauze in a receiver needed
4. Hand towel 8. Liver biopsy needle
5. Gloves 9. Test tubes
Clean
Rubber sheet and towel
A small bottle containing formalin
for the specimen
Local anesthesia
Cleaning solution
Plaster and scissors
A laboratory required paper
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Procedure
Bleeding
Bile peritonitis
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Leukemia
Anemia
Thrombocytopenia
Other malignancies such as non–Hodgkin‘s lymphoma or multiple myeloma.
Precaution:
The client may be at increased risk for bleeding, infection, or other problems
Equipments:
Sterile set
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Clean
1. Do general assessment
2. Explain the procedure.
3. Have the client void.
4. Administer medication for sedation or pain
5. Wash hands and assemble the necessary equipments
6. Help the client assume a supine position (with one pillow if desired) for biopsy of the
sternum (sternal puncture) or prone position for a biopsy of either iliac crest; fold the
bed clothes back to expose the area.
7. Open the bone marrow set and pass sterile gloves to the physician, pour the antiseptic
solution into a container in the set or over sterile gauze squares.
8. Open and hold the ampoule or vial of local anaesthetic if it is not in the set.
9. Wear disposable gloves.
10. Describe the steps of the procedure and provide verbal support, observe the client for
pallor, diaphoresis, and faintness.
11. Nurse may assist with applying pressure to the site and applying the ointment and
dressing to the site of the puncture after the needle is withdrawn.
12. Assess for discomfort and bleeding from the site.
13. Provide analgesia as needed and ordered.
14. Arrange for the specimen with the completed request and label to be transported to the
laboratory.
15. Assist client into a comfortable position.
16. Put on gloves and discard supplies appropriately.
17. Wash hands
18. Document the procedure.
19. Regularly assess for discomfort and bleeding for several days.
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If edges are crumbling or peeling, or if the cast has been bivalved or windowed,
use tape to petal the edges
Do not allow the cast to get wet. Teach the client how to cover the cast when
bathing or showering.
7. Assess safety. If client is to ambulate provide cast boot for traction
8. Instruct client and caregiver about symptoms to report to the physician or qualified
practitioner:
An increase in swelling.
A tingling or burning sensation.
An inability to move muscles around the cast.
A foul odor around the edges of the cast.
Any drainage, which may show through the cast.
Any cracks or breaks in the cast.
9. Support the cast.
Use pillows for arms and legs.
Use a bed board under the mattress for a spica cast.
10. Assess for infection.
Check for foul odor under cast.
Check for drainage on cast.
Mark drainage and date on cast.
11. Synthetic casts should be kept dry. If the physician or qualified practitioner does
permit bathing or swimming, the wet cast should be dried quickly and thoroughly.
Dry the cast with a towel and then a hair dryer set on low. Dry until the padding
underneath does not feel cold or damp to the skin.
12. Wash hands.
Bandage scissors
Surgical or plaster knife
Procedure
1.Introduce yourself to client and explain the planned procedure.
2.Wash hands.
3.Assess vascular status.
4.Prepare equipment and have it at bedside.
5.Assess client‘s ability to communicate during cast removal.
6.Prepare environment and client.
7.Wear protective clothing as needed.
8.Prepare client for how extremity will look after reduction.
Extremity will look thinner than non fractured site.
Mobility will be less than non fractured site.
9.Client may need to continue to use crutches or immobilizer until full mobility of
extremity is regained
10. The cast removal technician will cut the cast with the saw. Support the limb in the
proper position as requested.
11. The cast technician will split the cast with a cast splitter, and cut the padding
underneath
12. The cast technician will then pull the cast apart and remove it. Support the limb,
and reassure the client, as this step can be anxiety producing and sometimes
uncomfortable
13. Assess the skin underneath the cast. Gently clean the skin with warm water. Do
not rub or use friction on the skin.
14. May need to apply Ace wrap after cast removal.
15. Document the extremity where the cast was removed and how the extremity looks
16. Wash hands.
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Definition: Skin traction is immobilizing body part intermittently over an extended time
through direct application of a pulling force on the skin.
Purpose
To control muscle spasms
To immobilize an area before surgery.
To reduce fracture
To treat dislocation
To correct/prevent deformity
To improve or correct contractures
Equipment
Procedure:
Purpose
To control muscle spasms
To immobilize an area before surgery.
To reduce fracture
To treat dislocation
To correct/prevent deformity
To improve or correct contractures
Equipment
1. Pain medication
2. Sterile pins
3. Sterile pin insertion kit
4. Local anesthetic
5. A topical cleanser such as povidone-iodine for cleaning the insertion site
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Procedure:
Definition:- Lumbar puncture is the introduction of a needle into the subarachnoid space
of the spinal column.
Purpose:
To collect specimen of cerebrospinal fluid for diagnostic purpose
To measure and reduce CSF pressure
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Indications
Infection of CNS such as suspected meningitis, encephalitis
Brain or spinal cord tumors
subarachnoid hemorrhage, hydrocephalus, benign intracranial hypertension
to inject medications into the cerebrospinal fluid ("intrathecally"),
Contraindications
Present or suspected epidural infection,
Topical infections or dermatological conditions at the puncture site
Patients with severe psychosis or neurosis with back pain
Precaution
Patient anxiety during the procedure can lead to increased CSF pressure.
Equipment:
Sterile:
1. Gallipots
2. Sterile towel with hole
3. Hand towel
4. Sterile gloves
5. Dissecting forceps and artery forceps
6. Two lumbar puncture needle with different size (Barker's needle) (5 to 12.5 cm long)
7. A measure for fluid to be collected
8. A short length of rubber tubing to be attached to the needle.
9. Needle (5⁄8 to 11⁄2 inches, 21 to 25 gauge) and syringe for local anaesthesia (3 to 5
ml).
10. Four test tubes for specimen.
11. Ten gauze sponges (4 x 4) (dressing and tape)
Clean
1. Tray
2. Monometer with three-way stopcock
3. local anaesthetic (lidocaine)
4. Skin cleansing lotion (ether, povidone-iodine, saline, etc.)
5. Rubber sheet and towel.
6. Plaster and scissors,
7. Receiver for used instruments
8. Alcohol swabs
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9. Straight chair
10. Pillow for placing between client‘s knees
11. Masks and goggles (optional)
Procedure:-
1. Explain the procedure to the patient
2. Have the client void before the procedure.
3. Wash hands
4. Assemble the necessary equipments
5. Maintain privacy of the client
6. Position the patient: lying on the side with the knee flexed and the head bent forward
with the chin touching the chest or sitting up with knees and spine flexed.
7. Have client grasp knees with hands if it helps maintain the position.
Place pillow between knees.
Expose the spine.
8. Put the rubber sheet and towel under the patient.
9. Open the sterile set and pour antiseptic solution into the gallipots.
10. Wear glove.
11. Hold anaesthetic bottle for the doctor.
12. During the procedure, the nurse/assistant might be asked to press the internal jugular
veins in order to see the pressure of the fluid.
13. Observe the patient for signs of shock, nausea and vomiting.
14. The procedure is ended by withdrawing the needle while placing pressure on the
puncture site & applying sterile dressing.
15. After the procedure place the patient comfortably flat (can be raised if needed) and
watched for headache.
16. Label the specimen and send to the laboratory.
17. Return equipments to proper place.
18. Record time of procedure, amount, colour and consistency of the fluid withdrawn
19. Observe client after the procedure for neurologic changes:
Change in level of consciousness, pupil size, or reaction.
Vital signs, respiratory status.
Numbness, tingling, or pain in legs.
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CHAPTER SEVENTEEN
CARE OF THE TERMINALLY ILL AND POST MORTEM CARE
General objective: - At the end of this chapter leaner will be able to
1. give appropriate Nursing care for the terminally ill
2. meet need of terminally ill client
3. give care for dead body
17.1. Care of the terminally ill patient
Purpose
4. Take vital signs often, and observe for pallor, diaphoresis, and decreased LOC
5. Reposition the patient in bed at least every 2 hours because sensation, reflexes, and mobility diminish
first in the legs and gradually in the arms. Make sure the bed sheets cover him loosely to reduce
discomfort caused by pressure on arms and legs.
6. When the patient's vision and hearing start to fail, turn his head toward the light and speak to him from
near the head of the bed. Because hearing may be acute despite loss of consciousness, avoid whispering
or speaking inappropriately about the patient in his presence.
7. Change the bed linens and the patient's gown as needed. Provide skin care during gown changes, and
adjust the room temperature for patient comfort if necessary.
8. Observe for incontinence or anuria, the result of diminished neuromuscular control or decreased renal
function. If necessary, obtain an order to catheterize the patient, or place linen saver pads beneath the
patient's buttocks. Put on gloves and provide perineal care with soap, a washcloth, and towels to prevent
irritation.
9. With suction equipment, suction the patient's mouth and upper airway to remove secretions. Elevate the
head of the bed to decrease respiratory resistance. As the patient's condition deteriorates, he may breathe
mostly through his mouth.
10. Offer fluids frequently, and lubricate the patient's lips and mouth with petroleum jelly or lemon-glycerin
swabs to counteract dryness.
11. If the comatose patient's eyes are open, provide eye care to prevent corneal ulceration. Such ulceration
can cause blindness and prevent the use of these tissues for transplantation should the patient die.
12. Provide ordered pain medication as needed. Keep in mind that, as circulation diminishes, medications
given I.M. will be poorly absorbed. Medications should be given I.V., if possible, for optimum results.
Some medications can be given sublingually or rectally if the patient can't swallow or has no I.V. access.
Meeting emotional needs
13. Fully explain all care and treatments to the patient even if he's unconscious because he may still be able
to hear. Answer any questions as candidly as possible without sounding callous.
14. Allow the patient to express his feelings, which may range from anger to loneliness. Take time to talk
with the patient. Sit near the head of the bed, and avoid looking rushed or unconcerned.
15. Notify family members, if they're absent, when the patient wishes to see them. Let the patient and his
families discuss death at their own pace.
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16. Offer to contact a member of the clergy or social services department, if appropriate.
17. Record changes in the patient's vital signs, intake and output, and LOC. Note the times of cardiac arrest
and the end of respiration, and notify the physician when these occur.
Special considerations
If the patient has signed a living will, the physician will write a Do-not-resuscitate (DNR) • order on his
progress notes and order sheets. Know your state's policy regarding the living will. If it's legal, transfer
the DNR order to the patient's chart or Kardex and, at the end of your shift, inform the incoming staff of
this order.
If family members remain with the patient, show them the location of bathrooms, lounges, and
cafeterias. Explain the patient's needs, treatments, and care plan to them. If appropriate, offer to teach
them specific skills so they can take part in Nursing care. Emphasize that their efforts are important and
effective. As the patient's death approaches, give them emotional support.
At an appropriate time, ask the family whether they have considered organ and tissue donation. Check
the patient's records to determine whether he completed an organ donor card.
17.2.Postmortem care/Care after Death
Purpose
Equipment
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12. Fill out the three identification tags. Each tag should include the deceased patient's name, room
and bed numbers, date and time of death, and physician's name. Tie one tag to the deceased
patient's hand or foot, but don't remove his identification bracelet to ensure correct
identification.
13. Place the shroud or body wrap on the morgue stretcher and, after obtaining assistance, transfer
the body to the stretcher. Wrap the body, and tie the shroud or wrap with the string provided.
Then attach another identification tag to the front of the shroud or wrap, and cover the shroud or
wrap with a clean sheet. If a shroud or wrap isn't available, dress the deceased patient in a clean
gown and cover the body with a sheet.
14. Place the deceased patient's personal belongings, including valuables, in a bag and attach the
third identification tag to it.
15. If the patient died of an infectious disease, label the body according to your facility's policy.
16. Close the doors of adjoining rooms if possible. Then take the body to the morgue. Use corridors
that aren't crowded and, if possible, use a service elevator.
17. Although the extent of documentation varies among facilities, always record the disposition of
the patient's possessions, especially jewelry and money. Also note the date and time the patient
was transported to the morgue.
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1. Abebaw Eredie. 2008. Operating Room Technique Lecture note for Nursing Students
2. Abraham Alano. 2002. Lecture note on basic clinical Nursing skills: Hawassa University.
3. Altman, BG, Buchsel P & Coxon V. 2000. Dalmar's Fundamental and advanced Nursing skills.
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practice. 8th :Pearson international edition,
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Implementation Guidelines Volume 1 Ethiopian Hospital Management Initiative March
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international 8th Ed.
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Edition;Elsevier Mosby. Australia.
15. Perry AG & Potter PA. 2006. Fundamental of Nursing. 6th Edition: Elsevier Mosby .
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Edition: Lippincot willams &wilkins.
18. Suzanne C. O‘Connell Smeltzer, & Brenda G. Bare. (2004). Brunner and Suddarth‘s Text
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