Basicnursig Hidar2003

Basic nursing care
GENERAL OBJECTIVE
At the end of this course, the trainee is expected to bring relatively permanent change on behavior in / her knowledge, skill and attitude.
Ruman Abdurashid- Menilik H.S.College
Page 1
Basic nursing care
SPECIFIC OBJECTIVES Develop quality/ good nursing care. Be creative enough to improvise the necessary equipment. Economize time, effort and material. Prepare equipment for different procedures. Acquire a deeper knowledge and skill in the use of aseptic technique.
6. 7. 8. 9.
1. 2. 3. 4. 5.
Show skill in nursing procedures. Assist the physician in examining the patient. Help the physician in examining the patient. Solve problems within her/his capacity/ limit. care in proper environment which gives due respect to the values, customs and spiritual belief to the patient.
10. Provide
11. Take
care of equipments after use.
Page 2
Basic nursing care
General instruction for all nursing procedures

1. Wash your hands before and after any procedure. 2. Explain procedure to patient before you start.
3. Close doors and windows before you start some procedures
like bed bath .. 4. Do not expose the patient unnecessarily. 5. Whenever possible give privacy to all patients according to the procedure. 6. Assemble necessary equipment before starting the procedure. 7. After completion of a procedure, observe the patient reaction to the procedure, take care of all used equipment, and return to their proper place. 8. Record the procedure.
Page 3
Basic nursing care
UNIT ONE Learning objective

At the completion of this unit the learner will be able to: Define nursing Define patient & patient unit Take care of patient unit & equipment in health care facilities Define ventilation
Identify the difference between sterilization & disinfection
INTRODUCTION TO BASIC NURSING ART

NURSE: - Are individuals committed to identifying and meeting the health care needs of other individual, families, communities and groups NURSING Definition: - the act of utilizing the environment of the patient to assist him in recovery (Nightingale 1860). Nightingale considered a clean, well-ventilated, -the unique function of the nurse is to assist individual, sick or well, in the performance of those activities contributing to health or its recovery (or to 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 gain independence as rapidly as possible (Virginia Henderson 1966). Like Nightingale, Henderson described nursing in relation to the clients environment .Unlike Nightingale, Henderson saw the nurse as concerned with both well and ill individuals. and quite environment essential for recovery. Often considered the first theorist.
- direct, goal oriented, and adaptable to the needs of the individual, the family, and community during health and illness (ANA1973).
Ruman Abdurashid- Menilik H.S.College Page 4
Basic nursing care
-Is an art with scientific base. It is dominated by ideas of services in which certain principles are applied with the skilful handling in care of sick persons.
An art and science that deals with prevention of disease, care of the
sick and treatment of the patient. It also deals with teaching and rehabilitation of the patient. (Clinical nursing manual Ethiopia) ART Fine skill, needs professional quality, creation, interaction, communication, needs to see a person holistic. An art involves the conscious application of learned skill and creative imagination. SCIENCE nursing is based on scientific principles. Nursing is a science that deals with human needs and problems. CARE To give protection, to be responsible for, to look after, to provide food etc. CURE To bring back to health, provide and use successfully a remedy for disease, ill health, and suffering. IN GENERAL:
Nursing is caring. Nursing is an art. Nursing is a science. Nursing is client centered. Nursing is holistic. Nursing is adaptive. Nursing is concerned with health promotion, health Nursing is a helping profession.
Page 5
maintenance, and health restoration.
Basic nursing care
A nurse should be:
N Neat, Noble Near U Unique, Understanding, Unselfish, Uniform R Reasonable, Reliable, Respectful, & Reactive S smile, sincere, sympathy, sociable E- Educate, Energetic, Eager.
PROFESSIONAL NURSING:Is the practice of the art in a professional manner. Some essential qualities of a nurse are: Honesty Loyalty Discipline and obedience Courtesy Dignity Personal appearance Tact, sympathy, sense of humour and patience Optimistic out look Observation and adaptability Gentleness and quietness Economy Sense of responsibility Adaptability
Page 6
Basic nursing care
1. TAKING CARE OF THE PATIENT ENVIRONMENT AND EQUIPMENTS Caring for the patient care unit.
1.1.1.
Define patient, patient unit and cleaning.
Patient: A Latin word meaning to suffer or to bear. -Is a Person who is waiting for or undergoing medical treatment and care.
Patient Care Unit: Is the space where the patient is accommodated in hospital and consists of the bed, an over bed table, a bed side table, and possibly a chair. There may also be closet space or drawer. TYPES OF PATIENT CARE UNIT There are three types of patient care unit:
1. Private room is a room in which only one patient be admitted. 2. Semi private- is a patient unit which can accommodate two
patients.
3. Ward- is a room, which can receive three or more patients.
Hospital bed: Standard bed has 60-66 cm height, 0.9 m width & 1.9 m length. Height & length of beds might be adjustable either electrically or mechanically. High position bed help in giving nursing care without stretch & fatigue. Low position help patient to sleep on or get in & out of the bed.
Page 7
Basic nursing care
Cleaning patient bath room, toilet utility-room, floor & walls
Cleaning patient unit
Page 8
Basic nursing care
Cleaning Is the activity of making things clean, usually in a domestic, hospital or commercial environment. Cleaning removes all visible blood, body fluids & dirty. There is a definite difference between hospital cleanliness, with its relation to germs & spreading of infection, & that of domestic cleanliness. A hospital is a place where there is much infection (disease), & many germs. To avoid the spread of this infection, we must follow proper cleaning technique. Nursing staffs are not responsible for actual cleaning of dust & other dirty materials from hospital. However, it is the staff nurses duty to supervise the cleaner who perform this job. METHODS OF CLEANING. Moving dirty from one place to another with a duster or broom is insufficient. The germ laden dust be entirely removed & completely disposed off, either by burning or washing away. DANGER OF DUST & DIRT The germs harbored in hospitals are of a very virulent type. The resistance of the hospital patient is usually greatly lowered .Therefore, the removal of this dust is essential because: 1. It endangers health by a. Spreading disease, b. Irritating the mucous membrane lining of the eyes, throat,& lungs, c. Causing infection through food & water,
d. Infecting wounds. 2. It has a depressing effect on the mind & spirit of the patients.
General rules /principles for cleaning

Dry dusting of the room is not advisable. Ruman Abdurashid- Menilik H.S.College Page 9
Basic nursing care
Equipments -Basin of water -Closes for cleansing -Scouring powder (vim) or soap, disinfectant solution - Dirty container Procedures A. collect all refuse and dispose B. removes flowers, magazines and other article from the bedside table and cleans the table C. collects waste and put in to wastebasket D. clean mirrors E. wash sink in the room F. wash the windows with soap and water and rinsed and dry with a clean dry cloth G. mope the bed with disinfectants solution and make up bed H. ventilates the room and expose to sunlight I. Clean water pitcher and refill fresh water J. inform the cleaner to sweep and mop the floor K. wash sputum mug L. leave room tidy and in order
1
Terminal cleaning: - Cleaning after the patient is discharged or moved to another unit
PURPOSE 1 To prepare & clean the room for newly admitted patient 2 To prevent cross-contamination for newly coming patient
Page 10
Basic nursing care
EQUIPMENT Basin of water Closes for cleansing

Scouring powder (vim) or soap,
Disinfectant solution Floor mop Broom Dirty container PROCEDURE

-
Bed should be stripped (take used linen)
- Remove used equipment from the room& take to the utility room - Collect waste and put in a waste basket. - Wash rubber sheet and hangover bed or rod to dry. - Wash the bed. - Put matters out side in the sun if possible. - Wash bed side table inside and outside including drawers - Clean all other equipment in the unit such us over bed table, chairs etc. - Inform cleaner to mop the floor and clean toilet - Make closed bed and ventilate the room.
-
Leave the room tidy and in order for the next patient.
Ensuring Ventilation & lighting of the patient room

Definition of ventilation & lighting Ventilation: - the means of supplying fresh air to an in closed space Lighting: - There should be adequate light.
Page 11
Basic nursing care
TYPES OF LIGHT There are three types of light - Central over head light - Over bed light - Bed side light Ventilation is the process of changing or replacing air in any space to control temperature or removes moisture, odor, smoke, heat, dust & air born bacteria. Ventilation includes both the exchange of air to the outside as well as circulation of air with in the building. It is one of the important factors for maintaining acceptable in door air quality in buildings. Ventilation helps to remove bad odors in patients room. Ventilation in short way it is replacement of stale (stagnant or low in oxygen) or noxious (harmful) air with fresh air.
Techniques of room ventilation & lighting

They are two, mechanical or forced & natural type Mechanical or forced ventilation Is used to control indoor air quality excess humidity, odors, & contaminates can often be controlled via dilution or replacement with the outside air with the use of fan or other mechanical system. However, in humid climates much energy is required to remove excess moisture from air. Natural ventilation Is the ventilation of building with the outside air with out the use of fan or other mechanical system. It can be achieved with operable windows.
Page 12
Basic nursing care
Carrying for nursing equipments

TYPES OF NURSING EQUIPMENTS 1. Rubber goods 1.1 Rubber bags such as hot water bottle ice bags should be drained and dried they should be inflated with air & closed to prevent the sides from sticking together 1.2 Rubber tubing
Rubber
tubes should be flushed with 0.5% chlorine solution.
The inside of the tube should flushed and rinsed well

They
should be taken not to be bend or kink tubes
They should be hanged over a rod to dry Clamps should not be left on the tubing Adhesive marks are removed by rubbing with ether or benzene After cleaning properly, tubing should be put away by rolling loosely
Rubber
tubing are sterilized for 15 minutes on autoclaving
1.3 Rubber gloves Hand, coupled with the use of protective gloves, is a key component in minimizing the spread of disease and maintaining an infection free environment.
Basic nursing care
Types of gloves available in Ethiopia

Sterile or high - level disinfected surgical glove Clean examination glove Utility gloves Wear gloves: When there is a reasonable chance of hands coming in contact with blood or other body fluids, mucus membrane or none intact skin.
Before performing invasive medical procedures.
Before handling contaminated surfaces.
General principles for gloves use

Wear appropriate gloves. A separate pair of gloves must be used for each client to avoid cross contamination. Wearing gloves does not replace the need for hand washing.

Keep finger nails trimmed and moderately short. Do not use oil based hand lotions or creams; rather use water soluble hand lotion.
What type of gloves to use

Basic nursing care
Disposable clean examination gloves are preferred (High-level disinfected reusable gloves are acceptable) when there is contact with mucous membrane & non intact skin (e.g., performing medical examinations & procedures such as pelvic examination).
Sterile surgical gloves should be used when performing surgical procedures.
High-level disinfected surgical gloves are the only acceptable alternative if sterile surgical gloves are not available, when performing surgical procedures.
Clean, heavy duty household (utility) gloves should be used for cleaning instruments, equipment, contaminated surfaces, & while handling or disposing of contaminated waste. Double gloving using either new examination gloves or reprocessed surgical gloves provide some protection in case utility gloves are not available.
When to double glove
The procedure involves coming in contact with large amounts of blood or other body fluids.
Orthopedic procedures in which sharp bone fragments, wire sutures & other sharps are likely to be encountered. Surgical gloves are reused. Surgical procedures lasting more than 30 minutes.
Removing and discarding or reprocessing gloves

Basic nursing care

If
gloves are to be discarded, briefly immerse them in 0.5% chlorine
solution, remove & dispose in a container for contaminated waste. If gloves are to be processed and reused, remove gloves by inverting them and sock the gloves in 0.5% chlorine solution for ten minutes before cleaning and processing them.
1.4 Rubber sheet
Rubber sheets are cleansed by placing them on a flat surface scrubbing chlorine, soap and water
They should be rinsed well and hanged on rods to dry Plastic articles are cared in the same way as rubber articles When not in use it should be powdered, rolled & stored.
2 Metal Goods
2.1 Pickup forceps Wash pickup forceps and jars sterile daily.
Place forceps in a jar & cover them.
Care should be taken not to contaminate tip of forceps.

Always hold pickup down ward. If tip of forceps is contaminated accidentally it should be sterilized before placing it back in the jar.
Page 16
Basic nursing care
2.2 Care of the sterile container
Care should be taken not to contaminate the inside of the lid.
While opening the sterile container the lid should be placed with inner side up and covered immediately after use.
When removing instruments from sterile containers, sterile pickup forceps should be used. Dont touch the inside of the container or lid with hand or unsterile gloves. Keep the container covered all the time. Forceps, Scissor

All instruments should be unclamped before washing. Special attention should be paid to hinges and grooves of instruments. If instruments are to be put away for long time, they should be divided and oiled at the hinges.
Instruments are sterilized by boiling, dry heat or by immersing into disinfectant.
Place all instrument in 0.5% chlorine solution for 10 minutes immediately after completing the procedure. Remove instruments after 10 minutes, wash with soapy water & then rinse them with cool water to remove residual chlorine.
Page 17
Basic nursing care
REMEMBER: Leaving instruments in plain water for more than one hour can lead to rusting. 2.3 Care of bed pans and urinals Empty immediately and rinse with cold water. Disinfect with disinfectant solution and wash with brush.
Rinse with water and put them back in their proper place.
3 Glass ware
Rinse in cold water and soapy water using brush when necessary. Dry medicines glasses thoroughly so that tablets will not stick to them. Take precautions when handling glass ware and sterilized by boiling or dry heat.
Page 18
Basic nursing care
4 Plastic Goods
4.1 Care of syringe and needles A safe injection is an injection practice that does not harm the recipient, does not expose the provider to any avoidable risk, and result in any waste that is dangerous for other people. Precaution
Use a single syringe & needle for a single use.
Avoid recapping and other hand manipulation of needles. If recapping is necessary, use a single handed scoop technique. All used syringe and needles or any other sharps should be discarded in an enclosed sharp container that is puncture and leak proof and that is sealed before completely full [fill three quarter full level]
4.2 Utility Room Utility room defined as a work room
It is a place where important equipment is cleaned and stored such as bed ban, urinal, basins, sputum mug etc.
4.3 Toilet room
Is a room where feces, urine and vomit disposed.
4.4 Bath Room Is a room where body washing are done.
Page 19
Basic nursing care
N.B The toilet room and bath room should be kept clean and tidy and their floors dry to prevent the risk of cross infection and accidents such as falls. Any problem in the room should be reported. 4.5 Care for the walls Hospitals or any health institutions walls, floors be clean and dry from blood, body fluid and discharges, medicines etc. If accidentally happened has to be cleaned immediately. 4.6 Hand Washing
What is the most important Infection Prevention Practice?
Hand washing is the single most important infection control method. The purpose of hand washing is to mechanically remove oil and debris from the skin and reduce the number of transient microorganisms.

Nothing is more effective in preventing infection than hand washing Hand washing is practiced at the beginning and end of work
Page 20
Basic nursing care

Before and after contact of the patient Between contact with different patient Before and after any procedures After contact with any patient secretion or excretion (secretion e.g. Sweat. Excretion e.g. urine)
If hand washing done properly, removes bacteria by two means of action:1)
CHEMICAL ACTION
Use soap 2) MECHANICAL ACTION Soap & brush How to Wash Hands? Steps: Use a plain or antiseptic soap. Vigorously rub lathered hands together for 10-15 seconds.
Rinse
with clean running water from a tap or bucket.
Dry hands with a clean towel or air dry them.
Nurses role about the procedure Never handle the faucet with contaminated hand
Basic nursing care

Keeps
hand down ward during washing
Use liquid soap if possible

Rub
between fingers starting from the tips & rub back each hand with
circular motion (vigorously rub all areas of hands and fingers for 10-15 seconds). Clean under finger nails use brush if necessary Rinse all soap leather because soap residue cause irritation & chapped skin Repeat hand washing Use personal clean towel, paper towel or air dry (towels should not be shared and personal towel should be washed every day) Use paper towel or towel to close the faucet to prevent recontamination of hands 4.7 Care of the equipment in the utility room
Bedpan must be first rinsed in cold water.
Wash bedpans urinals, basins and kidney basin with vim or disinfectant solution. Dry and keep in proper place

Enema can should be cleansed and boiled after use Clean sink, table and shelves in the utility room. Report dripping faucet to the person in charge.
Keep the utility room clean and in order.

Basic nursing care
4.8 Care of linen and removal of stains Clean linen should be folded properly and kept neatly in the linen cupboard. Dirty linen should be put in a dirty linen bag and never be placed on the floor.

Torn linen should be mended or sent to swing room. Linen with blood should be soaked in cold water to which small Linen stained with urine and feces is immersed in cold water and are
amount of hydrogen peroxide be added if available.
washed with soap.
Tea and coffee stains - wash in cold water and then pour boiling
water on the stain.

To remove vitamin B complex stain dissolves water or sprit. Mucus stain can be removed from linen by soaking it in salted water. To remove rust, soak in salt and lemon juice and then bleach in sun.
4.9 Care of instruments and appliances Source can be metals, glass, rubber, plastic, enamel, linen and stainless steel. It can be made single source or two, electrical or manual and disposable and none disposable. It is known that all kinds of equipment and goods used in a health institution are directly or indirectly in contact with sick people. General instruction for care of hospital equipment
Page 23
Basic nursing care
- Use articles for the purpose for which they are intended. - Keep articles clean and in good condition. Use method - Protect mattresses with rubber sheets - Use protective pillowcases on pillows - Do not boil articles especially rubber articles and instruments longer than the correct time
- Do
the proper cleaning
not sterilize rubber goods and glass articles together. Wrap glass in
gauze when sterilizing it by boiling

-
Protect table tops when using hot utensils or any solution that may leave stain or destroy the table top.
- Report promptly any damaged or missing equipment.
Care of equipment and goods in general

Careful handling can prevent breakage because hidden cracks or broken wires may cause injury.
None disposable equipment and supply need to be washed rinsed and sent to central supply department to sterilize.
Lose and damage should be reported on time for replacement. Any difficulty in handling or operating equipment should be reported. The nurse should ask for instruction or assistance before handling un familiar equipment.
Basic nursing care
Meaning of sterilization & disinfection

Sepsis Asepsis means the presence of microorganisms. means absolute freedom of from all microorganisms.
Categories of aseptic practices - medical asepsis- clean technique - surgical asepsis- sterile technique Contamination: unclean condition when microorganisms are actually or potentially present. Infection: is the invasion of the body by germs or microorganism or organ or tissues dysfunction caused by microorganism Disinfection: chemicals used to kill microorganisms on lifeless objects. Disinfectants minimize the growth of microorganisms but not the spores. (E.g.
alcohol, chlorine, formaldehyde)
Sterilization: Destruction of all bacteria, spores, fungi, & viruses on an item; accomplished by heat, chemicals or gas.
Some of the sterilization methods are discussed below.
Page 25
Basic nursing care
-Steam sterilization: high pressure steam (autoclaving) - super saturated steam under pressure is the most widely used and a dependable method of sterilization. - Sterilize at 1210c for30 min for wrapped items, 20min for unwrapped items. -Free steam: 100co (212F) is used to sterilize objects that would be destroyed at higher temperature and pressure of the autoclave usually it is necessary to steam the article for 30 minute on 3 consecutive days. The intervals are required so that spores that are not killed will return to their vegetative state and again become vulnerable to the heat. -Gas sterilization: ethylene oxide is used to sterilize medical products that can not be steam sterilized e.g. plastic, rubber, cotton etc. -Dry heat/hot air: use dry heat only for items that can withstand a temperature of 170 0c. Dry heat in the form of hot air is used primarily to sterilize anhydrous oils, petroleum products and talcum powder that steam and ethylene oxide gas cannot penetrate. In the absence of moisture, higher temperatures are required than when moisture is present because microorganisms are destroyed through a very slow process of heat absorption by conduction.
Page 26
Basic nursing care
-When available, dry heat is a practical way to sterilize needles and other sharp instruments. -Recommended time for dry heat: 170 160 150 140 121
0
c 60min c 120min c 150min c 180min c overnight.
-Boiling water: this is the most practical and inexpensive method for sterilizing in the home. The main disadvantage is that spores &some virus are not killed by this method. The water temperature rises no higher than 1000c (212F). Boiling a minimum of 15 minutes is advised for disinfection of articles in the home.
N.B Store sterile packs and containers with sterile items should be stored 2025cm off the floor, 45-50cm from the ceiling and 15-20cm from an outside wall. - Date and rotate the supplies (first in first\ first out). This process serves as a reminder, but does not guarantee sterility of the packs.
Instrument Processing Steps

Basic nursing care
Inst e P rum nt ro
Step 1: Step 2:
Dec
Instrum en
Decon in tam ation
Step 3:
Should be done im ed m Makes objects safer to
HLD
Page 28
Basic nursing care
Preparing Chlorine Solu
% Chlorine in bleach Instrum Pr ent % Chlorine desired
Sterilization
Page 29
Destroys all m icroorgan Includes autoclave, dry
Basic nursing care
DECONT Soa Chlorine solu
How microorganism (MO) spread? MO move through space on air current
THOR WASH Wear glove a barriers(glasse
MO are transferred from one surface to another whenever objects touch MO are transferred by gravity when one items is held above another MO are released into the air on droplet nuclei Why is Infection Prevention Important? Protects patients/clientshelps provide quality care that is also safe
Preferred method
STERILIZATION
Chemical Autoclave Dry He Lowers healthcare costsprevention is less expensive than treatment Soak 106 k Pa pressure 1700C Prevents infection among healthcare staff and community 10-24 hours spread of(15 lbs./in2) that can become 60 min Limits number and infectious agents 1210C (2500F) antibiotic-resistant 20 min. unwrapped Ruman Abdurashid- Menilik H.S.College Page 30 30 min. wrapped
Basic nursing care
Principles of infection control Consider every person potentially infectious & susceptible to infection Washing hands before & after any procedure Keep your hand away from your own hair and face keep linen away from your uniform
Always keep clean items separate from the dirty ones Place clean items on upper shelves and potentially dirty items on the
avoid passing dirty items over clean items
lower shelves Routinely cleaning & disinfecting equipment & furniture in the patient care unit Disposing contaminated materials & contaminated waste properly Wear gloves before touching anything wet (e.g., broken skin, mucous membranes) or performing invasive procedures
Wear personal protective equipment (PPE)such as goggles, face
masks, aprons, gloves-if splashes or spills of body fluids are anticipated Use antiseptic agents before invasive procedures Follow safe work practices (e.g., proper waste disposal practices, not recapping or bending needles, proper instrument processing) Vaccinate staff who are in direct contact with patients/clients for: hepatitis B, rubella, measles, mumps, influenza
Page 31
Basic nursing care
UNIT TWO
BED MAKING Learning objectives Describe the different types of bed making Develop understanding about general instruction of
bed making
Develop a skill to make different types of bed making Mention purpose of bed making List necessary equipment for bed making Arrange bed making equipment in order of their use
General Principles of Bed Making

2. Put bed coverings in order of use 3. Wash hands thoroughly after handling a patients bed linen. Linen
and equipment soiled with secretion and excretion harbor microorganisms that can uniforms
4. Hold soiled linen away from uniform
be transmitted directly
by hand or
Basic nursing care
5. Linen for one client is never( even momentarily)placed on another
client bed
6. Soiled linen is placed directly in a portable linen hamper or pillow
case before it is gathered for disposal

7. Never shaken linen in the air because shaking can disseminate
secretion and excretion 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 other side.
9. When removing sheets from the bed, lift the mattress while
loosening the bed linen. Never pull sheets with force.

10. The open end of pillow should be placed away from the door. 11. Never throw soiled linen on the floor 12. To avoid unnecessary trips to the linen supply area, gather all
needed linen before starting to strip bed.

13. While tucking bedding under the mattress the palm of the hand
should face down to protect your nails.

14. Make toe pleat in the sheet to provide additional room for the
clients feet. NB- pillow should not be used for babies

Basic nursing care
The mattress should be turned as often as necessary to prevent sagging, which will cause discomfort to the patient. Types of Bed Making
Bed making is the most important part of hospital and hospitalization. To know how to prepare various types of bed is the responsibility of the nurse. Clean, smooth and dry bedding provide psychological and physical comfort as well prevents complications. There are different types of bed making based on the patient conditions Closed Bed
Is a smooth, comfort and clean bed which is prepared for new patient. 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 provide a clean comfortable bed -To give the bed a good appearance -To keep ready for the next patient -To prevent cross infection
Basic nursing care
Equipment -Two large sheets -Cotton draw sheet -Rubber draw sheet (water proof sheet) -Blanket -Bed spread -Pillow case -Hamper -Bed side chair
Procedure Wash hands and collect the necessary materials

Place the materials to be used on the chair. Turn mattress and Arrange evenly on the bed Place bottoms sheet with correct side up, center of sheet on center of bed and wide hem at the head of the bed. Tuck sheet under the mattress at the head of bed and miter the corner
Page 35
Basic nursing care
Remain on one side of bed until you have completed making the bed on that side
tuck sheet on the sides and foot of bed, mitering the corners tuck sheet smoothly under the mattress, there should be no wrinkles
place rubber draw sheet on center of the bed and tuck smoothly and tightly Place cotton draw sheet on the top of rubber draw sheet and tuck. The rubber draw sheet should be covered completely place top sheet with wrong side up, center of sheet on center of bed, tuck at the foot of beds and miter the corner
Place blanket with center of blanket on center of bed & tuck at the foot of bed & miter the corner fold top sheet over blanket Put pillow cases on pillow & place on bed
Place bed spread with right side up. Tuck at the foot mitering corners & cover top bedding.
Go to other side of bed & tuck in bottom sheet & draw sheet mitering corner, smoothing out all wrinkles. See that bed is neat smooth. Leave bed in place & furniture in order Open Bed
Basic nursing care
Is one of which is made for ambulatory patient are made in the same way but the top covers of an open bed are folded back to make it easier for a client to get in. Purpose -To provide a clean comfortable bed -To give the bed a good appearance Equipment The same as closed bed. Procedure The same as closed bed but in open bed procedure the top bedding is folded to the center of the bed.
Occupied bed
Page 37
Basic nursing care
Is a bed prepared for a weak patient who is unable to get out of bed. Purpose To provide comfort and facilitate movement of the patient To conserve patients energy and maintain current health status Equipment The same as open and closed bed add pijamas (gown) if necessary and extra blanket if available. Procedure N.B- If bath is not given this time, the back of helpless patient should be washed & give back care to prevent pressure sore. - Explain the procedure to the pt and wash your hands - Assemble the equipment and arrange in order of its use - Carry equipment to the bed side; make sure the windows and door are closed - Remove extra pillow and have pt. flat if possible
-
Loosen all bedding, beginning at the head of bed and remove the spread the blanket and place it over the chair
- Place dirty pillow case on chair to receive dirty linen.

Basic nursing care
- Have patient flex knees or assist patient to do so with one hand over patients shoulder & the other over patients knees turn patient towards you. Never turn a helpless patient away from you as this may cause in to fall out of bed - Place pillow infront of patient for support as needed - When you have made the patient comfortable & secured as near the edge of the bed as possible, go to other side, carrying your equipment with you - Loosen all beddings on that side - Fold spread down from head half way, then fold side ways in half. Place it on the chair. Do the same thing with the blanket. - Roll soiled draw sheet & rubber sheet close to the patients back
-
Place the bottom sheet on the bed, tuck it under the near half the head of the bed, miter the sheet at the top corner & tuck under the side of the mattress
Place the rubber draw sheet & cotton draw sheet on the bed & tuck it under side of the mattress
Page 39
Basic nursing care

-
Turn patient towards you, on to the clean sheet & make comfortable on the edge of bed
Move to the other side of the bed, taking basin & wash clothes with you & give back care.
Loosen & remove all bottom linen place these in the hamper or pillow case but not on the floor
Pull & secure the bottom sheet under the head of the mattress, miter corners. Pull the side of the sheet & tuck under the mattress. Repeat these with draw sheet.
Assist the pt to turn to the centre of the bed, remove the pillow & change the pillow case before replacing.
- If top sheet is to be changed, place clean sheet over top sheet & ask patient to hold it. Go to foot of bed & pull the dirty top sheet out - Pleat top sheet at the bottom to give space for his feet - When room is cold, leave blankets on bed instead of top sheet.
-
Straighten top sheet, replace or straighten blankets, replace spread miter the corner. Tuck in along sides for low bed. Leave sides hanging on high beds. Fold spread under top of
Page 40
Basic nursing care
blanket & top sheet down over blanket at the head of the bed - Loosen top bedding over patients toes. Be sure patient is conformable. Wash bedside table remove dirty linen leave room or ward unit in order - Wash hands
Anesthetic bed Is a bed prepared for patient recovering from anesthesia. Purpose: - to facilitate easy transfer of the patient from stretcher to bed with a minimum of time and movement. Equipment The same as closed bed but add: - towel - hot water bottle
- IV - small
rubber& draw sheet
- syringe and needle - emesis basin - receiver
stand drugs
- oxygen
- emergency - v/s
- bed block - an extra rubber & draw sheet for operated area
- tongue
equipment paper or gauze
- tissue
- suction machine
depressor
- paper and pencil(pen)

Page 41
Basic nursing care
Procedure -Make the bottom sheet, rubber and cotton draw sheet as usual. -Place a small rubber and cotton draw sheet where site of operation will rest. - place another across head of the bed where head lie (to protect bed from vomitus). -Place the top bedding as usual but do not tuck it under the mattress -Fold top bedding back at foot of bed even with edge of mattress - Fold top covers up from sides so they are even with the edge of mattress all the way round. -Place hot water bottle in the middle of the bed -Place pillow at the head of the bed b/n the bed and mattress & tie it back with a piece of bandage to protect head of patient. -Place v/s equipment, emesis basin, and tongue blade on bed side stand - Place bed side table & chairs so they will not be in the way for the stretcher. Close the windows. Leave room clean and in order.
Page 42
Basic nursing care
Receiving patient from operating room.
Keep the bed warm ( extra blanket) if needs
Close windows and doors Remove folded top covers of the bed.

Place patient on bed, covering him quickly. See that patient is properly placed in bed with the head to the side and comfortable
Cheek patients condition: - operated area, urine, vital signs, co lour of patient etc.
Amputation bed A regular bed with a bed cradle and sand bags Purpose: -To leave the amputated part easy for observation -To allow to do repeated procedure
Equipment Same as anesthetic bed but add the following -Two upper sheets
Basic nursing care
-Two bed spread -One large rubber sheet -One large cotton draw sheet -Tourniquet -Bed cradle -Two sand bag with its cover -Safety pin - Two blanket if available Procedure Prepare the bed in the same way as anesthetic bed. After receiving patient from OR put bed cradle over the affected extremity also the extra blanket to keep the patient warm. Place the sand bag on each side of the stump Leave the tourniquet in good sight. Divided amputation bed (option two) -Make the bottom bedding as usual -Spread bath blanket next to the pt body, make bottom half of the bed -Fold sheet cross wise at the centre of the bed at bottom tuck in and make a corner
Page 44
Basic nursing care
-To make the upper half of bed, fold the sheet in a half. Fold back over the top bedding. The two halves should be overlap about 7.5cm where both sheets meet -Place blanket & fold the top sheet down over it. -Do likewise with the bed spread. - Remove the bath blanket placed next to the patient fold it & put it in its proper place. -Use sand bag to keep the part in place -Place the bed cradle over the affected part. Fracture bed A bed board under normal bed and cradle Purpose:
-
To provide a firm, flat, unyielding surface to support a fracture To maintain position.
part. -
Equipment: - The same as closed bed and add -Fracture board -Bed cradle -Small rubber and draw sheet -Sand bag
Basic nursing care
-Small blanket
Procedure -Place a fracture board directly over the bed spring with the mattress on it -The procedure to make this bed is same as for and ordinary occupied bed -Fold back the top bedding at the foot of bed. -Place the cradle over the injured part and adjust the cover over it. Cardiac bed Is one prepared for patient with heart problem. Purpose: - To ease difficulty in breathing (to relieve dyspnea) -To provide comfort for the patient Equipment -Ordinary bed equipment -Over bed table if available -Extra pillow -Back rest
Basic nursing care
-Foot rest -Oxygen
Procedure -Make bed the same as closed bed with the foot rest at the foot of the bed -Place the back rest at the pts back, make it comfortable with pillow -Place the cardiac table/over bed table/ in front of the patient with pillow on it. -Leave your patient comfortable in bed.
Page 47
Basic nursing care
UNIT THREE
Admitting and Discharging a Patient Learning Objective
Define admission& discharge
Explain purpose of admission& discharge
Mention nurse responsibilities during admission & discharge

[[
A. Admission: is the process of receiving a new patient to an individual unit

(ward) of the hospital. Hospitalized individuals have many needs and concerns that must be identified then prioritized and for which actions must be taken.
Purpose To help a new patient to adapt to hospital environment with minimum distress.
Basic nursing care
To alleviate the patients fear and worry about the hospitalization. To provide necessary bed rest or diet, & therapy not available in the home. Equipment
Admission kit for personal hygiene Vital sign equipment (e.g. thermometer) Urine container Kardex card, client chart
Nurse Responsibilities During Admission of a Patient to Hospital

1. make introduction and orient the patient
-
Greet the patient Introduce yourself to the patient and the family Explain what will occur during the admission process (admission routines) such as admission bath, put on hospital gown etc
Orient patient to individual unit: bed, bathroom, call light and how these items work for patient use
- Orient patient to the entire unit: location of nurses office, lounge - Explain anything you expect a patient to do in detail (this helps the patients participate in their care)
Basic nursing care
- Introduce other staff and roommates 2. check for orders of admission

3.
Assess the patients immediate need and take actions to meet them. These needs can be physical (e.g. acute pain ) or emotional distress,(upset)
4.
Perform base line assessment A. Observation and physical examination such as

-
Vital signs, temperature, pulse, respiration and blood pressure Input and output Height & weight (if required)
- Obtain specimens
B.
General assessment
Interview patient and take nursing history to determine what medication the patient is currently taking. Any allergies, patients complaints and concern.
5.
Take care of the patients 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 labeling with patients name
6. Record keeping or maintaining records

-
Record all part of the admission process Other recording include:-
Page 50
Basic nursing care -
Notification to dietary departments, starting kardex card and medication records, if there is specific form to the facility, complete it.
B. Discharging a patient: Preparation of the patient to leave the hospital

after completing obligation to the hospital & receiving instructions for medical care.
Discharge should be authorized by the physician
Purpose
To allow the client to verbalize his her feeling about discharge
To identify the clients strength & weaknesses To assist in the transfer of a client whose condition necessitates care at another
facility To help the client become aware of potential changes in environment & lifestyle due to his or her disability or limitation Indications for discharge - Progress in the patient condition - No change in the patents condition (referral use of other service outside the hospital) - Against medical advice - Death
[
Equipment
Educational pamphlets
Basic nursing care
Telephone numbers& information regarding clinic appointment. Specific equipment such as wheel chair Medications.
Materials for dressing changes (if indicated)
Nurses Responsibilities During Discharging a Patient
Check for orders that a patient need to be discharged
Notify all hospital departments: cashier, dietary.
Plan for continuing care of the patient - Referral if necessary - Give information for new person involved in the patient care - Contact family or significant others if needed - Arranging transportation
1.
Teaching the patient about what to expect medications (treatment) activity diet need for continued health supervision
2.
Do final assessment of physical and emotional status of the patient and the ability to continue own care
Page 52
Basic nursing care

3.
Check and return all patients personal property (personal item in patient unit and those kept in safe area)
4. Keep records Write discharge note Keep special forms for facility Discharge Summaries Usually Include the following: -Describing of clients condition at discharge -Current medication -Treatment (e.g. wound care) -Diet -Activity level -Restriction Referral summaries usually include the following -Any active health problems -Current medication -Current treatments that are to be continued -Eating and sleeping habits -Self care abilities
Basic nursing care
-Support networks -Life style patterns -Religious preferences This exchange of information ensures continuity of health care for the client.
Discharging a patient against medical advice (AMA)

Is when the patient wants to leave an agency without the permission of the physician. During unauthorized discharge the following activities are indicated:1. If client insists on leaving the hospital, notify the physician immediately
2.
Ascertain from the client exactly why he wants to leave the agency
3. Explain & validate the physicians reasons that continued hospital care is necessary 4. Explain risks of leaving hospital (AMA)
5.
If client still insists on leaving, offer the patient the appropriate form to complete
Page 54
Basic nursing care

6.
If the client refuses to sign the form, document the fact on the form and have another health professional witness this
7.
Provide the patient with the original of the signed form and place a copy in the record
8.
When the patient leaves the agency, notify the physician, nurse in charge and agency administration as appropriate
9.
Assist the patient to leave as if this were usual discharge from the agency (the agency is still responsible while the patient is on premises).
UNIT FOUR
PROVIDING SAFTEY AND COMFORT Learning objectives
Basic nursing care
Define safety and comfort.
Describe different types of comfort devices. Mention purposes of each comfort devices.
SAFETY Safety is to protect oneself from harm.

Safety should be applicable in health institution due to the following reasons. - Altered consciousness - Loss of ability to move - Loss of ability to think clearly Hospital injuries:1. Thermal/ electrical injury 2. Chemical injury 3. Bacteriological injury 4. Mechanical injury 1. Thermal/ electrical injury It occurs from temperature affection such as therapeutic procedure. e.g. Heat and cold application. The commonest one is excessive water temperature during bath, shower etc.
Basic nursing care
- Touching of hot objects - Electrical shocks - Excessive radiation - Burns from hot water bottles and ice bags.
Nurses responsibility to prevent Thermal/ electrical injury

-
Identify and use appropriate teaching especially safety precaution e.g. this is hot, dont touch it!!
- Be familiar with equipments

-
Be patient in giving explanation
- Always have call device for patient to summon help during heat or cold therapy
-
Keep hot objects away from children or confused and sedated patients
- Make sure that all electrical appliances are routinely checked and maintained
-
When oxygen sources are used, past precaution sign. NO SMOKING. 2. Chemical injury
-
Chemicals may irritate burn or poison body tissue. Chemicals can be medication, gases, oils, paints and cleaning compounds.
Safety measures to prevent chemical injury
Page 57
Basic nursing care

-
Poisons or toxin substances must be stored safely and appropriately, labeled in safe container preferably their original container in a locker and away from medication, food, drinking water etc.
- Keep drugs away from children and confused patients. - Report any error in the administration of medication. - Follow the 5Rs in administering or dispensing drugs. The five rights of drug administration:
-
Right Patient Right Drug
- Right Route - Right Dose - Right Time 3. Bacteriological injury - Any hazard caused by microorganisms Safety measures to prevent bacteriological injury - Wash hands before and after giving care. - Use gloves when hand become in contact with body discharge. - Wearing of a mask or protecting eye wear to prevent the nose, eyes, and mouth.
-
Use proper handling of sharp instruments on disposing, washing, and sterilizing.

Page 58
Basic nursing care
- Incineration of bag of wounds, paper trash and disposable items soiled with body substance. - Keep environmental sanitation. 4. Mechanical injury Mechanical injury is any injury which can occur due to body and another object contact. Safety measures to prevent mechanical injury - Keep floor dry, wipe spilled liquids immediately. - Use call device. - Keep doorways and common path ways free from obstacles. - Use bed side rails and restrains for elderly, confused and surgical patients. - Keep electrical cords and tubing out of way.
-
Protect yourself from standing on chair or table. Lock wheel chair, beds, and stretcher and release the locks after the patient is secured.
- Use safe coordinated team movements when transferring individuals.

-
Use non skid (slip) tips on crutches and walkers.
- Open and close doors carefully and slowly.
Page 59
Basic nursing care
COMFORT Comfort is a feeling of physical & mental well being.
There are different methods and devices that are used to provide comfort to the patient. These play a great role in the process of patient recovery. Discomfort: is feeling of physical or psychological unwell beingness. Causes for physical discomfort - Pain - Restricted movement. - Soiled bed, untidy and wrinkled sheet. - Bright (excessive) light from lamp or window. - Not properly supported parts of body or extremities. - Corrective device as plaster cast, splints, and other orthopedic devices. - Pressure on body parts. Causes for mental discomfort - Fear and anxiety - Lack of privacy - Disorderly room - Worry about job
Page 60
Basic nursing care
- Noise - Improper room temperature Mechanical comfort and safety devices 1. Cotton rings Are small circles of cotton rolled with gauze or bandage with hole in the middle. Purpose - It is used to relive pressure from small areas such as the elbows and heels.
Size -
The size depends on the part which they are used
2. Description of Body Prominence Areas (Common Locations) Pressure point is an area of skin that can become irritated with pressure, especially over bony prominence areas Pressure ulcers most commonly develop over bony prominences, where body weight is distributed over a small area with inadequate padding. The majority of pressure ulcers develop in the pelvis. When supine:
The back of the skull. The sacrum & coccyx. The heels.
The elbows.

When sitting: Ischial tuberosities. The sacrum. 3. Air rings

[
Are circle rubber bags with the whole in the middle & filled with air.
Basic nursing care
Should be filled with air and covered with much.
pillow case. It is not commonly used
and should be changed frequently at least after 2 hours. They should not be filled too
Purpose - It is used to relieve pressure from the buttocks (to prevent bed sore).
[
4. Cradles (bed cradle)
It is also called Anderson frame, made of wire, wood or iron. Is a device designed to keep the top bed cloths of the feet, legs and even abdomen of the client.
Purpose - to keep the top bed clothes off the injured part of the body. e.g. burn,
ulcers, a wet cast, or specific circulatory diseases.
5. Pillow
Is a case filled with springy material (as feather) & used to support the head of the person. They are placed under the head, back, b/n knees or at the foot of the bed. Indication (purpose)

Prevent foot drop and to prevent the patient from sliding down. Give comfort, support and to position a patient properly. Elevate extremity in case of injury should be covered by rubber.
Prevents pressure on skin Types made with different types of materials, such as feather, foam or fiberfilled. 6. Sand bags Are heavy, cylindrical, or rectangular sand-filled bags.
Purpose - They are used for supporting or immobilizing a limb.
Page 62
Basic nursing care
Precaution
They should be covered with towel and placed one on either side of a limb (or part to be immobilized). Avoid excessive pressure on affected part.
7. Splints Are rigid supports that help to maintain the wrists or other body part in a functional position.
Purpose (indication)
Used for conditions that does not require rigid immobilization.
For those in which swelling may be anticipated. For those that require special skin care. To prevent discomfort due to pain.
Precaution
Must be well padded to prevent pressure, abrasion and skin break down. Over wrapped the splint with an elastic bandage applied in spiral fashion and with
pressure uniformly distributed so that circulation is not restricted asses frequently for neurovascular status and skin integrity. Check & inspect color of the toes or fingers.
8. Fracture boards Fracture is a break in the continuity of a bone. A complete fracture involves a break across the entire section of the bone which is frequently displaced.
Basic nursing care
Fracture boards are used to make the bed firm and to prevent bed from sagging. They are placed under the mattress of Patients with fracture.
Indication fractured spine, hip, lower limb, or slipped disk. 9. Back rest
Back rest is a mechanical devise which is used to give support to the sitting position. Is used for elevating and supporting the head and back of the patient. Gatch beds have back rest, which can be elevated or lowered as desired. If Gatch bed is not available, pillows or boards can be used.
Purpose
To relive pressure To prevent complications To provide comfort
10. Foot rest (board)

A foot rest is something firm (a firm box/ board) which is placed between mattress & foot of bed against which the patients feet rest. Are rigid, vertical structures and placed at the foot of the bed where soles of the feet touch. The footboard may also have side supports to help maintain proper alignment of feet. It should be padded for support and adjusted to the clients height so that the soles rest firmly against it and the ankles are maintained at 900.
Purpose
To prevent foot drop.
prevent the patient from sliding down To keep the top bed covers off the clients feet, relieving the pressure of the weight of the covers.
Basic nursing care
11. Side rails (safety rails)

Movable rails attached to the sides of hospital beds & stretchers designed to decrease the risk of client falls.
Purpose
Used to prevent falling of the patient in case of unconscious, children. Help weak client turn independently. It is sealed at the side of the bed.
UNIT FIVE
Lifting, positioning & moving a patient Learning objectives
Define body mechanics
Develop skill to promote proper body mechanics while caring for a client
List precautions during lifting & moving
Introduction to body mechanics
Page 65
Basic nursing care
Body mechanics movement of the body in a coordinated & efficient way so that
proper balance, alignment, & conservation of energy is maintained.
Principles
A person maintains balance as long as the line of gravity passes through the center of the body & the base supports. The wider the base of support & the lower the center of gravity, the greater the stability. Objects that are close to the center of gravity are moved with the list effort. Line of gravity an imaginary vertical line drawn through an objects center of gravity.
The point at which all of the mass of an object is centered.
Base of support: the foundation on which an object rests.
Purpose of proper body mechanics

Prevents injuries to clients Prevents injuries to all health care providers Reduces the energy required to move & maintain balance Facilitates safe & efficient use of appropriate groups of muscle
Lifting a patient in bed

Lifting a patient to raise patient, to move patient from one position to another, higher position.
Moving a patient to change previous location/ position. Guidelines / principles of patient lifting/ body mechanics
Assume a proper stance before moving or tuning clients
Basic nursing care
Distribute work load evenly before moving or tuning clients Establish a comfortable height. Push and pull objects when moving them to conserve energy. Use large muscles for lifting and moving, not the muscle. Avoid leaning and stretching Request assistance from others when working with heavy clients.
Avoid twisting your body.
Purpose of lifting & moving

To assist patient who is unable to move To prevent fatigue &injury To maintain good body alignment To stimulate circulation
Precautions on patient lifting & moving

Asses clients condition Use good body mechanics when moving & turning clients. Avoid leaning & stretching. Request assistance when working with heavy clients.
Moving a patient from bed to stretcher & from stretcher to bed. Purpose
To transfer patient to other department To take patient to surgery or examination
Steps for moving a patient from bed to stretcher

Basic nursing care
Requires helper Method - 1 - Fold top bedding to the foot while covering the patient with a bath blanket.
-
Place stretcher at a right angle to the bed with the head of stretcher to foot of bed.
- All stand on same side of bed. Place hands well under patient to support head &entire body. - All helpers should lift together in unison, swing half way round, bring head to foot of bed & place patient on stretcher. - Cover the patient with sheet or bath blanket. Method 2 - Place stretcher parallel to the bed.
-
Four nurses or helpers are required, one stands on the opposite sides of the bed. Three will have to reach across the stretcher. The nurses at the head & the foot of the stretcher may find it easier to step around the end of the stretcher.
- Grasp sheet beneath patient & support shoulders & legs separately.
-
Co-ordinate lifting, & swing patient to stretcher by pulling the sheet & patient towards stretcher quickly & gently.
- The sheet can be removed at this time by turning patient from side to side. Or wait until he has been transferred from the stretcher to the bed or table again.
-
The opposite method is used when moving a patient from the stretcher to the bed.
Precaution on moving a patient from bed to stretcher

-
Lock the wheels of the bed & stretcher.

Page 68
Basic nursing care
- Fasten safety straps across the client on a stretcher, &raise the side rails. - Never leave a client unattended on a stretcher.
-
Always push a stretcher from the end where the clients head is positioned
Moving a patient from bed to chair & from chair to bed Purpose of moving a patient from bed to chair
- To simulate circulation - To prevent fatigue
Equipment
- Chair - Bath blanket - Slipper
Steps/ procedure
- Identify the patient.
-
Wash your hand. Explain procedure. Lock the bed in place. Place the chair at the head of the bed. Be sure to lock chair wheals or have someone hold the chair as you move the patient. Dangle the client until she or he is stable. Give the client nonslip shoes or slipper. Have the client reach across the chair or grasp the chair arm, if possible. (Helps stabilize client to prevent falls during transfer of chair).
- Place your hands under the clients axilla or around clients back. - Place your feet slightly to the side and infront of the client.
Basic nursing care -
Rock the client and, on the count of three, pivot (rotate) the client in to the chair. Position the client in the chair to prevent pressure area. If the client has circulatory impairment, elevate legs while out of bed. (This promotes venous return).
Precautions on moving a patient from bed to chair

-
Lock the bed & chair wheals. Prevent trauma e.g. pulling joints
- Keep movements smooth & rhythmic. - To avoid injury to the care giver when a patient starts to fall, gently guide person to the floor, rather than attempting to hold the patient up.
Positioning a patient Position any one of many postures of the body, as the anatomic position, semi-fowlers
position .. Therapeutic positioning is used to prevent complications when mobility is reduced.
Purpose of positioning a patient

- To stimulate circulation - To prevent some potential problems of immobility - To prevent bed sore
Types of positions
The patient may be placed in specific positions to facilitate diagnostic testes or surgical intervention. Common positioning postures includes
Basic nursing care
- Prone (face down ) - Supine (lying on back) - High-fowlers (head of the bed elevated 80-90 degrees) - Semi-fowlers (head of the bed elevated 30-45 degrees) - Low-fowlers (head of the bed elevated 15 degrees) - Dorsal recumbent (supine with legs flexed in an elevated position )
-
Knee-chest position (prone with butt ocks elevated and knees drawn to the chest).
- Trendelenburg (supine with head lowered than feet ) - Lateral or side-lying position - Sims (semi prone between a prone & side-lying position )
Page 71
Basic nursing care
~I
Dor sal recumb ent: T he client li es s upine with l egs flexed and rotated outward. This position is used extensively for vaainal examination but no; for abdo mina! assessmen1 be;aus e it promotes contraction of abd ominal mu scles .
Knee-ehest: The client lies prone with butt ocks elevated and knees drawn to the che st to accommodate a rectal pr ocedure o r exam ination A cl ient with arthritis or othe r joint deformity may be unable to lie in this position.
Lithotomy : The client li es s upine with hips flexed and calves and heels parallel to the floor. This uncomfortable and ernLF.HfJSSii19 position req'J:l r:~ -.df 2ping tile client for privacy. 11 is used for vaginal and rectal examination and may pose gre at difficulty for cli ents with immobilizing arthritis or a joint deformity.
Trendelenburg's: The cl ient lies s upin e with head 30 -40 lower than feet. The position m ay be used for postural drainage and to promot e venous return. Hypotension may be an a fter effect of Ruman Abdurashid- Menilik H.S.College Page 72
Basic nursing care this position.
Page 73
1------
Supine : The client lies flat on bac k. Pillows may be used un der the head. knees and calves to ra ise heels off the mattress. An alte rnative pos ition for a client on bed rest, the pr one position is used afte r spine surgery and some spin al anesth esia. It is not used f or cl ients "\llth dyspn ea or at risk for aspiration.
Fowler's: This sitting position raises the c lient's head 8o O-90 c Pillows can b e used unde r the hea d and arms and a f ootboard may a lso be used. The pos ition improve s cardi:::c output. promotes ventliation and e ases eating , talking. and watching TV. It is not us ed aft er spine or bra in surgery.
\\
Sims' : In this se miprone position the cli ent lies on the side with we ight distributed toward the anterior il eum, humerus , and clavicle . Pillows s upport the flexed arms and legs. The po sition is contraindicated by m any spine or or thope dic condit ions.
Semi-Fowler 's: In this semi -sitting pos ition the client 's head is elevated 30 -45. This pos ition has the same ad vantages and contra lnc!lcations as Fowler's position.
L_ . _______ __ ______ _ . ___ __ ____ __ ___ __ ____ __ __ __ ___ __ __ ____ __ __ ___ __ __ __ __ __ __ __ ___ __ __ __ __ __ __ __ __ ___ __ __ __ __ __ __ __ __ ____ __ __ __ __ __ __ __ __ ___ __ __ __ __ __ __ __ __ ____ __ __ __ __ __ __ __ __ ___ __ __ __ __ __ __ __ __ ____ __ __ __ __ __ __ __ __ __ ~ __ __ . __ _ .
._--- ~ I
~I
(((lllliilU,_'di
_ __ _ --.--_ _ . --J
Page 74
Figure
33-5 Common client posit ions. Among selected body positions, 1I1e prone, supine, Fowler's, semi-Fowler's,
side-lying, and Sims' positions are typically chosen for clients in heoll11core facilities, whereos the dorsal recumbent, lithotomy, knee-chest, and Trendelenburg POSitiOns are typically used durinl) certain tests and surgical ,()((>(edures
Prone: The client lies face down . Arms may cushion the head or may be flexed An alternative pos ition for an immobi lized client, the prone posit ion is contraindicated after abdom inal surgery and in clien ts with resDiratory or s pinal p roblems .
Side-lying : The c lient lies on the side w ith weight on hip and shoulder . Pillows suppor t and st abilize uppermost leg. ar m, head, an d back. A c hoice pos ition for clients wi th pressure on bony prominences of the back and sacral pressure sor es, sid e-lying is no t used after hip r eplace'Ti(;nt an d oth er orthoped ic surgery.
Page 75
Ambulating a patient
- Is to move from place to place by walking.
-
Is the act of walking. Early ambulation significantly reduces complications of immobility. Waking exercises almost all body muscles & promotes joint flexibility. Most surgical clients are permitted & encouraged to get out of bed & walk on their first postoperative day.
Purpose
To increase muscle strength & joint mobility. To prevent some potential problems of immobility.
To increase the clients sense of independence & self esteem.
Precaution of patient ambulation
Check vital signs for base line data before walking, especially if this is the clients first time up.
Remain physically close to the client in case assistance is needed at any point. Use a transfer or walking belt if the client is slightly weak & unable.
Page 76
UNIT SIX
Providing hygienic care for patient Learning objectives
Describe several aspects of general care to the patient.
Identify & list the materials required to do these procedures. Demonstrate the ability to perform each of these specific care procedures.
Introduction
General patient cares are techniques of meeting daily patients need by assisting the patient. Bathing - is the washing of body or body parts.
Kinds of bath
There are generally two categories of baths given to clients:
1. Therapeutic and
2. Cleaning 1. Therapeutic bath - usually ordered by physician, are given for physical effects, such as to sooth irritated skin or to treat an area (example the perineum). Medications may be placed in the water. A therapeutic bath is generally taken in a tub one third or one half full, about 114 liters. The client remains in bath for a designated time, 20-30 minutes. The bath temperature is generally included in the order; 37.7-46OC may be ordered for adults and 40.5 OC is usually ordered for infants. Medication may be placed in a tub and affected area need to be immersed in the solution. Usually for 20 minutes.
2. Cleaning bath are given chiefly for hygienic purposes and include these types:
a. Complete bed bath the nurse washes the entire body of a
dependent client in bed.

b. Self help bath clients confined to bed are able to bath themselves
with help from the nurse for washing the back and perhaps the feet.
c. Partial bath (abbreviated bath) only the parts of the clients body
that might cause discomfort or odder, if neglected, are washed: the face, hands, axillae, perineal area, and back. Omitted are the arms, chest, abdomen, legs and feet.
d. Tub bath tub baths are preferred to bed baths, because it is easier
to wash & rinse in a tub. The amount of assistance the nurse offers depends on the abilities of the client.
e. Shower many ambulatory clients are able to use shower facilities
& require only minimal assistance from the nurse.
Giving bed bath

It is a bath given to a patient in the bed who is unable to care for him / herself.
Purpose To remove transient microorganisms, body secretion & skin cells. To promote relaxation & comfort. To stimulate circulation. To produce sense of well-being.
To eliminate unpleasant body odors. Equipment

- Two bath towels. - Face towel - Wash cloth. - Gown.
-
Pillow case
- Linen for making bed - Soap in soap dish

-
Two bath basins or one large jug containing warm water & one basin Personal articles(i.e., deodorant, powder )
- Brush & comb

-
- Bed pan or urinals if needed - Tray for nail care & mouth care if needed - Gloves
-
Hamper for soiled clothes
Procedure
a) Close the windows & doors
Before starting bath, offer bed pan or urinal. Find out what linen is needed. b) Screen patient and remove unnecessary articles from bed side table. Place linen on chair in order of use and bring bath basin with hot water.
c) Place the bed in a high position & remove top covers except top sheet,
if available place bath blanket over the patient and remove the top sheet
Page 79
while the patient hold the bath blanket in place. Put top cover over back of chair.
Remove pillow unless this is uncomfortable for the patient. Remove solid pillow case, place soiled linen in it.
Do not expose the patient unnecessarily.

d) Make a bath mitt with the wash cloth. A bath mitt retains water & heat
better than a cloth loosely held. Place face towel under the chin, wash face, eyes ears and neck [avoid soap on the face]. Watch for signs of fatigue, report and chart any redden spot, rash, sores or swelling. Change water as often as necessary. Never use dirty or soapy water. e) Protect the bed from dampness by placing bath towel under each part. Place one hand under each part to support it while washing and drying the extremities.
f) Using long, firm, even strokes, wash the far arm from distal to proximal
areas (wrist to shoulder). - Washing from distal to proximal areas stimulates venous blood flow.
g)
Place basin on towel on side of bed and sock the patients hand in basin, wash, rinse and dry the hands.
h) Repeat step f and g for the arm which is nearer to you. i) Bath chest, dry and cover with towel, then bath abdomen. j) Flex knee on far side, uncover leg and lie and drape to protect bed.
Wash and dry leg. Place the patients foot in the basin, wash, rinse and dry. Do the same for the other leg.
k) Get clean water turn patient on one side, spread towel close to body,
wash backs and heaps. Rinse and dry carefully. l) Give the patient back rub.
m) Place towel under heaps put basin and soap within easy reach of the
patient. Give the wash close to the patient if he is able to wash the perineal area. If the patient is unable to do so the nurse should do and finish the bath.
n) Put on a clean gown; protect the pillow with towel and comb the
patients hair. o) Change bed linen. p) Return equipment to its proper place.
q) Record your procedure, time and observation.
Precautions & contraindication Close the windows & doors air current increase loss of heat from the body by convection. The water should feel comfortably warm to the client. People vary in their sensitivity to heat; generally, the temperature should be 43- 46c. Avoid harsh rubbing. Avoid scratching skin with jewelers or long sharp finger nails.
Soap must not be applied directly over an open & excoriated skin & ensured that all soap is rinsed off the skin.
Give special care to skin folds & creases. Always wash from clean area to dirty body parts.
Giving tub bath

Tub bath is washing ambulatory clients in a tub. Tub baths are preferred to bed baths, because it is easier to wash & rinse in a tub.
Purpose same as bed bath.

Equipment - Soap - Wash cloth - Bath towel - Gown - Slipper - Chair or stool (if needed)
Procedure
- Assist patient to undress
-
Fill the tub about one-third to one- half full of water at 43-46c. Assist patient in to the tub & avoid falling & fainting. Allow patient to bath himself or assist if needed.
- Check the temperature of the water

-
- Assist patient out of tub and dry his body and put on gown. - Return patient to room and put to bed.
-
Clean bath tub and leave room in order. Discard soiled linen.
- Wash your hand.
Precautions & contraindication

- Have correct temperature of water. - Avoid chilling.
-
Apply a rubber bath mat or towel to the floor of the tub.
- Always keep bath room unlocked. - Check patient frequently for signs of exhaustions.
Showers and bath do not need to last more than 10 minutes.
Giving back care

Back care also called back rub or back massage. It is the process of massaging or rubbing the back especially the areas with bony prominence in order to relax the muscle and stimulate circulation.
Bed Sore - Also called pressure ulcer, decubitus ulcer, pressure sores, or distortion
sores. It is defined as any lesion caused by unrelieved pressure [a compressing down ward force on a body area] that result in a damage to underline tissue.
Signs of pressure ulcer

- Redness - Blister - Breakage of the skin (ulcer). - Necrosis (death of tissue).
Stages of pressure ulcers

1. Stage 1 - the skin is red. The color does not return to normal when the skin is relieved of pressure. 2. Stage 2 - the skin crack, blister, or peels. There may be a shallow crater (depression). 3. Stage 3 - the skin is gone, and the underling tissues are exposed. The exposed tissue is damaged. There may be drainage from the area. 4. Stage 4 - Muscle and bone are exposed and damaged. drainage is likely
Risk or predisposing factor

- Immobility - Inadequate nutrition. - Fecal and urinary incontinence. - Decrease mental status unconscious, heavily sedated by analeptics or tranquillizer. - Diminishes sensation. - Excessive body heat.
-
Advanced age, obese, or very thin.
- Circulatory problems. - Incorrect application of pressure relieving devices. - Repeated injection in the same area.
Prevention of bed sore
Change patient's position frequently (at least every 2 hours or as scheduled in the person's care plan).
Keep bed free from wrinkles& crumbs. Keep bed dry. Use air ring, cotton rings to relieve pressure. Apply powder where skin touches skin.
Give well balanced diet.
Give back care frequently, paying special attention to reddened areas.
Purposes of giving back care

- To relieve muscle tension. - To promote physical & mental relaxation. - To stimulate circulation. - To relieve insomnia.
- To provide relief from pain.

-
To prevent pressure sore.
- To prevent hypostatic complication in lungs
Precaution/ observations to be made during back care

o Avoid massaging over pressure points. NEVER RUB OR MASSAGE reddened areas. o Do not irritate the skin. Avoid scrubbing vigorous rubbing when bathing or drying a person o Avoid skin injuries by taking off the wrist watch & keep your finger nails short. o Handle the person gently during lifting, moving, transfer, bathing, & dressing procedures. o Report any signs of skin breakdown or ulcers immediately.
Techniques / Types of Back Rub/

1. Effleurage :- Smooth, long strock moving the hands up and down the
back. The most Common type of rubbing. 2. Tapotement :- Sharp backing movement or hitting the back by a little finger side of the hand.
3. Petrissage
: - Making large quick pinches of the skin, subcutaneous : - Fast rub of the skin by hands.
tissue and muscle.

4. Friction
Equipment
Soap and basin of water. Wash cloth. Bath towel.
Alcohol or powder. Other medication as ordered [castor oil, zinc oxide etc]. Air ring, cotton ring (if needed). Pillow.
Procedure
- Explain procedure. - Place Patient on his side and expose the back. - Place towel under patients side. - Wash with soap and water and dry. - Warm lotion or oil by pouring it into your hands before applying it to the clients back. - Apply powder or lotion and rub the back. - Pay special attention to prominences.
-
Use firm, long strockes up wards and down wards in a circular motion.
- Repeat upward and down ward soothing strocke several; times. - Use the towel to dry and remove excess lotion. - Apply powder if needed.
-
Turn patient on his or her back or side and put pillow as necessary. Make the patient comfortable.
- Observe any reddened area and report. - If there is a pressure sore [breakage of the skin] sterile dressing should be applied with ordered solution or ointment. - Record the procedure, time, observation. Clean and return equipment to its proper place.
Page 86
N.B If the patients skin is dry use of powder may not be advisable.
Giving sitz bath

Sitz means seat in German. The sitz bath involves immersing the perineal & rectal areas in warm or hot water for 20 minutes.
Purpose
To clean perineal & anal wounds. To promote healing, relieve pain & soreness. To increase circulation, & stimulate voiding.
Precaution
Observe for signs of weakness, fainting, or fatigue. Protect the person from injury. Check the person often; keep the signal light within reach. Prevent chills & burns.
Equipments
Basin or bath tub Towel Ordered medication Warm water Bath thermometer
Procedure
Wash hands, assemble equipment & explain procedure. Clean basin or tub & 1/2 or 2/3 fills with warm water. Add ordered medication, if any. Check temperature of the water & make sure it is comfortable to Take patient to bathroom & help him/ her to uncover the area. Help patient to sit in the basin or tub. Place a bath blanket around the shoulders. Observe patients condition every 5 minutes for complains of
the patient.

weakness, faintness, & drowsiness. If any occur, discontinue the procedure.
Allow the patient to sit in the water for 20 minutes or as directed Help patient to dry, & return to room. Chart treatment, time, & observation. Clean equipment to its proper place. Wash hands.
by physician.
Mouth Care / Oral Hygiene/

Definition: - Cleaning of the patients mouth who is unable to take care for himself. Types of Mouth Care
1.
Routine Mouth care: - Mouth care done on a daily bases for hygienic
purpose.
2.
Special Mouth Care: - Mouth care which requires increased

frequency, increased mechanical cleaning, use of solution and lubrication.
Page 88
Indication of Mouth Care - Inadequate nutrition. - Dehydration. - Halitosis. - Presence of sore. - Fever.
Purpose
- To keep the mouth, teeth and gums clean.
-
To prevent dentalcaries. To stimulate appetites, make food taste better and increases the pts sense of well being. To prevent and treat halitosis. To prevent infection.
- To remove dental plague.

-
Mouth wash solution

o
Normal saline solution: - a solution of common salt with Hydrogen peroxide Soda-bicarbonate solution 4gm of soda in pint of water. Thymal solution :- 1/4 - 1/2 TSF of thymal in one cup of Lemon juice 2 TSF lemon juice in a cup of water - an
water in proportion of 4 gm/500cc of water. o

o o
water [100-150cc of water]

o
improvised method for mouth wash.
Page 89
Equipment
- Glass of water.
-
Mouth wash solution /e.g. hydrogen per oxide, normal solution, lemon juice etc./ Cotton tipped applicator.
- Tongue depressor wrapped with gauze bandage. - Emesis basin. - Towel. - Paper bag for waste.
-
Lubricant /e.g. glycerin, Vaseline etc./
- Tooth brush and tooth paste. - Denture cup, if needed.
Procedure
- Greet patient and explain procedure. - Wash your hands and prepare equipment. - Assist patient to sit if possible or turn the patients head to the side. - If the patient is unconscious position him on the side with the head turned towards you. - Place towel across the patients chest under his chin.
-
Place the kidney basin under the chin. tongue and teeth gently and carefully.
- Moisten the applicator in a solution and clean the inside of the mouth, - Rinse the mouth with water and spit in to emesis basin. - If the patient is in unconscious, open the mouth with tongue blade. - Apply lubricant to the patients lip if needed.
Remove equipment and assist the patient to be in a comfortable position.
- Frequent mouth care should be given to a patient who has fever. - Wait at least ten minutes after patient has eaten to prevent nausea. Do not go far back on the patients tongue as it may gag him.
-
Chart procedure, time and observation.
Giving bed pan & urinals Definition: - To give a suitable container to a bed patient for passing urine & stool
in bed. - Bed pan is a material used to receive urine & feces in females & feces in males. - Urinals are a material used to receive urine only.
Types of bed pan

1. Regular (high-back pan). 2. Slipper, or fracture, pan - has a low back & is used for clients unable to raise their buttocks. It is used for persons with cast or those in traction. Older persons may have fragile bones from osteoporosis, painful joints from arthritis, or a hip replacement so Fracture pans are more comfortable for this people.
Purpose
- To provide a receptacle for elimination of waste material for clients confined to bed. - To obtain a specimen of urine or stool for laboratory examination.
- To obtain an accurate measurement or assessment of the client's urine or stool.
Equipment
-
Bed Pan, urinal and cover. Basin with soap and water Disposable glove
- Toilet Paper
-
- Specimen container.
-
Procedure
-
Warm & dry the outer part of the bed pan & carry to bed side & place it on chair.
- Screen bed. - Fold the cover of the bed pan & hang it over side frame of bed.
-
Turn bed cover at the side. Place free hand under pt's buttocks & have him flex knees and help in lifting his body with the other hand, adjust bed pan under him.
Place paper within reach and be sure patient can reach bell. Be ready to remove bed pan when pt calls. If he is not able to care for himself, give necessary are, leaving him clean and dry. Arrange bedding neatly. Draw back screen and carry bed pan or urinal to utility room.
- To hand urinal, elevate bed clothes slightly at the side of bed. - Note out put sheet to see if urine is to be measured. Collect specimen if ordered.
-
Observe color of stool, consistency, amount, check foreign bodies & parasite.
Page 92
Observe color of urine whether clear or cloudy & report any thing unusual.
Suggestions for helping patient to void.

- Elevate head of bed if it is not contra indication.
-
Turn on water tap for sound of running water. Force fluids if no contra indication. Pour warm water over external genitalia.
- Place pt's hand in warm water.

-
Precaution
- Never offer wet & dirty bed pan. - Choose appropriate type.
-
Follow medical asepsis, & standard precaution when handling bed pans & their contents.
Perineal Care Perineum: Are a diamond-shaped area b/n thighs and buttocks of both male and
females that contain the external genitals and anus.
perineal care - is cleaning of the perineal area with aseptic techniques. Patients in special needs of perineal care
-
All maternity patients after delivery or c/s.
- All abortion cases - Before and after perineal surgery - Non-surgical patients who unable to care for them selves - Genito-urinary inflammation - Patients with catheter
- Incontinence of urine or feces - After using bed pan
Purposes
To prevent sepsis(infection) To remove discharge and to prevent bad odour To relieve itching To promote healing of stitches To promote the patients comfort
Equipment
- Bath Towel - Cotton balls and gauze squares(sterile) - Pitcher with warm water or & prescribed solution in container - Gloves - Bed pan with cover - Small forceps for lifting sponges from the jug - Sterile pads or napkins - Kidney basin - Bed protecting materials
Procedure
-
Give adequate explanation washing hand and wear masks if possible Provide privacy Position patient on back with knees flexed
Page 94
Put on gloves Place bed protecting materials under the patients hip Place the bed pan under the patients buttock Remove dressing or pad used
For females
-
Inspect the perineal area for inflammation excoriation, swelling or any Clean by pouring warm water or a prescribed solution over the Separate the labia with one hand to expose the uretral & vaginal With your other hand, wipe from anterior to posterior direction (down
discharge
-
perineum while client is positioned on the bed pan.

-
openings.
-
ward strokes) using separate swab for each stroke. - Wash the external labia & anus - Dry thoroughly. - Remove articles & make client comfortable. - Wash your hands & record your findings.
For males
- Hold the shaft of the penis gently with one hand and the wash cloth with the other hand-to prevent erection - Use a circular motion, start at the tip of the penis & wash downwards towards the shaft. - Replace the foreskin over the glans penis.
- Wash around the scrotum. - Wash the anus last. - Rinse & dry all areas thoroughly. - Remove articles & make client comfortable.
-
Wash your hands & record your findings.
Precautions & contraindication

Use a separate section of cloth for each cleaning. - Avoid hurting the patient with the forceps. Careful with episiotomy stitches. - Never bring swabs up over perineum after it has touched the rectum. - Remember - entry of organisms into the urethral orifice can cause UTI. The urethral orifice is the cleanest area and the anal orifice is the dirtiest area.
MORNING, AFTERNOON AND EVENING CARE

Morning, afternoon and evening care are used to describe the type of hygienic care given at different times of the day. A.EARLY MORNING CARE Also called AM care: - routine care performed before breakfast; early morning care. Is provided to clients as they awake in the morning. Helps patients ready them selves for break fast or for early diagnostic tests as well as for refreshment.
In a hospital it is provided by nurses on the night shift.
Consists of
Providing a urinal or bed pan if client is confined to bed.
Washing the face and hands Giving oral care. B.MORNING CARE Is care provided after clients have breakfast. Cleanliness & skin care measures are more thorough at this time.
[
Consists of
Provision of urinal or bed pan A bath or shower Perineal care Back massage Oral, nail and hair care Making clients bed
C.AFTERNOON CARE

Is care given when clients return from physiotherapy or diagnostic tests. Routine hygiene is performed after lunch& the evening meal. If it is done before visiting hours, the person feels more refreshed & can visit with family & friends with out interruption.
Consists of
Providing bedpan or urinal Washing the hands and face.
Assisting with oral care: refresh clients D.EVENING, HS (HOUR OF SLEEP), PM CARE Is a care given in the evening at bed time. Hygiene measures are performed before the person is ready for sleep.
Consists of
o Providing for elimination needs o Washing face and hands o Giving oral care o Back massage
E. AS NEEDED CARE
Is provided at any time as required by a client. E.g. for diaphoretic patient
Purpose
- To promote comfort & relaxation. - To prevent complications.
Giving pediculosis treatment

Pediculosis (lice) is the infestation with lice. Lice are parasites. Lice bites cause severe itching in the affected body area. Lice easily spread to other persons through clothing, furniture, bed linen, & sexual contact.
Are of three common kinds:

Pediculosis capitus is the infestation of the scalp (capitus) with lice. Pediculosis pubis is the infestation of the pubic (pubis) hair with lice.
Page 98
Pediculosis corporis is the infestation of the body (corporis) with lice.
Purpose of Pediculosis Treatment

prevent abrasion due to scratching To prevent impetigo of the scalp To make the patient comfortable Essential equipment Fine comb Cotton swabs in gallipot Waste receiver Patients comb and brush Plastic cape Cover DDT emulsion of antipediculosis Gloves
Procedures
Wash hands Collect equipment on trolley Explain procedure to the patient Put on gown, gloves and cap for yourself, and protect the shoulders of the patient by putting towels. Comb the hair, which should be free of tangles. Part the hair and comb it with the fine comb Continue until all the hair is combed.
Page 99
Close the patients ears with cotton and instruct the patient to close his/her eyes.
Make many parts in the hair applying a few drops of DDT emulsion Wrap the hair & wait not less than 24 hours before washing it. Wash the hair with warm water, the nits gradually will be removed.
and rubbing it in to the scalp with the fingertips.

Repeat treatment after one week since usually the eggs of the lice (nits) are not killed. Make the patient comfortable. Wash equipment properly and return it to its proper place. Chart the procedure and results. Comb the hair with a fine comb daily for a week.
Special precaution

Avoid contact with eyes (protect eyes with wash cloth). To protect skin react, apply Vaseline to forehead & around the edges of hair.
Giving hair shampoo Definition: - washing the hair of patient confined to bed. Purpose
To stimulate blood circulation to the scalp through massaging. To remove dirty & perspiration. To keep hair clean & tidy. To clean hair after medication.
Equipments
Two jugs with hot and cold water Soap solution or soap. Basin Bucket for dirty water Two mackintoshes Wash close to cover eyes Cotton to plug ears Oil, comb and brush if used. Two towels and bath blanket Jug [small size to pour water on hair] Kidney tray and paper bag. Lotion thermometer if available
Hot water bottle in winter.
Procedure
[
Take equipment to the bedside of the patient. Help patient assume comfortable position.
Place mackintosh under patients shoulder keeping the head down. Plug ears with cotton. Place washcloth over the patients eyes to Mix hot and cold water 42 o C and wet the hair.
Should form a trough to carry dirty water into the bucket.
prevent soapy water into them.
Apply soap solution and wash the hair and massage scalp well, using the tips of finger. Rinse it thoroughly and repeat several times. Dry with towel.
Apply oil. Part hair down the centre of the back of head. Comb hair gently starting at the ends going upward towards head. Make two braids behind the ear. Leave patient comfortable and tidy. Take equipment back to its place. Record it on the temperature graphic sheet.
Feeding the Patient General Instructions

- Check the diet order. - Make the surrounding neat and clean. - Prepare patient and over bed table. Tray should be complete, clean and neat. - The food no matter how simple should be attractive and appetizing. - Hot food should be served hot and cold food should be served cold or as it should have to be.
-
Keep patient in a cheerful mood. Do not hurry the patient. Feed the patient at his own speed.
- Use tact rather than force in trying to get patient to take his food. - Encourage to chew his food well. - In carrying liquids to the patient in a cup or glass, always carry them on a small tray or saucer. - Allow the patient to do as much as possible without help.
Purpose
To be sure the patient receives adequate nutrition.
To promote the patient well-beings.
Equipment
-
Extra pillow, if not a gatch bed.
- Food on a clean tray. - Drinking tube or feeding cup, if needed. - Over bed table. - Towel.
Procedure
-
Make the patient comfortable. Elevate head and shoulder if Protect the patients gown and bed with towel. Arrange tray conveniently. Place tray where it can be reached Feed patient as indicated. Observe the amount, any special likes or dislikes. Chart amount of food taken, reaction to food. i.e. nausea,
permissible. easily. -
vomiting and pain. For liquid diets, the exact amount should be charted.
Precaution in feeding
- Serve food at the correct temperature. - Offer fluids during the meal. - Give patient enough time to chew & swallow.
Page 103
UNIT SEVEN
Collecting patient specimen Learning objectives
Assist the patient in laboratory diagnosis. Collect specimen with accuracy as indicated. Definition of Specimen A Sample or part of thing, or of several things, taken to show or to determine the Character of the whole, as a specimen of urine A preparation of tissue for pathological examination or of a normal tissue, organism of its structure. It refers to the collecting various specimen (samples) such as stool ,urine , blood and other body flood or tissue from the patient for diagnostic or therapeutic purposes.
General consideration for specimen collection

When collecting specimen wear gloves to protect self from contact with body fluids 1. Get request specimen collection and identifies the type of specimen being collected
2. Get the appropriate specimen container and it should be clearly labeled with the patients identification such as name, age, card number the ward and bed number, the time and date of the specimen collected. 3. Assemble and organize all the necessary materials for the specimen collection 4. Give adequate explanation to the patient about the purpose, type of specimen being collected and the method used. 5. When collecting the specimen wear gloves to protect self from contact with the specimen (body fluid in particular) 6. Put the collected specimen to its container without contaminating outer parts of the container and its cover. 7. All the specimen should sent promptly to the laboratory, so that the temperature and time dont alter the content.
Collecting urine specimen:Urine: - the of water & waste products excreted by the kidneys. Urinalysis: - laboratory analysis of the urine. Urine specimen: - The analysis of urine is important indicator of a persons health status. Alteration in metabolism infection, renal disease, and fluid volume problems can be confirmed by examination of the urine. Characteristics of normal urine 96% water, 2 % urea &2% mineral. It is voided without pain and discomfort It is clear and light amber in color It has slightly aromatic ordure increasing when left to stay.
Has PH of 5-6 (slightly acidic) Specific gravity 1010 - 1030 Normal amount of excretion 1000 - 2000ml/24hrs.
Types of urine collection specimen 1. Clean voided urine specimen (also called clean catch or midstream urine specimen) 2. Sterile urine specimen--culture 3. Timed urine specimen -it is two types I. short period ---1-2 hours II. Long period ---24 hours:-occasionally urine is collected for 24 hours analysis for urine metabolites to evaluate the clients for abnormalities in metabolism, kidney function, hormone activities.
Purpose:A. For routine laboratory analysis: - Routine urinalysis is a common procedure performed on admission to the hospital and during physical examination. Reported information include the urine color and turbidity PH and specific gravity presence of protein, glucose, or ketones and the presence of bacteria, blood cells and sediment B. To check the presence of cells or microorganisms C. For culture and sensitivity tests:-culture refers to the growth of microorganisms in a specialized growth medium under precise condition (heat, moisture, nutritive ingredients, oxygen.)
Sensitivity (susceptibility to specific anti microbial drugs e.g antibiotic) can be determined during culture process.
[
Collecting stool specimen

Stool: - is solid waste products of digestion; feces. Purpose:-for laboratory diagnosis such as microscopic examination, culture and sensitivity tests. Types of stool specimen collection Stool specimen collection for culture. Stool specimen taken to grow bacteria & multiply to detect microorganism. Stool specimen collection for parasite. Stool specimen collected to detect parasite such as worms, protozoa etc. Stool specimen collection for occult blood. Stool specimen collected to detect hidden internal bleeding. N.B A person should not eat red meat for 3 days before the test. Hemorrhoids & menstrual periods also affect the test results. GENERAL CHARACTER OF STOOL Stool consists of food residues, bacteria, some white blood cells, epithelial cells, intestinal secretions, & water. The Characteristics to assess to identify GI problems are Frequency varies from person to person. The normal range for an adult is from two to three times per day to one to three times per week. Infants often
have 3-5 stools per day, but for adults & older children, passing stools more than three times a day or less than once a week may indicate a problem.
N.B Frequency of bowel movements is individualized, & it is not necessary to have a bowel movement every day.
Amount varies according to the amount & type of food ingested, fluid intake, & frequency of bowel evacuation. It is normally about 150gm per day. Because much fecal material is not dietary in origin, the person with no oral intake still passes stool. Also, it may take several days for food to move through the entire GI tract. Therefore, the colon is not empty even if the person has not eaten for several days. Color The normal brown color of stool is produced by bile pigments. Absence of bile causes the stool to be white, gray, or clay colored & may indicate bilary obstruction or acholia a lack of bile production. White stool also result from barium or antacid. Black stools may result from charcoal, iron intake, or upper GI bleeding, especially if the feces have a tar like consistency. This tary black stool is called melena. Red colored stools are caused by the ingestion of beats, anti-parasitic agent or maybe the result of bleeding in the lower GI tract where the red blood cells have not been hemolyzed by digestive processes in the intestine. If this red color is smeared on the surface of fecal mass, hemorrhoid may be the source
[
Consistency - The consistency of stool is often reflection of the water content, but other constituents may play a part. Steatorrhea, for example, is the passage of greasy stools that tend to float and are mixed with observable fat and mucus. This indicates malabsorption of fats.
Page 108
Shape - The shape normally resembles that of the rectum. Abnormal finding would be that of consistently narrowed, pencil-shaped stool, which indicate obstruction of the distal-portion of the large intestine, as might occur with carcinoma. Odor - the Odor of the stool is characteristically pungent and is produced by bacterial flora present and by the food and medication ingested. Blood and infection in the GI tract causes detectable noxious changes in the normal Odor.
Taking blood specimen

Is collection of blood for examination. It involves withdrawal of blood. Purpose: - for diagnostic purpose Type of taking blood specimen Blood test which require no special preparation. Blood test which require fasting i.e. no food is given for eight to twelve hours (after the evening meal). Sites of taking blood specimen Vein Venipuncture: - the procedure for blood sampling known as venipuncture, involves puncturing the vein with a needle for the purpose of blood withdrawal. Aseptic technique is used during the procedure. The most common site for veinipuncture are the antecubital area (basalic, median cubital, or cephalic veins), or the dorsal surface of the hand (the dorsal metacarpal, basilica, or cephalic veins).
Page 109
To obtain sample using venipuncture, the nurse applies an occluding tourniquet above the area where the sample will drawn; cleans the area with antiseptic solution ;pierces the skin with the bevel of needle up and with draw the blood sample in to syringe or vacuum tube. Pressure is applied to the venipuncture site for 1-2 minutes until the bleeding has stopped. \
Artery Arterial puncture Performed to evaluate blood gases, which indicate the metabolic, oxygen & ventilatory status of the client. The radial artery at the wrist is preferred because it is superficial and easily palpable, but occasionally brachial and femoral arteries are used pressure should be applied over the punctured site for at least 5 minutes to prevent bleeding and hematoma formation. Capillary Capillary puncture Fingers or heel pricks with a lancet can be used to obtain small samples of capillary blood for analysis. Most commonly, this method of blood sampling is used for glucose, hematocrite, or peripheral blood smear studies, or for phenylketoneuria test in newborns.
Page 110
Obtaining a capillary sample can be aided by warming the finger or heel or placing the extremity in a dependant position to improve blood flow. To acquire the capillary blood sample, the skin is cleansed, usually with alcohol. Wear glove and the point of the lancet is briskly pierced through the skin. If a finger is used, the side of the finger pad, rather than the center, is pricked; this is less painful for the client. Likewise, the side of the heel should be selected for infants. Precaution The specimen should be clearly labeled with the patients name, hospital number, ward, date and time of collection. Clean puncture site using antiseptic swabs. Send immediately to laboratory. Use universal precaution. Apply pressure over the puncture site after all venipuncture. If bleeding continues, have the client elevate the area & continue to hold pressure.
[
Taking sputum specimen

Sputum is mucus secreted & produced by the mucus membrane of the respiratory tract in response to infection & congestion. Normal respiratory secretions are clear, white, has no odor & is of medium consistency. Sputum that is thick & sticky is usually difficult to expectorate. It may indicate that the patient is poorly hydrated. Sputum that is yellow or greenish or has a putrid (decaying) odor usually indicates infection. When infection is suspected, a sputum sample should be collected & sent to laboratory for
Page 111
examination. The best time for specimen collection is in the morning. up on awakening (that have been accumulated during the night). Purpose For culture & sensitivity test For cytological examination. Acid fast bacillus (AFB) test. To assess the effectiveness of the therapy. Precaution Keep privacy. Do not contaminate the outer part of the container. Ask patient to cough deeply to raise up sputum. Give oral care following sputum collection. Always follow standard precautions & blood borne pathogen standard when collecting a sputum specimen. Taking other body discharge specimen Specimens of tissue exudates, nasopharyngeal discharge, & vaginal & cervical discharge are obtained by a swab. Purpose: - for laboratory diagnosis such as microscopic examination, culture and sensitivity tests. Precaution
wear gloves to protect self from contact with the specimen (body fluid in particular)
Page 112
UNIT EIGHT Taking patients vital signs

Learning objectives
Compare normal and abnormal vital sign assessments Discuss nursing responsibilities in assessing vital signs Describe the equipment necessary to assess vital signs
Identify sites for assessing T, P, and Bp.
Describe advantage and disadvantage of using each body temperature sites Identify indication and contraindication for using oral, rectal and auxiliary body temperature sites. Describe various methods and sites used to measure blood pressure
The vital or cardinal signs

Vital signs are signs that reflect changes in the functions of the body. They are: Temperature
pulse rate
Respiratory rate Blood pressure Are the most important signs that reflect or show changes in the function of the body Careful attention to the details of vital sign procedures and accuracy in the interpretation of findings is extremely important. Time to asses vital signs - Assessing vital sign is part of nursing care in any setting
Page 113
- monitoring a clients vital signs should not be an automatic or routine procedure. It should be thoughtful, scientific assessment. - When and how often to assess a specific clients vital signs are chiefly nursing judgments, depending on the clients health status. Some agencies have policies about taking clients vital signs, & physicians may specifically order a vital sign. We need to assess vital signs:-
On admission to a health care agency-to obtain base line data. When a client has a change in health status or reports symptoms such as
feeling faint. - Before and after surgery or an intensive diagnostic procedure.

-
Before and after administration of medication that could affect V/S e.g. Before and after any nursing intervention that could affect V/S. In an emergency situation.
before giving Digitalis.

-
Measuring blood pressure

Blood Pressure: - Is a measure of pressure exerted by the blood as it flows through the arteries. There are two blood pressure measures Systolic BP: - As a result of contraction of ventricles of the heart - Blood is forced out of the heart - Pressure in blood vessels is the highest Diastolic BP: - As a result of ventricular relaxation - less force is exerted against the walls of blood vessels - Ventricles relaxed and filled with blood.
Systolic reading- 1st sharp clear thumping sound heard when valve of BP apparatus is opened Diastolic Reading - 2nd dull or muffle sound pulse Pressure:-is the difference b/n systolic and diastolic pressure. - Standard unit of measuring BP is millimeter of mercury (mmHg) and is recorded as fraction. Numerator is systolic pressure and denominator is diastolic. Purpose To obtain baseline measures of arterial blood pressure for subsequent evaluation
To determine the clients hemodynamic status disease process and medical therapy.
To identify and monitor changes in blood pressure resulting from a
Position of taking blood pressure Position the client in a sitting position unless otherwise specified. The arm should be slightly flexed with the palm of the hand facing up and the fore arm supported at heart level. The blood pressure is normally similar in sitting, standing, and lying positions, but it can vary significantly by position in certain persons and may need to be measured in all three positions. The blood pressure increases when the arm is below heart level and decreases when the arm is above heart level.
Sites for taking blood pressure

Upper extremity:-the blood is usually measured in the arm with cuff wrapped around the upper part of the limp and the flow auscultated or palpated at the brachial artery.
Page 115
Lower extremity: - The cuff wrapped around the thigh or above ankle (mid thigh). The flow is auscultated or palpated over popliteal artery. It requires a large cuff. A systolic blood pressure in the thigh is generally 20 to 30 Hg higher than that measured in the arm. Factors affecting blood pressure Age: - The pressure rises with age, reaching a peak at the onset of puberty, & then tends to decline somewhat. In elderly people, elasticity of the arteries is decreased (more rigid) & less yielding to the pressure of the blood. This produces an elevated systolic pressure. Because the walls no longer retract resulting in higher diastolic pressure. Exercise: - Increased metabolism == increased CO ==increased Bp -Blood pressure should not be measured right after exercise. Stress: - Stimulation of the sympathetic nervous system increases cardiac output & vasoconstriction of the arterioles, thus increase in the blood pressure reading. However, severe pain can decrease blood pressure greatly & cause shock by inhibiting vasomotor center & producing vasodilation. Obesity:-pressure is generally higher in some overweight and obese people than in people of normal weight, increased cardiac output = increased blood pressure. Sex: - After puberty, female usually have lower blood pressure than male of the same age; this difference is thought to hormonal variations. After menopause, women generally have higher blood pressure than before. Medication: - Many medications my increase or decrease the blood pressure. Diet: - a high-sodium diet increases the amount of water in the body. The extra fluid volume increases blood pressure.
Page 116
Position: - blood pressure is generally lower when lying down & higher in the standing position. Sudden changes in position can cause sudden changes in blood pressure. A person who stands suddenly may have a sudden drop in blood pressure. Dizziness & fainting can occur. Smoking: - increases blood pressure. Nicotine in cigarettes causes blood vessels to narrow. Normal fluctuation:-blood pressure fluctuates from minute to minute in response of variety of stimuli. Diurnal variation: - Pressure is usually lowest early in the morning when the metabolic rate is lowest. Abnormalities
-
Hypertension:-is the condition in which blood pressure is chronically higher than normal (120/80). Hypotension:-is the blood pressure below 100/60. Orthostatic hypotension :-inadequate compensation to position change results in orthostatic hypotension
Normal Blood Pressure Value

Age New born - - - - - 1 month - - - - 1year 6 Year 10-15 Year 14-17 Year 18+ Year Average BP 85/54 mmHg - 95/65 mmHg 105/65 mmHg 110/65 mmHg 120/80 mmHg120/80 mmHg Hypertensive BP - Undetermined >= 110/70 mmHg >=120/85 mmHg >= 125/85mmHg >= 135/90 mmHg >= 140/90 mmHg 40mmHg (systolic) - - - - - - - - - Undetermined
N.B- Adults of any age with BP above 140/90 should be evaluated for hypertension Ruman Abdurashid- Menilik H.S.College Page 117
Common errors in taking blood pressure measurement - Use of a wrong size cuff - An correct positioning of arm
-
Not using the same arm consistently. Not having the gauge at eye level Deflating the cuff too slowly or too quickly.
- Mistaking an auscultatory gap Do not attempt to measure BP using an arm that is the site of an intravenous infusion, a cast, paralyzed, or injured limb and if edema is present. If you are not sure of accuracy, wait 30 to 60 seconds before repeating the measurement. Equipments - Stethoscope - Sphygmomanometer - Pencil or pen - v/s sheet - Alcohol wipes Procedure - Assemble the equipment needed - Great the pt and explain the procedure - Have person sit or lie down. - Position the persons arm so it is level with the heart. - Support the arm, with palm of the hand facing up ward on the bed or table
-
Roll the sleeve of the gown up above the elbow.
Page 118
Place the arrow on the cuff over the brachial artery. Wrap the cuff around the upper arm. Locate the brachia artery with the fingers place the stethoscope directly over the artery. Place stethoscope earpieces in your ears. Close the valve attached to the air bulb and inflate the cuff until you can no longer feel the pulse. Inflate the cuff 30mmHg beyond the point where you last felt the pulse.
Slowly open the value and let air escape until the first sound is heard. At this first sound, note the reading on the gauge. This is the systolic pressure. Not the pressure at which the sound first become muffled. Also observe the point at which the sod completely disappears. Take this as diastolic pressure.
Blood pressure readings which seem abnormal or are difficult to hear should be rechecked.
- Remove cuff, expel the air, and replace the equipment - Record the blood pressure as a fraction
Measuring pulse rate Pulse

Def:-Is a wave of blood created by contraction of the left ventricle of the heart i.e. the pulse reflects the heart beat or in the same as the rate of ventricular contraction of the heart. In same types of cardiovascular disease heart beat and pulse rate are not detectable in peripheral pulse (far from the heart). Peripheral pulse is a pulse located in the peripheral of the body e.g. in the foot and, or neck
Page 119
Apical pulse (central pulse), it is located at the apex of the heart. The pulse rate is expressed in beat/minutes (BPM). Purpose To obtain baseline measures of heart rate for subsequent evaluation. To assess the adequacy of the blood flow to a certain area. To assess the rate, rhythm, volume and tension of a pulse that may reflect general problems, such as a slow heart rate. To compare the normal to abnormal heart rate Factors affecting pulse rate A pulse rate varies according to a number of factors. The nurse should consider each of the following factors when assessing a client's pulse.
1. Age:- As age increases, the rate gradually decrease 2. Sex: - After puberty, the average male's pulse rate is slightly lower than the
females.
3. Exercise: - The pulse rate normally increases with activity. The rate of
increase in the professional athlete is often less than in the average person because of greater cardiac size, strength, & efficiency.
4. Fever: - The pulse rate increase s (A) in response to the lowered B/P that
results from peripheral vasodilatation associated with elevated body temperature and (B) b/c of the increased metabolic rate.
5. Medication:- some medication decrease the pulse rate, and other increase it
(e.g. digoxin, Epinephrine)

6. Hemorrhage:- Loss of blood from the vascular system, normally increase
pulse rate (compensates for temporary adjustment)

7. Stress: - In response to stress, sympathetic nervous stimulation increase the
overall activity of the heart.

8. Position changes:-Sitting or standing position Increases the pulse rate b/c
blood usually pools in dependent vessels of the venous system. pooling results in a transient decrease in the venous blood return to the heart & reduction in blood pressure and increase in heart rate.
Pulse sites
1. Temporal:- artery over temporal bone of the head when radial pulse is not
accessible
2. Carotid:- at the side of neck below the lobe of the ear, where the carotid
artery runs b/n the trachea & sternocleido mastoid muscle used for infants & cardiac arrest.
3. Apical: - at the apex of the heart left side of the chest, in an adult this is
located on the left side f the chest, no more than 8 cm to the left of the sternum and under fourth, fifth, or sixth intercostals space (area between the ribs). Routinely used for infants & children up to 3 years age.
4. Brachial: - at the inner aspect of the biceps muscle of the arm (used to
measure blood pressure).

5. Radial: - where the radial artery runs along the radial bone, on the thumb side
of the inner aspect of the wrist (readily accessible and routinely used).
6. Femoral: - Where the femoral artery passes alongside the inguinal ligament
(used to determine circulation to leg).

7.
Popliteal:- where the popliteal artery passes behind the knee( used to determine circulation to the lower lip , to determine leg blood pressure), difficult to find but it can be palpated if the client flexes the knee slightly.
8. Posterio tibal: - On the medial surface of the ankle where the posterior tibial
artery passes behind the medial malleolus .
Page 121
9. Pedal ( dorsalis pedis):- where the dorsalis pedis artery passes over the bones
of the foot. It is palpated by feeling the dorsum (upper surface) of the foot on an imaginary line drawn from the middle of the ankle to the space between the big & second toes.
Normal Pulse Rate per minute at various age Age New born 1month 1 month 2 month 12 month 2yrs 2- 6yrs 6 12yr 12yrs & older Approximate range 120-160 80- 140 80-130 75- 120 75-110 60-100 App. Average 140 120 110 100 95 80
Over 100 beats per minute in adult referred to as tachycardia (an excessively
fast heart rate) & a heart rate in an adult of 60 beats per minutes or less is called bradycardia.
Assess the pulse for

Rate Rhythm Volume
Pulse Rate
Normal 60-100 /min (80/min) Tachycardia-excessively fast heart rate (>100/min)
Bradycardia <60/min
Pulse Rhythm
The pattern and interval between the beats. Irregular beats- dysrythymia or arrythemia.
Pulse volume
Also called the pulse strength or amplitude. Is the force of blood with each beat. A normal pulse can be felt with moderate pressure of the fingers and can be obliterated with greater pressure. Forceful or full blood volume obliterated with difficulty is called Full or bounding pulse A pulse that is readily obliterated with pressure from the fingers is referred to as Weak, feeble or thready. If the pulse is regular, measure (count) for 30 seconds and multiples by 2 & if it is irregular count for 1 full minute. Equipments used 1. Watch with a second hand 2. Vital sign sheet and pen 3. Stethoscope Procedure for taking radial pulse - wash hands - explain the procedure to the client - Position the client comfortably with for arm across chest or at side wrist extended
Page 123
Place your three middle fingers along the groove at the base of the thumb on clients wrist
- Press against radial artery when pulse is felt, exert slight pressure and count for 1 minute - Assess pulse for regularity, strength - Wash hands - Chart the rate, time and character of the pulse Taking Apical Pulse 1. Counted by placing stethoscope over the chest on the lower part of the heart 2. Wash hands 3. Explain the procedure 4. Position client in supine or sitting position and sternum and left chest exposed 5. Warm stethoscope by holding in the palm of hand for 5-10 seconds 6. Insert the ear pieces of stethoscope in to your ear and place the diaphragm over the apex of the clients heart 7. Assess the heart for regularity and asthmas 8. Count for 30 sec if regular for 1min if irregular 9. Place clients gown and assist in returning to comfortable position 10.Wash hands 11.Chart Pulse Deficit: - the difference b/n the apical and radial pulse rate Two nurses are needed One listens with a stethoscope over the apex of the heart beat.
Other: - counts the rate at the radial artery
One watch for the two nurses Start coating simultaneously

Counted for 1 full minute and record their counts Cautions

-
Do not make to great pressure Do not use thumb to feel pulse
Respiration
Definition: - Is the act of breathing air into the lungs (inhalation) and out of the lungs (exhalation). 0xygen is taken into the lungs during inhalation. Carbon dioxide is moved out of the lungs during exhalation. The chest rises during inhalation & falls during exhalation. External respiration refers to the exchange of O2 & CO2 b/n alveoli & pulmonary blood. Internal respiration, by contrast, takes place throughout the body; it is the exchange of O2 & CO2 b/n circulating blood and cell of body tissues. Hyperventilation very deep rapid respiration Hypoventilation very shallow respiration Respiration is made up Four Parts the lungs the thoracic cavity respiratory control center in the brain the nerves and nerve tracts that connect the brain and the muscle Basically there are two types of breath that the nurse observe
1. Costal or thoracic breathing (can be observed by chest movement upward &
down ward. involves chiefly the external intercostals muscles and other accessory muscles, such as the sternocleidomastoid muscles.
Page 125
2. Diaphragmatic (abdominal) breathing: involves the contraction and
relaxation of the diaphragm, and observed by the movement of the abdomen. Purpose To acquire baseline data against which future measurement can be compared. To monitor abnormal respirations & identify changes. To asses respiration before the administration of a medication (e.g. Morphine if abnormally slow, you may withhold the medication). To monitor respiration following the administration of a general anesthetic or any medication.
To monitor clients risk for respiratory alterations (e.g. those with fever,
respiratory infection, pulmonary edema, chest trauma ..). Factors affecting Respiration
Age:-normal growth from infancy to adult hood results a larger lung capacity that lowers RR because if the lung capacity is high it is sufficient to exchange air. ( infants & children have higher respiratory rates than adults).
Fever:-heat loss from the lung and metabolism rate increase this result in increasing respiratory rate. Increased altitude:- Decreased oxygen concentration & increased RR Medication ( i.e. narcotic, analgesic) - decrease RR Stress: - Stimulate sympathetic - readies the body for fight or flight -increases respiratory rate and depth of respiration. Exercise: - Increases metabolism - increase RR because when people exercise the tissue needs more oxygen. Gender:-men have less respiratory than women because men have larger lung capacity.
Page 126
When assessing respiration check (observe) 1) Rate 2) depth 3) rhythm 1. Rate: - breaths per minute Age At birth 1 year 2 years 8 years 16 years 20 years
[
RR Average 35 30 25 20 18 16
RR Range 30 -80/min 20-40/min 20-25 /min 15-25/min 15-20/min 12-20/min
Eupnea - respiration that is quiet, rhythmic, and effortless. Tachypnea or polypnea:-is abnormally fast respiratory rate marked by quick, shallow breath. Usually >20 Bradypnea: - is abnormally slow breathing. Usually <12 Apnea: - cessation of breathing. 2 Depth: - the depth of a person's respirations can be established by watching
the movement of the chest. It is described as normal, deep, or shallow. Deep respirations are those which a large volume of air is inhaled and exhaled, inflating most of the lungs. Shallow respiration involves the exchange of small volume of air and often minimum use of lung tissue. 1. Shallow respiration(usually rapid)commonly found in shock, lung disease 2. deep respiration (usually slow) common in air hunger
During a normal inspiration and expiration an adult takes in about 500ml of air. This volume is called Tidal volume. 2. Rhythm:Refers to the regularity of the expiration & the inspiration. It can be described as regular or irregular. An infants respiratory rhythm may be less regular than adults. Respiration should be regular in rhythm and depth. Equipment
-
Watch(2nd hand)
- Paper and pen or pencil Procedure

-
The client should be at rest position put your hand as if the pulse were Count the rise and fall of the chest for min or 1min. Observe the rate and regularity, depth abnormal sound, color of the pt. Dont let pt know that his respiration is being counted. Observe the rate, depth, & rhythm.
taken.
-
- Chart procedure, time & observation. Terms

Ventilation: - word that is used to refer the amount of air in and out of
the lung
Hyperventilation:- an increase in the amount of air in the lung, refers
very deep, rapid respiration

Hypoventilation:- a reduction in the amount of air in the lung, Refers
to very shallow respiration Stridor respiration

a shrill, harsh sound heard during inspiration Due to obstruction in the upper air passages (laryngeal
obstruction).Difficulty in getting the air in. Wheezing Continuous, high-pitched musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moved through a narrowed or partially obstructed air way. Common: - in asthma Apnea Temporary cessation of breathing Dyspnea Is forced, difficult or labored breathing Accompanied by pain and cyanosis Orthopnea
Is inability to breath while except in upper right position
A person is to sit or stand to breath comfortably Cheyne-Stokes breathing Cyclic breathing pattern characterized by period of respiration of increased rates &depth alternating with period of apnea. Periodic breathing usually found in terminal states (near death ) Rhythmic waxing and waning of respiration from very deep to very shallow breathing and temporary apnea Gradually up in rate and depth until it reaches a climax(hyperpnoea)
Asphyxia when lungs do not get a sufficient supply of fresh air to the vital organs and they are deprived Kussmauls breathing is abnormally deep but regular characterized by increased rate and depth
Measuring patients body temperature

Body Temperature: - Is the balance b/n the amount of heat produced & the amount of heat lost from the body. There are two kinds of temperature Core temperature and surface temperature. Core temperature is the temperature of the deep tissues of the body, such as cranium, thorax, abdominal cavity, & pelvic cavity. It remains relatively constant. Surface temperature:-is the temperature of the skin, the subcutaneous tissue, and fat. It by contrast, rises and falls in response to the environment. Hypothalamus: - is center for heat regulation. Thermometer: - is an instrument used to measure body temperature. Different thermometers are used for oral and rectal temperature Rectal thermometer have a flat or blunt end this will prevent injury to the rectum. Thermometer must be clean before being put in to the pts mouth or rectum.
Purpose To obtain baseline data for subsequent evaluation. To determine changes in the body temperature in response specific therapies (e.g. antipyretic, invasive procedure).
To monitor clients at risk for alteration in temperature (clients at risk
for infection.). To compare the normal to abnormal temperature. Factors affecting body temperature
Age: - The infant greatly influenced by the temperature of the environment and must be protected from extreme changes. They are sensitive to extremes in the environment temperature due to decreased thermoregulatory control.
Environment: - Extremes in environmental temperatures can affect a person's temperature regulatory systems. Diurnal variation (circadian rhythms):- Body temperature normally changes throughout the day, varying as much as 1OC (1.8OF) b/n the early morning and late afternoon.
Exercise: - Hard work or strenuous exercise can be increase body temperature to as high as 38.3 to 40 OC (101 - 104) measured rectally. Stress: - stimulation of sympathetic nervous system can increase the production of epinephrine & nor epinephrine thereby increasing metabolic activity & heat production.
Hormone: - Women usually experience more hormone fluctuation than men. During ovulation progesterone rises by 0.3 - 0.6 OC
Food, fluids and smoking

Page 131
If a person had hot or cold liquids, you should wait 15 minutes. This allows the mouth temperature to return to base line. If a body temperature is measured orally immediately after a clients has been smoking the measurement may be altered 0.2OC
Sites for taking body temperature

A persons body temperature can be measured in four common sites

Oral (Mouth) - 370c Rectum - 37.5oc Axillary - (36.7oc) and Ear (Tympanic membrane) Each of these measures vary some what Rectal temperate reading is higher than oral (on average 0.6 OC) Axillary lower than oral (on average 0.6oc) Pts condition determines which is the best site for measuring the temperature.
Oral Route Most accessible and convenient Equipment

Oral thermometer in disinfectant solution. Soft tissue or cotton swab to wipe the thermometer. Pencil or pen to record the temp. Vital sign or worksheet.
Jar for used thermometers. Receiver for dirty cotton swabs. Procedure 1. Wash hands 2. explain to the pt what you plan to do
3. Remove the thermometer form its container. 4. If the thermometer is stored in disinfectant, wipe off the solution form the
thermometer with a soft tissue & rinse it under cold water, wipe from stem to bulb end using fingers in a rotating fashion.
5. Check the temperature reading on the thermometer. If necessary, shake down
mercury to below 95Of or 35Oc

6. Ask the pt to open his or her mouth, and place the thermometer at the base of
the tongue 7. ask the pt to close the lips, not the teeth and avoid talking 8. leave the thermometer in place for 2-3 minute 9. Remove the thermometer, wipe with a tissue or swab from stem to bulb. 10.Read the temperature (hold the thermometer at eye level, and rotate it until the mercury column is clearly visible.
11. Clean and shake down the thermometer & wash hands.
12.Record temperature on work sheet. Contraindication Unconsciousness Seizures prone pts Irrational pts Infants and young children Disease of the oral cavity Surgery of the mouth and nose Nasal obstruction
Pts receiving o2, cough
Just after hot drinks, smoking

Rectal Route Considered to be the most reliable b/c few factors can artificially Influence the reading but it is Inconvenient and more unpleasant. Equipment A rectal thermometer (short, rounded tip).
[
lubricant to lubricate the thermometer in order to ease insertion in to the rectum Pencil or pen to record temp. Soft tissue or cotton swab to wipe the thermometer. Vital sign or worksheet. Jar for used thermometers. Receiver for dirty cotton swabs. Procedure 1. Follow steps 1-5 in procedure above 2. Assist the pt to assume a lateral position but allow infants to remain in a supine position 3. place some lubricant on a piece of tissue then apply lubricant to the thermometer
4. With one hand raise the pts upper buttock to expose the anus 5. Ask the pt to take deep breath and insert the thermometer 6. Hold the thermometer in place for 2-3 minutes 7. Remove the thermometer 8. (follow steps 9-12 in above procedure)
Contraindication
New born & infants will result in ulceration rectal perforation.

Page 134
Pts having rectal surgery Pts having diarrhea Pts having disease of the rectum Axillaries route - Least accurate least reliable - Safest & most noninvasive.
-
The thermometer should be left in place a long time Preferred sites for measuring temperature in new born.
- Affected by number of factors bathing, friction

-
Equipment 1. The same as oral Procedure 1. prepare the equipments

2. Prepare the client (expose the client's axilla. If the axilla is moist dry it with
the towel using a pitting motion. Do not use friction). 3. Remove the thermometer form its container. 4. If the thermometer is stored in disinfectant, wipe off the solution form the thermometer with a soft tissue & rinse it under cold water, wipe from stem to bulb end using fingers in a rotating fashion.
5. Check the temperature reading on the thermometer. If necessary, shake down
mercury to below 95Of or 35Oc

6. Place the thermometer in the client's axilla and leave the thermometer in place
for 5-10 minutes.

7. Remove the thermometer and repeat steps 10 - 12 as above.
Page 135
Ear route (tympanic membrane) - Readily accessible and permits rapid readings
-
Equipment is expensive. Can be uncomfortable and involves risk of injuring membrane if the probe is inserted too far.
Types of devices used to assess or measure body temperature Thermometer: - is an instrument used to measure body temperature. 1) The glass mercury thermometer
2) Electronic thermometer: - They can provide a reading only 2 to 60sec
depending on the model. Consists of a battery-operated portable electronic unit.

3) Disposable paper thermometer:- are also manufactured these are used only
once 4) Tympanic membrane thermometer 5) Temperature sensitive strips Temperature values Temperature Values can be expressed in either of two scales.
1. Fahrenheit scale( OF ) 2. Celsius scale( OC )
Formula:1. 2.
O O
F to OC = 5/9( OF-32) C to OF = ( 9/5 x OC ) + 32
For example, when the Celsius reading is 40,

O
F= (9/5x 40) +32 (72) + 32 = 104OF
Page 136
For example, when the Fahrenheit reading is 100,

O
C = 5/9(100oF-32) 5/9 x 68 37.7 OC
Alterations in BT Normal body temperature is 37Oc or 98.6OF the range is 36Oc-38OC Pyrexia:-A body temperature above the normal ranges is called hyperthermia or in lay terms fever (38OC- 41OC) Hyper pyrexia
-
A very high fever such as 41OC >42OC leads to death A client who has a fever is referred to as febrile the one who not is afebrile.
Hypothermia Body temperature between 34oc-35oc, < 34oc is death. Common types of fevers 1. Constant fever - Remains at the same level for a period of time (constantly elevated), fluctuates minimally. fluctuates minimally but always remains above normal.
2. Intermittent fever -
Is when the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperature .
3. Remittent fever -
Wide range of temp fluctuation (more than 2oC) occurs over the 24hr period, all of which are above normal.
- But never falls to normal

Measuring Patients Body weight and Height

- Changes in weight are a frequent indicators of the patients condition - Baseline (original) measurement of height and weight is usually obtained on admission - Measurements of weight and height must be accurately made and recorded according to facility policy b/c medications may be ordered according to patient's size. - Height measurements may be recorded in feet and inches or in centimeters (cm) - Weight measurements may be recorded as pound or kilograms(kg) - Weight measurement can be done on a variety of scales the choose depends mainly on the status of the client Purpose of weight and height measurements Weight measurement can be used to evaluate fluid status. To provide baseline data. To assess response of the client to medical treatment.
It provides data regarding a persons general health & nutritional status.
Factors affecting body weight and height Clothes & shoes Full bladder Patient position when taking body weight and height
Weight
A) An up-right (standing) scale
- Is appropriate for the client with normal mobility who can step on to a plat form and maintain balance while weight is determined. B) A chair scale: - used when client can transfer to a chair but is unable to support the body in standing position. C) A bed scale: - Used for clients who is too weak or immobile.
Height
Is measured with a measuring stick attached to a standing scale - The client stands correct without shoes on the scale and the height is determined by lowering the sliding arm until it rests on the clients head Conversions (inches/centimeters)
To covert inches to centimeters

multiply inches by 2.54 to convert centimeters to inches divide centimeters by 2.54
Conversions (Kilogram/pound)
To covert kilogram to pounds

-
Multiply the number of kilogram by 2.2 Divide the number of pounds by2.2 Procedure 1. Carry out each beginning procedure action
To covet pounds to kilogram

-
Page 139
2. Check the balance scale for accuracy (before putting the patient on the scale,
set the weight on zero)

3. Place a paper towel on the scale plat form (protects patients from possible
infection)
4. Assist the patient to remove his shoes and help him step up on to the scale plat
form
5. Move the large weight to the closest estimated patient weight 6. Move the small weight to the right until the balance bar hangs free half way
between the upper and lower bar guides

7. Add the two figures and record the total as the patients weight in pound or
kilogram
8. While the patient is still standing on the scale, instruct him to stand erect 9. Raise the height scale rod so the top is above the head more the bar of the
height scale done until the bar rests flat on the paints head 10. Read the scale and recode the height on the chart
UNIT NINE
Assisting patient in physical examination Learning objectives
- Define terms associated with health assessment - Identify purposes of physical examination - Explain the four methods physical examination
Preparing complete equipment for a procedure

Definition: - A physical examination is a means of ascertaining the general condition of the body by a means of:
1. Inspection (looking). 2. Palpation (feeling). 3. Percussion (tapping with fingers), & 4. Auscultation (listening).
Purpose
- To determine the patients physical condition To AID:- Eye - Ear - Nose - Throat - Chest - Abdominal - Extremities - Pelvic or vaginal
-
Rectal examinations Help doctor in making a diagnosis
Types of examination Equipments for physical examination. General, ENT, chest, abdomen and extremities.
Stethoscope BP apparatus Percussion hammer Otoscope and ophthalmoscope Torch Tongue depressor
Page 141
Purpose -
Sheet or blanket Towel Hospital gown Any other equipment required Prepare the patient in such a way that the doctor may take a complete
examination with as little discomfort as exposure of the patients as possible Procedure -
Have quiet warm and free from draughts and well lightened room Offer patients bedpan before examination is started. Place articles to be used during examination on the table or trolley Assist doctor: for women patient in admitting room or private rooms
adjust light. must be attended by a female nurse. As far as possible nurse should remain with women patients in ward during entire examination. The nurse assistance is obligatory during rectal and vaginal examinations.
-
Reassure the patient and tell her what to expect. See that the patient is clean (may need to be given a bath before the
examination) patients should be undressed and wearing a hospital gown. He should be lying down with one pillow under the head and the knees slightly flexed & cover with sheet or blanket. Eye examination Equipment - Ophthalmoscope - Droppers
- Eye drops - Eye dressing - cotton - torch - eye chart - eye tray Procedure - obtain eye tray from central supply - hold patients in position - assist doctor as necessary Ear, nose and throat examination Equipment
-
Otoscope Nasal speculum and forceps Tunning forks Head mirror Tongue depressor Applicators, sponges, small dressings Cotton Emesis basin Torch or drop light Hydrogen peroxide Spirit Others solutions as required Ear currete
- ENT tray
Procedures - Obtain ENT tray from central supply Hold patient in position - Assist doctor as necessary Chest examination Position Dorsal and sitting Draping: remove gown or draw it well up across chest. Place bath blanket or towel across chest and fold clothes to waist line. Procedure Remove head pillows, exposes only part of the chest at a time. Always have patients turn his face away from the side the doctor is examining. Hold folded handkerchief in front of patients face when he is asked to cough. Precaution Much care should be taken to protect the patient from draughts and unnecessary exposure. Abdominal examination Have patient void before examination Position: dorsal Draping: blankets or sheet over chest and abdomen. Fold upper bedding to lower abdomen. Fold gown above waist line. Turn bath blanket up over chest when doctor is ready. Lower extremities Position : Dorsal
Draping. Cover genitalia with folded towel extending from lower abdomen between thighs to buttocks. Pleat top bedding, up from foot to about hip line, leaving lower extremities covered with blanket. Uncover one or both legs as desired. Pelvic examination
-
Have patient carefully clean. Rectum and bladder should be emptied before examination. Purpose
To examine condition of anus and rectum and in male the prostate gland. Position Modified dorsal recumbent, sims position, lithotomy. Preparation
- Explain - Empty bladder - Drape Draping Place a treatment pad (small rubber sheet covered with paper), under the hips then drape with blanket or sheet, exposing the patient as little as possible. Equipment - Right hand rubber glove or finger stall - Glove powder - Swabs in bowl - Kidney tray and paper bag
- Rectal speculum or proctoscope - Torch - Sponges forceps (a ). if a digital examination is to be made, supply the doctor with a glove,( sterile if a doctor so desires). Lubricate glove with lubricating jelly (b). If protoscopic or anoscopic examination is to be made, warm the proctoscope, lubricate with jelly or oil. Hold the light if doctor uses a head mirror (see that long applicators and cotton balls are at hand if needed for cleansing protoscope). (c) Clean patients after examination Vaginal examination Position Modified dorsal recumbent lithotomy, sims kneechest. Draping: place a treatment pad under the hips and drape with a sheet or blanket. Place drape over knees and lower abdomen make reverse twist in centre of drape, to cover thighs and feet if possible or lay untwisted blanket pushed up loosely over abdomen to make examination easier. Equipment
-
For ordinary digital examination supply of sterile or non sterile gloves with lubricant may suffice. If vagina or cervix is to be completely examined, torch or drop light and a PV tray are brought from central supply. It should contain at least the following equipments. (a) vaginal speculum (b) lubricant or sponges with
Page 146
solution bowl (c) sterile glove and towels (d) dettol 1-40 or savlon 1 percent After care of patient and equipment - Remove draping sheet and treatment pad then tighten bed covers and remake corners. Replace nightgown if soiled
-
See that patient is comfortable See that tray and all instruments are carefully cleaned. Special trays are to be sent back to central supply where the materials can be resterilized
List of some important instruments

Ophthalmoscope a lighted instrument used to examine the eye. Otoscope - a lighted instrument used to examine the external ear Percussion hammer Used to tap body parts to test reflex. It is Vaginal speculum Used to open the vagina so it &the cervix Nasal speculum Used to examine the inside of the nose. Tuning fork vibrated to test hearing. Laryngeal mirror - Used to examine the mouth, teeth, & throat.
& the eardrum (tympanic membrane).
also called a reflex hammer.
can be examined.

Keeping a patients privacy during physical examination Privacy: - a deserved degree of social retreat that provides a comfortable feeling or freedom from unauthorized intrusion (disturbance). Many people who inter a health care facility fear exposure & loss of identity. Providing privacy is more than luxury. It is necessary & vitally important to the individuals attitude toward health care.
UNIT TEN Cold and heat application Learning objectives

Describe various types of heat & cold application. Explain purposes of the procedure in the unit.
Mention different devices used in heat & cold application.
Demonstrate skill for application as ordered or required.
Application of Heat and Cold

Heat and Cold applications are not usually curative, but provide relief of symptoms
Unless administered competently heat and cold applications can produce complications such as, burns, tissue necrosis or further edema.
1.
Types of heat
2.
Dry heat Hot water bottle Electric blanket Electric heater Moist heat Hot compress Hot soak Sitz bath Dry cold Ice bag Ice collar Moist cold Cold compress Cold soak
1.
Types of cold
2.
Heat application Promotes healing & suppuration. Decrease inflammation by accelerating inflammatory process. Decrease musculoskeletal discomfort Cold application Controls bleeding. Decreases edema (decreases capillary permeability). Relives pain (decreases nerve conduction velocity; induces numbness or
paresthesia).
Tepid Sponge (Alcohol Sponge)

It is sponging of the skin with alcohol and water for the purpose of reducing the temperature. Tepid == slightly warm (Luke warm)
Purpose Precaution
To lower body temperature (fever).
Do not lower the temperature more than 1 OC at a time. Be cautious to avoid chilling the client. Before administering a tepid sponge, measure the patients temperature. Equipment for Tepid Sponge Washcloth Bath basin with tepid water (Slightly warm) and alcohol (one part alcohol to
three part water)
Face towel Bath towel Bath blanket, if available Rubber sheet Clinical thermometer
Procedure
Take equipment to bed side Replace the bed cloths with bath blanket Take pts. temperature , pulse, and respiration Remove patients gown Sponge the body using the wash cloth alternately use light stroke. Do not rub.
Do not squeeze the wash cloth and sponge each part two to three minutes
changing wash cloths as often as necessary
Put on clean gown Put on bed covers and straighten bed Make patient comfortable Clean used equipment and put away Check temperature half an hour after treatment Chart temperature, time and observation Applying hot water bottle
Dry Heat:-heat applied to the body without using moisture.
Hot Water Bottle Purpose To relax & relieve pain. To provide warmth to the body. To relieve pain & congestion. To relieve retention of urine. Precaution
Do not use it for abdominal inflammation this may provide perforation .E.g. appendicitis. Babies & patients with heart diseases should not be given hot water bottle. Properly wrap bottle before giving to any patient. Never place a hot water bottle next to an unconscious or paralyzed patient.
Never place a hot water bottle under the persons body.

Equipment
Hot water bottle Hot water bottle cover Hot water in a jug Clinical thermometer.
Temperature . about 54.4 OC Duration of Produce . Variable
Procedure
[

leaks
Fill bottle about one half to two-thirds with hot water Expel the air by placing the hot water bottle on a flat surface and press lower
half until water is seen at the neck close securely and dry the neck - Test bottle for
Cover hot water bottle Place on the part of the body to be treated Check the area frequently to prevent burning. Maximum effect occurs in 20-30 min. Remove after 30-45min. Refill as needed After completing the treatment empty the bag, wash & inflate with air and
hung it.
Applying hot compress

Heat Application
Purpose To relieve pain and muscle spasm

To relieve swelling ( increase blood flow) To relive inflammation and congestion Hasten suppuration (E.g. abscess) Reduce contracture and stiffness Relieve chilling Relax and give comfort
Precaution
Be careful not to burn the pt.
Precaution and contraindication for application of heat

1.
Mental status impairment. e.g. confusion, unconsciousness
2. Sensory impairment. pt. must be able to feel the heat 3. Inadequate thermal regulation e.g. Infants, small children, elderly persons 4. Impaired circulation e.g. peripheral vascular disease, heart disease, diabetes
5. Malignancy -accelerate growth

6. Hemorrhage 7. Skin disorder eg. Sunburn. 8. Pregnant women do not apply heat on abdomen may affect fetal growth or
cause mutation.
9. Do not apply during first 24-48 hrs of injury. May increase bleeding and
swelling. 10. Open wounds tissues are more sensitive to temperature changes. Cold can decrease blood flow to the wound, there by inhibiting healing.
Page 153
Cold Application
Purpose
To relieve pain (cold decrease prostaglandins which intensify the sensitivity of

pain receptors and to stop bleeding or hemorrhage).
To reduce swelling and inflammation ( by decreasing the blood flow to the

area (vaso constriction effect)
To reduce raised body temperature due to fever can be applied.

Dry cold--- Ice bag or collar Purpose Used for sports injuries e.g sprains strains, fractures to limit post injury swelling & bleeding.
Controls bleeding. Equipment Ice bag or collar
Cracked ice Ice bag cover Towel Procedure

Duration of procedure- 20-30 min
Fill ice bag about half full with ice Expel the air Check bag for leakage Fasten cap on tightly
Dry out side of the bag and put on cover Apply to the affected part Observe for reaction Refill as necessary After treatment is completed, wash and dry bag inflate with air and hang up Precaution and contraindication for Application of cold
1. Mental status impaired 2. Sensory impairment
3. Inadequate thermal regulation (Infants, Children and elderly patients).
4. Reaction to cold producing sever vasoconstriction 5. Sever cold hypersensitivity or cold allergy 6. Open wounds-causes damage 7. Condition as rheumatoid arthritis
8. Poor peripheral circulation (may cause tissue damage)
UNIT ELEVEN
Giving Enemas Learning objectives Define enema List purposes of different types of enema. Mention types of enema. Provide enema according to its purpose & needs.
Cleansing enema Enema is a solution introduced into the rectum & sigmoid colon for cleansing, therapeutic, or diagnostic purposes. Cleansing enema: - Is an enema which is given for cleansing or evacuating the colon from feces & flatus. It stimulates peristalsis by irritating the colon and rectum and by distending the intestine with the volume of fluid introduced.
Purpose
- To treat constipation & fecal impaction - To prepare the patient for an operation or delivery - To help establish regular bowel movement - For diagnostic test - before certain x-ray or instrumental examination to promote visualization - To keep the colon empty Precaution
-
Avoid too much soap because it produces sever irritation of the membrane of colon. This condition also makes examination of the Lower colon difficult
If rsistance is encountered at the internal sphincter ask the client to take deep breath, and then run a small amount of solution (relaxes the internal anal sphincter). Never force tube entry. If resistance persists, report.
Contraindication
Inflammatory bowel disease eg. Colitis.
Perforation of intestine. Peritonitis.

Paralytic ileus.
Cleansing enema can be

1. High enema - Given to clean as much of the colon as possible (Ascending, descending & transverse colon). -
Often used before diagnostic studies Amount of solution is 1000ml(500-1500ml) The fluid is administered at a higher pressure about 45 cm.
2. Low enema - Used to clean the lower portion colon (rectum) & sigmoid colon only. - Amount of solution is about 500ml. - For constipation but does not need to clean the higher portion of the Colon - The height at which the container of solution is held should be not more than 12-20cm. - For patients who is unable to retain large volume enema.
Types of solution used for cleansing enema

1. Tap water:-usually prepared in large quantity(500-1500ml) 2. Normal saline:- (Physiologic saline solution)
- is a salt solution made up by mixing one tea spoon of salt in a litter of water.(500-1000) 3. Soap Solution:-
Solid soap 1gm in 20ml of H2O.

Page 157
- Usually prepared in large quantity 500-1000ml (3 to 5ml soap to1000ml of water). - The purpose of soap in the water is to aid in stimulating peristalsis by chemical irritation to the mucus membrane aid thus loosen the feces.
4. Epsom salt (magnesium sulphate solution) -
15gm -120gm of mgso4 in 1000cc of H2O Type of enema Age The person ability to retain the solution. The following are approximate amounts:
The amount of solution to be administered depends on:-
Amount of solution Age Infants Toddlers Adolescent Adult Volume 250ml 250-350ml 500-750ml 750-1000ml
Temperature of the solution

-
For infants 100OFor 37.7OC For adult 40.5OC-43OC
Equipment for cleansing enema Tray containing - Enema can with tube
- Solution - Bath thermometer - Mackintosh with towel(water proof material) - Rectal tube - Clamp or connector - Lubricant - Swab in gallipots to lubricate rectal tube
-
IV-stand
- Glove - Warm, dry bed pan with toilet paper if patient is confined to bed - Tray cover - Receiver(kidney dish) - Screen - Bath blanket(if possible) Procedure 1. Explain purpose of the procedure to the patient. 2. Put the bed side screen for privacy 3. Prepare the amount of solution ordered (750-1000ml for an adult) 4. Bring equipment to bed side
5. Place the pt in left lateral position, with the right leg flexed.
6. Protect the bed with Mackintosh and towel 7. Check the temperature of the solution 8. Fill the enema can with solution 9. Expel air from tubing by allowing water to run through it then clamp 10.Lubricate the rectal tube(about 5cm)-facilitate insertion and minimize trauma
11.Expose only the buttocks by folding the top linen towards the other edge of bed 12.Separate the buttocks with one hand using toilet paper or gauze and insert the rectal tube 7-10cm in adults smoothly & slowly 5-7.5cm in the child 2.5-3.75cm in an infant 13.Open the clamp and allow fluid to run in, elevate the funnel to the point where the solution begins to flow slowly in to the colon -
The higher the elevation of the fluid the grater will be the rate of If the pt complains of cramps stop the solution for 30 seconds
flow in to the colon and pressure exerted on the colon. then start the flow at a slower rate. 14. After all of the solution has been instilled or when the client cannot hold any more & wants to defecate (the urge to defecate usually indicates that sufficient fluid has been administered), close the clamp & remove the rectal tube. Place the rectal tube in a disposable towel as you withdraw it. 15. Replace the equipment on tray. 16. Ask the client to remain lying down (easier to retain enema ). Finally Place the pt in a sitting position on the bed pan or assist him to go to bath room. 17. Observe the color and the presence of unusual constitutes. 18. Clean the patient, change his bed if soaked, and leave the patient comfortable.
19. Wash all your equipment thoroughly and sterile it before reuse 20. Record the time, result and effects on the patients. N.B Enema is most effective if solution is retained for 15 minutes. Retention Enema Definition is a type of enema retained in the bowel over a prolonged period. Purpose: To lubricate or soften a hard fecal mass& facilitate its expulsion To supply body with fluid To administer medication To protect and sooth the mucous membrane Types of solution Salad oil Mineral oil Liquid paraffin Olive oil Amount of solution Children Adult Equipment The same as cleansing enema but the tube for retention enema is smaller Procedure - Similar preparation is made
-
75-150ml 150-200ml
But the enema should be administered very slowly.

Page 161
NB 1- Most medicated- retention enema must be preceded by cleansing enema and patient should rest for hrs before giving retention enema. 2- If necessary, elevate foot of bed to help patient retain enema 3- Report and write on the report book, time of treatment amount and kind of solution used, purpose, reaction of patient, & length of time retained. 4- The patient should be instructed to retain the oil (for at least 30minuts for best cleansing result)
5- Dont attempt to break up fecal impaction before trying retention enema
Rectal Wash out Definition:-It is repetitive instillation of fluid into and drainage of fluid from the rectum by the action of siphonge. Total amount of 1000ml solution 100-200ml at a time Purpose - To prepare the patient for x-ray examination & sigmoidoscopy - To prepare the pt for rectum and colon operation ( to clean the rectum from mucus, blood and debris before rectal operation) Equipment Tray containing Large jug for the fluid Pint jug (small jug) Funnel, tubing & glass connecter Rectal tube and clamp
Swabs and towel Bucket/Bed pan Screen Lotion thermometer Solutions used Normal saline Sodium bi-carbonate solution(to remove excess mucus) Tap water Procedure 1. Explain the purpose of the procedure to the pt toughly 2. Prepare the solution ordered by the physician 3. Bring equipment to bed side
4. Screen the bed and place the patient in the right side lying position so that
the sigmoid colon is uppermost, thus facilitating drainage of the solution from the rectum & the colon with buttocks on the edge of the bed. 5. Place mackintosh and towel under the buttocks
6. Check the TO of the fluid and fill the small jug
-Temperature should be about 38oc or 100oF 7. Lubricate the catheter 8. Run the fluid though to expel air and then clamp it 9. Expose the anal region, separate the buttocks, with one hand and insert the rectal tube in to the rectum 10.Open the clamp and allow running about 100cc, of fluid in the bowel, then siphon back in to the bucket/bed pan. 11.Carry on the procedure until the fluid returned is clear.
12.Remove the tube and leave the patient comfortable. The amount returned should be measured to ensure that none has been retained 13.Record or chart the time, result and effect on the patient.
NOTE
Rectal wash out should not exceed for more than 2 hrs Give cleaning enema half hour before the rectal wash out. Rectal wash out should be finished one hour before examination or x-ray that is to give time for the large intestine to absorb the rest of the fluid.
Insertion of flatus tube (Rectal Tube)

Definition: - inserting a rectal tube into the rectum to relieve flatulence & intestinal distention. Purpose - For the relief of abdominal distention due to intestinal gas - Before giving a retention enema Equipment - Flatus or rectal tube - Lubricant - Gauze - Tape to attach the rectal tube to the buttock - Rubber tubing - Large bowel of water - Receive for used tubes - Water proof material & towel - Glass, Plastic connecter
Page 164
Procedure 1. Explain the procedure for the pt 2. Assist the pt to a left lateral position then fold back the bed cloth to expose anus 3. Lubricate the insertion tip of rubber tube(Rectal tube) 4. Gently insert the tube in to the rectum 10-15 cm for adult 5. Tape the rectal tube to the buttock. Attach the open end of the tube to a connecting tube/put in the basin or bowel of water/ 6. Leave the pt in a comfortable lateral position, after 30 minutes remove the rectal tube
7. Determine whether flatus has been expelled (by asking your patient or by
observe) & Palpate the abdomen for change in the degree of firmness and distention. Record insertion& removal of rectal tube, all observation.
UNIT TWELVE
Giving post mortem bath Learning objectives
Define death. Identify signs of death.
Provide care for the dead body with respect. Reassure relatives of the dying patient. Death Death is ending of life & all the vital processes. Legal death is the total absence of brain activities as assessed & pronounced by the physician.
Stages of dying
Kubler-Rosss stages of dying - Kubler-Rosss theory focuses on the dying as facing the loss of all that is important. According to this model, the terminally ill individuals move from denial & anger to bargaining to depression & finally to acceptance.
1. Denial serves as a protection from constantly being confronted with a
very painful reality.

2. Anger the response of anger is very often hardest on family &
caregivers.
3. Bargaining is a way of trying to postpone the inevitable e.g. looking for
a physician or treatment that will give a better bargain: life. However, the person reaches the point at which he or she realizes that the inevitable cannot be postponed. This leads into the next stage: depression.
4. Depression a period of depression through which terminally ill
individuals go is a very realistic period of grieving for all that is about to be lost as well as for the losses that have already occurred. The individual tends to withdraw from the world. Appetite may decrease, & sleep patterns may be altered.
5. Acceptance during this period the individual realizes & accepts the full
implication of the prognosis. There is a sense of closure on & satisfaction with the life that has been lived.
Post mortem care is a care of the body after (post) death (mortem).
Purpose
To perform the last duty and rites (burial) reverently (respectfully).
To protect other patients from sights and sounds which might frighten
them. To maintain the bodys appearance.
To prepare body for burial.
To prevent spread of infection. Signs of death Signs of death include: No pulse, respirations, or blood pressure. Pupils are fixed & dilated. A doctor determines that death has occurred & pronounces the person death. General instructions:1. If death occurs suddenly while the patient is in the ward, remove him to a
separate room. This must be done quietly so as not to disturb other patients in the ward. 2. Report the time of death to the ward sister and notify the doctor in charge of the case who certifies death.
3. Remove all the apparatus and other equipment & clean any blood &
secretions. 4. If the relatives are present, leave them alone with the body. Request them not to mourn loudly and disturb other sick patients. 5. If the relatives have not arrived, wait if possible until they do arrive. Find out if they wish you to prepare the body.
6. Try to meet the wishes of the relatives with regards to customs and religion
rites, for example, it may be necessary to inform religious personnel. 7. All valuables should be handed to relatives, and a signature taken in a register.
8. Always remember that the body is still dear to someone and when preparing
it, do not handle carelessly or allow unnecessary exposure. Equipment Gown, sheet, patients own clothing
Basin with water, wash cloth (bed bath equipment). and other articles
In case of infectious case dettol solution or Lysol 1-500 is used for bath Comb, hair oil and scissors. Bandage and cotton dressing adhesive. Waterproof bed protector Two ID tags. Procedure 1. Note the exact time of death & chart it. 2. Call doctor to pronounce death.
3. Determine if client has signed a donor card and / or has made a decision to
donate any organs.( kidneys should be removed within 1 hour after death. Eyes should be removed within 6-24 hours after death). 4. Collect articles and take them to the room. 5. Position the body supine. Arms & legs are straight. Put a pillow under the head & shoulder.
6. Close the eyes. Gently pull the eyelids over the eyes. Replace dentures if
the jaw has not yet stiffened. If there is any resistance, leave the dentures for the mortician. 7. Remove patients clothes. 8. Wash face, neck and ears.
9. Wash the remaining parts of the body as when giving a bed bath, step by
step.
10. Support the lower jaw in a natural manner with a soft, folded towel under
the chin. Do not tie the jaw closed with gauze (it leaves disfiguring marks). 11.Braid hair after combing.
12. If there is a wound, cover it with a clean dressing and strap with adhesive
tape. 13.Straighten & place the body on clean bedding in a natural position and with absorbent pads placed under the body to absorb leakage of urine or feces, which can occur as a sphincter muscle relaxes.
14. Put a clean gown on the body.
15.Fill out the ID tags. Tie one to an ankle or to the big toe.
16. Fold sheet neatly around the body & attach the second ID tag on the sheet.
17.Remove gown and the equipment to the utility room. Wash clean and dry store in place. 18.Wash hands. Legal issues & quality of life Much attention is given to the right to die. Many people do not want to be kept alive by machines or other measures. Consent must be given for any treatment. People make their own decisions when they are able. Some make their wishes known about prolonging death before the time comes.
Positioning & purpose of positioning a cadaver (dead body) The best position is most often supine with arms at the side or folded across the chest. OR tie limbs loosely together, using padding & gauze roll. Attach wrist & ankles, using proper alignment. Put pillow under the head & shoulder (promote drainage so the face will not become discolored. Place the body in the shroud or in morgue bag. Positioning needs to be done before the onset of rigor mortis. Rigor mortis is the stiffness or rigidity (rigor) of skeletal muscles as a result of chemical changes occurring in the muscle protein. It apparent first in the muscles of the jaw & progresses down ward towards the legs. The feet are the last to be affected. Rigor mortis usually begin to appear 2 to 3 hrs after death &is completed in 6 to 8 hrs.
UNIT THIRTEEN
Charting and writing Notes Learning objectives Define charting.

Explain the purpose of charting and writing notes. Identify rules of charting & writing notes.
Page 170
Charting: - is also known as medical record. Is writing notes in the patients record. Is a written account of a persons illness & response to treatment & care. It provides a way for the health team to communicate information about the person. The record is permanent &can be retrieved years later if the persons health history is needed. The record is a legal document. It can be used in court as evidence of the persons problems, treatment, & care. Written & verbal communication among health professional is vital to the quality of client care. Generally, health personnel communicate through discussions, reports, & records.
1. A discussion is an informal oral conversation of a subject by two or more
health care personnel to identify a problem.

2. A report is oral, written, or computer- based communication intended to
convey information to others.

3. A record is always written; it is a formal, legal documentation of a clients
progress. The process of making an entry on a client record is called recording or charting.
Purposes of client records or charts
Communication serves as the vehicle by which different health professionals who interact with a client communicate with each other. This prevents fragmentation, repetition, & delays in client care.
Planning client care each health professional uses data from the clients record to plan care for that client.
Page 171
Legal documentation the clients record is a legal document & is admissible in court as evidence. Research information from a number of records can be a valuable source of data for research. Records also provide a rich source of statistical information.
Education students in health discipline often use client records as educational tools. The records present a comprehensive picture of clients & their health related problems.
Quality assurance monitoring (nursing audit) the record can be monitored to assess the health care received by the client as well as the competence of the care giver. A retrospective review of the record can be conducted to determine whether care met specific predetermined standards.
Statistics - Statistical information from client records can help to anticipate & plan for peoples future needs. Some statistics, such as records of births &deaths, are required by law.
Rules of charting and writing notes

Make sure writing is legible & neat. Include the date & the time whenever a recording is made.
Chart only for yourself. Chart procedure or treatments after you complete them, not before. Correct errors in documentation as soon as possible.

Do not erase the error or use correction fluid. Draw a single line through erroneous information; write the words incorrect entry, error, or error in charting above it along with your name & write the entry correctly.
Page 172
Sign all entries with your name & title.
Do not skip lines. Draw a line through the blank space of a partially completed line or to the end of a page. This prevents others from recording in a space with your signature.
Avoid words with more than one meaning. Use familiar words.
Be accurate, concise, & factual. Donot record judgments or interpretations. Record in a logical & sequential manner. Chart any change from normal. Also chart that you informed the concerned personnel & the time you made the report. Do not omit information.
Crutch walking Crutches may be a temporary need for some people and a permanent one for others. Crutches should enable a person to ambulate independently. There are several kinds of crutches, the most frequently used are the under arm crutch (axillary crutch with hand bars) and Lofstrand crutch which extends only to the forearm.
Under arm crutch can be extended. It has double upright an underarm bar and a hand bar. Lofstrand crutch is a single adjustable tube of aluminum to which are attached a curved piece of steel a rubber covered hand bar and a metal forearm cuff. It is most useful as a substitute for a cane. The metal forearm and the metal bar stabilize the wrists and thus make walking safer and easier. The person can release the hand bar to use his/her hand and the metal cuff will hold the crutch in place while a cane would fall. The Canadian or elbow extensor crutch: Like the lofstrand, it is made of a single tube of aluminum with lateral attachment, a hand bar and a cuff for the forearm but it also has a cuff for the upper arm. This crutch is usually used by clients who require support to weak extensor muscles of the arm e.g. (weak triceps brachii). All crutches require suction tips, usually made of rubber, which help to prevent the crutches from slipping on a floor surface. Using crutches: follow the plan of exercises developed for you strengthen your arm muscles before beginning crutch walking have a health care professional establish the correct length for your crutches and the correct placement of the hand pieces. Crutches that are too long force your shoulders upward and make it difficult for you to push your body off the ground. Crutches that are too short will make you hunch over and develop an improper body stance.
The weight of your body should be borne by the arms rather than the axillae (armpits). Continual pressure on the axillae can injure the radial nerve and eventually cause crutch palsy, a weakness of the muscles of the forearm wrist and hand. Maintain an erect posture as much as possible to prevent strain on muscles and joints and to maintain balance. Each step taken with crutches should be a comfortable distance for you. It is wise to start with a small rather than large step. Inspect the crutch tips regularly and replace them if worn. Keep the crutch tips dry and clean to maintain their surface friction. If the tips become wet, dry them well before use Wear a tie shoe with a low heel that grips the floor Measuring clients for crutches During measuring for axillary crutches, it is most important to obtain the correct length for crutches and correct placement of the hand piece. There are two methods of measuring crutch length: 1. The clients lies in a supine position and the nurse measures from the anterior fold of the axilla to the heel of the foot and adds 2.5cm 2. The client stands erect and position and the nurse make sure the shoulder rest of the crutch is at least 3 finger width that is 2.5-5cm (1-2in) below the axilla. To determine the correct placement of the hand bar:
Page 175
1. The client stands upright and supports the body weight by the hand grips of the crutches.
2.
The nurse measures the angle of elbow flexion. It should be about 30o.
Crutch gaits: the crutch gait is the gait a person assumes on crutches by alternating body weight on one or both legs and the crutches. The five standard crutch gaits are the four-point gait, three-point gait, two-point gait, swing- to gait and swing through gait. The gait used depends on the following individual factors (a) The ability to take steps (b) The ability to bear weight and keep balance in a standing position on both legs or only one and (c) The ability to hold the body erect A physiotherapist or a physician usually decides which crutch gait is best for the client. Nurses may participate in decision making and teaching the technique some times. Clients also need instructions about how to get into and out of chairs and go up and down stairs safely. All these crutch skills are taught best before the client is discharged and preferably before clients surgery. Crutch stance (tripod position): Before crutch walking is attempted, the client needs to learn facts about posture and balance. The proper standing position with crutches is called the tripod (triangle) position. Four-point alternate gait
Page 176
This is the most elementary and safest gait, providing at least three points of support at each time, but it requires coordination. It does not require much space. To use this gait the client needs to be able to bear weight on both legs. Three-point gait to use this gait the client must be able to bear entire body weight on the unaffected leg. The two crutches and the unaffected leg beat weight alternatively. Two- point gait This gait is faster than the four-point gait. It requires more balance because only two points support the body at one time. It also requires at least partial weight bearing on each foot. In this gait arm movement is with the crutches are similar to the arm movements during normal walking. Swing-to gait The swing-to gait are used by clients with paralysis of the leg and hips. Prolonged use of this gait results in atrophy of the unused muscles. The swing-to gait is the easier of these two gaits. Swing through gait This gait requires considerable skill, strength and coordination Getting into a chair Chairs that have armrests and are secure or braced against a wall are essential for clients using crutches. Going up stairs During this crutch walking the nurse, stand behind the client and slightly to the affected side of if needed. Going down stairs For this procedure, the nurse stands one step below the client on the affected side if needed.
Unit one Introduction to basic nursing care 1. Gatch bed; a manual bed which requires the use of hand racks or foot pedals to manipulate the bed into desired position i.e. to elevate the head or the foot of the bed. It is commonly found in Ethiopia hospitals, is less expensive & free of safety hazard, handles should be positioned under the bed when not in use. 2. Nelsons bed: made with turning handle attached at the foot of the bed & allows patient to elevate from buttock leg& foot. 3. recovery bed: smaller than Gatch bed but has fixed side rails. It is used to provide safety. Bed side stand: is a small cabinet that generally consist of a drawer and a cupboard area with shelves. It is used for storing the utensils needs for clients care & storing personal items that are desired near by or that will be used frequently. Over bed table: it is use for holding the tray during meals or care items when completing personal hygiene. The height is adjustable. It can be positioned & consist of a rectangular, flat surface supported by a side bar attached to a wide base on wheels. It can be put a side, over the bed or over a chair.
Overhead light (examination light): is usually placed at the head of the bed, attached to either the wall or the ceiling .it is useful for client for reading or doing close work& for the nurse during assessment. If overhead light is not available, a moveable lamp can be used. Suction & oxygen outlets: suction is a vacuum created in a tube that is used to pull (evacuate) fluids from the body e.g. to clear
respiratory mucus or fluids. Oxygen is one of the gasses frequently used for health care today. Oxygen is derived through a tube. Electrical outlets: almost always available in the west and at the head of the bed. Call light: used for clients to maintain constant contact with care providers Collecting equipment for cleaning patient unit: Daily cleaning of the patients room (small separate room) is called concurrent cleaning (keeping the room neat& orderly). Cleaning after the patient is discharged or moved to another unit is called terminal cleaning. Nursing staffs are not responsible for actual cleaning of dust & other dirty materials from hospital but it is the staff nurses duty to supervise the cleaner who perform this job & proper destruction &disposal of used supplies, cleaning, replacing of equipments & cleaning the area occupied by the patient. Prevention of disease is a major objective of nursing care. Do not discard anything, which may be claimed by the patient or by members of his/her family. cleaning the unit also invoves washing & dusting the bed stand, the overhead table, the chair. Place the bedside stand on the left side near head of bed, leave the over bed table across the bottom of the bed. Place chair near the foot of the bed.
Page 179
Daily care of the patients unit Equipments -Basin of water -Closes for cleansing -Scouring powder (vim) or soap - Dirty container Procedures A. collect all refuse and dispose B. remove flowers, magazines and other article from the bedside table and clean the table C. collect waste and put in to wastebasket D. clean mirrors E. wash sink in the room F. wash the windows with soap and water and rinsed and dry with a clean dry cloth G. mope the bed with disinfectants solution and make up bed H.ventilate the room and expose to sunlight I. Clean water pitcher and refill fresh water J. inform the cleaner to sweep and mop the floor K. wash sputum mug L. leave room tidy and in order 1.3 Nursing process Nursing process is a systematic, rational method of planning & providing individualized nursing care. Its purpose is to identify a clients health status actual or potential health care problem or needs, to establish plans to meet the identified needs and to deliver specific nursing interventions to meet those needs. Components of the Nursing process The nursing process consists of a series of five components or phases: assessing, diagnosing, planning, implementing &evaluating. 1. Assessment/assessing: is collecting, organizing, validating, and recording data about a client health status. Data are obtained from a variety of sources and are the basis for actions and decisions taken in
subsequent phases. No conclusion about the data are drawn in this phase. Its purpose is to establish a database about the clients response to health concerns or illness & the ability to manage health care needs. 2. Nursing Diagnosis/ Diagnosing: is a process, which results in a diagnostic statements or nursing. It is the process of sorting, clustering & analyzing data. The nurse identify the actual& potential health problems for which the client needs nursing assistance and the factors contributing to this problem. 3. Planning: invoves a series of steps in which the nurse and the clients set priorities and goal or expected out comes to resolves or minimize the identified problems of the client. Its purpose is to develop an individualized care plan that specifies clients goals / expected outcomes and related nursing intervention. 4. Implementation/ implementing: is putting the nursing care plan into action. The nurse carries out the prescribed nursing activities or delegates the care to an appropriate person & validates the nursing care plan. Its purpose is to assist the client to meet desired goals/outcomes promote health & wellness, prevent illness and disease and facilitate coping with health problems. 5. Evaluation/evaluating: is assessing the clients response to nursing intervention and then comparing the response to the goals or outcomes criteria written in the planning phase. The nurse determines the extent to which the outcomes/goals of care have been achieved. Its purpose is to determine whether to continue, modify or terminate the plan of care.
Page 181
Unit Two Cleaning, sterilization, packing, taking care of equipments Sepsis means the presence of microorganisms. Asepsis means absolute freedom of from all microorganisms. Contamination: unclean condition when microorganisms are actually or potentially present. Infection: is the invasion of the body by germs or microorganism or organ or tissues dysfunction caused by microorganism Principle of infection prevention How microorganism (MO) spread? - MO move through space on air current - MO are transferred from one surface to another whenever objects touch - MO are transferred by gravity when one items is held above another - MO are released into the air on droplet nuclei Principles of infection control -Keep your hand away from your own hair and face - keep linen away from your uniform - always keep clean items separate from the dirty ones - avoid passing dirty items over clean items - place clean items on upper shelves and potentially dirty items on the lower shelves - when ever a person breath or speak so we must cover mouth, noise and avoid direct contact with the patient Categories of aseptic practices - medical asepsis- clean technique - surgical asepsis- sterile technique Cleaning: refers to the physical removal of the dirt and debris by washing, dusting or moping surfaces that are contaminated.
Technique under medical asepsis -Hand washing -Gloving -Gowning - Disinfection (using disinfectants) Surgical asepsis: those practices that produce or maintain equipments and areas that are free or microorganisms. Surgical operations are those -All procedures that invade the blood stream -Procedures that cause a break in skin or mucus -That involve dressing change and wound care Principle of surgical asepsis *Moistures may cause contamination - handle liquids carefully near sterile fields to prevent splashing - place wet object on sterile basin - never assume that an object is sterile - check the label - always check the integrity of the package - always face the sterile field -sterile articles may touch any sterile e - sterile equipment must be kept above the waist and on the top of the sterile field -prevent unnecessary traffic and air current around sterile area - close doors - do not cough, sneeze, and talk excessively Hand washing Hand washing is the single most important infection control method. - Nothing is more effective in preventing infection than hand washing - Hand washing is practiced at the beginning and end of shift of work
- Before and after contact of the patient - Between contact of with different patient - Before and after any procedures - After contact with any patient secretion or excretion (secretion e.g. vomiting excretion e.g. urine) Care of hospital and health care unit equipment 1. General instruction for all Nursing procedures 1. wash your hands before and after any procedure 2. Explain procedure to patient before you start 3. Close doors and windows before you start some procedures like bath and back care 4. Do not expose the patient unnecessarily 5. when ever possible give privacy to all patients according to the procedure 6. Assemble necessary materials before starting the procedure 7. After completion of a procedure, observe the patient according to the procedure, take care of all used equipment, & return to their proper place 8. record the procedure at the end 2. General instruction for care of hospital equipment - Use articles for the purpose for which they are intended. - Keep articles clean and in good condition. Use the proper cleaning method - Protect mattresses with rubber sheets - Use protective pillowcases on pillows - Do not boil articles especially rubber articles and instruments longer than the correct time
- Do not sterilize rubber goods and glass articles together wrap glass in gauze when sterilizing it by boiling - Protect tables tops when using hot utensils or any solution that may leave stain or destroy the table top. - Report promptly any damaged or missing equipment. Care of equipment in general
-Rinse used equipment in cold water. Remove any sticky material. Hot water coagulates the protein of organic material and tends to make it adhere - wash well in hot soapy water. Use an abrasive, such as a stiffbristled, to clean equipment. - rinse well in under running water - dry the article - clean the gloves, brush and sink
Disinfection is the process used to reduce the number of microorganism that are potentially pathogens from the surface of an object usually by chemical or physical means. Disinfectants minimize the growth of microorganisms but not the spores. Disinfectants are physical gents used on agents outside the body (e.g. alcohol, chlorine, formaldehyde)
Sterilization: is a complete destruction of microorganism including spores. some of the sterilization methods are discussed below.
-Steam sterilization: super saturated steam under pressure is the most widely used and a dependable method of sterilization. -Free steam: 100co (212F) is used to sterilize objects that would be destroyed at higher temperature and pressure of the autoclave usually it is necessary to steam the article for 30 minute on 3 consecutive days. The interval are required so that spores that are not killed will return to their vegetative state and again become vulnerable to the heat. -Gas sterilization: ethylene oxide is used to sterilize medical products that can not be steam sterilized e.g. plastic, rubber, cotton etc. -Dry heat/hot air: dry heat in the form of hot air is used primarily to sterilize anhydrous oils, petroleum products and talcum powder that steam and ethylene oxide gas cannot penetrate. In the absence of moisture, higher temperatures are required than when moisture is present because microorganisms are destroyed through a very slow process of heat absorption by conduction. -Boiling water: this is the most practical and inexpensive method for sterilizing in the home. The main disadvantage is that spores &some virus are not killed by this method. The water temperature rises no higher than 100co(212F). Boiling a minimum of 15 minutes is advised for disinfection of articles in the home. Sterile equipment: material, which is free of all form of microorganism. Pick up forceps: an instruments that allows one to pick up sterile equipment. -Pick up forceps should be kept inside the jar in which 2/3 of the jar should be filled with antiseptic solution.
-Wash pick up forceps and jars and sterilize daily -Fill jar with disinfectant solution daily -Care should be taken not to contaminate tip of the forceps -Always hold tip downward -If tip of forceps is contaminated accidentally, it should be sterilized before placing it back in the jar to avoid contamination.
Loading sterilizer All packages must be positioned in the chamber to allow free circulations and penetration of steam and to prevent entrapment of air or water. Steam must be able to displace air downward and out through the discharge line. Wire mesh or perforated metal shelves separate layers of package. Loading as follows -Place packs on edge so that flat surface are vertical -packages must not touch the chamber walls floor or ceiling - rubber goods are placed on edge loosely arranged one layer to a shelf to allow free steam circulation and penetration. No other articles should be with them. -basins or any solid containers are placed on their sides to allow air to flow out of them. Position that water cannot collect inside and condensate and wet the pack - solution are sterilize alone. To allow the temperature to drop slowly other wise the solution will boil over. Universal blood and body fluid precautions 1. wear clean gloves for listed body fluids -blood -semen -synovial fluid -pleural fluid
Page 187
- vaginal fluids -CSF - amniotic fluid
-peritoneal fluid - pericardial fluid
2. wash your hands thoroughly and immediately after accidental contact with body substances 3. wear masks and protective eye wear or face shield 4. wear a disposable, moisture proof apron or gown during invasive procedures 5. wear glove for general purpose of utility and instrument cleaning 6. wear a sterile glove for procedures involving contact with normaly sterile areas of the body 7. dispose of equipment and secretion properly 8. do not recap needles 9. initiation of appropriate barrier precaution and client education about immunization hygiene, sanitation, nutrition and appropriate food handling practice are other examples of planned nursing strategies to prevent infection.
UNIT THREE ADMITTING AND DISCHARGING A PATIENT B.Admission: is the process of receiving a new patient to an individual unit (ward) of the hospital. Hospitalized individuals have many needs and concerns that must be identified then prioritized and for which actions must be taken. Purpose -to help a new patient to adjust to hospital -to alleviate the patients fear and worry about the hospitalization.
Page 188
Nurse responsibilities during admission of a patient to hospital 6. check for orders of admission 7. assess the patients immediate need and take actions to meet them. These needs can be physical (e.g. acute pain ) or emotional distress, (upset) 8. make introduction and orient the patient -greet the patient -introduce yourself to the patient and the family -explain what will occur during the admission process (admission routines) such as admission bath, put on hospital gown etc - orient patient to individual unit: bed, bathroom, call light and how these items work for patient use -Orient patient to the entire unit: location of nurses office, lounge -Explain anything you expect a patient to do in detail (this helps the patients participate in their care) -Introduce other staff and roommates 4. perform base line assessment A. Observation and physical examination such as -Vital signs, temperature, pulse, respiration and pressure -input and output -eight &weight(if required)
-general assessment B. interview patient and take nursing history to determine what medication the patient is currently taking. any allergies and patient is entering complaints and concern. 5. take care of the patients 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 patients name 6. record keeping or maintaining records - record all part of the admission process -other recording include - notification to dietary departments, starting kardex card and medication records, if there is specific form to the facility, complete it. B. Discharging a patient: should be authorized by the physician. Indications for discharge -progress in the patient condition -no change in the patents condition (referral use of other service outside the hospital) -against medical advice -death Nurses responsibilities during discharging a patient 1. check for orders that a patient need to be discharged 2. plan for contributing care of the patient -referral as necessary -give information for new person involved in the patient care
-contact family or significant others if needed -arranging transportation 3. teaching the patient about -what to expect -medications (treatment) -activity -diet -need for continued health supervision 4. do final assessment of physical and emotional status of the patient and the ability to continue own care 5. check and return all patients personal property (bath item in patient unit and those kept in safe area) 6. Help the patient or family to deal with business office for customary financial matters and in obtaining supplies 7. Keep records -Write discharge note -Keep special forms for facility Discharge summaries usually include -Describing of clients condition at discharge -Current medication -Treatment (e.g. wound care, oxygen therapy
-Diet -Activity level -Restriction Reason for referral includes the following -Any active health problems -Current medication -Current treatments that are to be continued -Eating and sleeping habits -self care abilities -support networks -life style patterns -religious preferences Discharging a patient against medical advice 10.when the patient want to leave an agency without the permission of the physician unauthorized discharge the following activities are indicated 11.ascertain why the person wants to leave the agency 12. notify the physician of the clients decision
13.offer the patient the appropriate from to complete 14.if the client refuses to sign the form, document the fact on the form and have another health professional witness this
Page 192
15.provide the patient with the original of the signed form and place a copy in the record 16.when the patient leaves the agency, notify the physician, nurse in charge and agency administration as appropriate -assist the patient to leave as if this were usual discharge from the agency (the agency is still responsible while the patient is on premises).
UNIT FOUR PROVIDING SAFTEY AND COMFORT There are different methods and devices that are used to provide comfort to the patient. These play a great role in the process of patient recovery. 1. Cotton rings: are small circles of cotton rolled with gauze or bandage with hole in the middle. It is used to relive pressure from small areas such as the elbows and hells. 2. Air rings: should be filled with air and covered with pillow case. It is not commonly used and should be changed frequently. It is used to relieve pressure from the buttocks (to prevent bed sore).
3. Cradles (bed cradle): it is also called Anderson frame, made of wire, wood or iron. it is designed to keep the top of the bed clothes off the injured part of the body. E.g. burn 4. Pillow: placed under head, head, back, b/n knees or at the foot of the bed to prevent foot drop and keep the patient. It is used to give comfort, support and to position a patient properly. 5. Sand bags: are heavy, cylindrical or rectangular sand filled bags. They are used for supporting or immobilizing a limb. They should be covered with towel and placed one on either side of a limb (or part to be immobilized). 6. Splints: are rigid supports that help to maintain the wrists in hyperextension as a means of preventing palmer flexion and constructors. 7. Fracture boards: are used to make the bed firm and to prevent bed from sagging. They are placed under the mattress of patients with fracture. 8. Back rest: is used for elevating and supporting the head and back of the patient. Gatch beds have back rest, which can be elevated or lowered as desired. If Gatch bed is not available, pillows or boards can be used. 9. Foot rest (board): are rigid, vertical structures and placed at the foot of the bed. It is used help to maintain the ankles in their normal functional position in order to prevent foot drop and also prevent the patient from sliding down. It should be padded for support and adjusted to the clients height so that the soles rest firmly against it and the ankles are maintained at 900. 10. Side rails: used to prevent falling of the patient in case of unconscious, children. It is sealed at the side of the bed. Crutch walking Crutches may be a temporary need for some people and a permanent one for others. Crutches should enable a person to ambulate independently. There are several kinds of crutches, the most frequently
used are the under arm crutch (axillary crutch with hand bars) and Lofstrand crutch which extends only to the forearm. Under arm crutch can be extended. It has double upright an underarm bar and a hand bar. Lofstrand crutch is a single adjustable tube of aluminum to which are attached a curved piece of steel a rubber covered hand bar and a metal forearm cuff. It is most useful as a substitute for a cane. The metal forearm and the metal bar stabilize the wrists and thus make walking safer and easier. The person can release the hand bar to use his/her hand and the metal cuff will hold the crutch in place while a cane would fall. The Canadian or elbow extensor crutch: Like the lofstrand, it is made of a single tube of aluminum with lateral attachment, a hand bar and a cuff for the forearm but it also has a cuff for the upper arm. This crutch is usually used by clients who require support to weak extensor muscles of the arm e.g. (weak triceps brachii). All crutches require suction tips, usually made of rubber, which help to prevent the crutches from slipping on a floor surface. Using crutches: - follow the plan of exercises developed for you strengthen your arm muscles before beginning crutch walking - have a health care professional establish the correct length for your crutches and the correct placement of the hand pieces. Crutches that are too long force your shoulders upward and make it difficult for you to push your body off the ground. Crutches that are too short will make you hunch over and develop an improper body stance. - The weight of your body should be borne by the arms rather than the axillae (armpits). Continual pressure on the axillae can injure the radial nerve and eventually cause crutch palsy, a weakness of the muscles of the forearm wrist and hand.
- Maintain an erect posture as much as possible to prevent strain on muscles and joints and to maintain balance. - Each step taken with crutches should be a comfortable distance for you. It is wise to start with a small rather than large step. - Inspect the crutch tips regularly and replace them if worn. - Keep the crutch tips dry and clean to maintain their surface friction. If the tips become wet, dry them well before use - Wear a tie shoe with a low heel that grips the floor
Measuring clients for crutches During measuring for axillary crutches, it is most important to obtain the correct length for crutches and correct placement of the hand piece. There are two methods of measuring crutch length: 3. The clients lies in a supine position and the nurse measures from the anterior fold of the axilla to the heel of the foot and adds 2.5cm 4. The client stands erect and position and the nurse make sure the shoulder rest of the crutch is at least 3 finger width that is 2.5-5cm (1-2in) below the axilla. To determine the correct placement of the hand bar: 3. The client stands upright and supports the body weight by the hand grips of the crutches.
4.
The nurse measures the angle of elbow flexion. It should be about 30o.
Page 196
Crutch gaits: the crutch gait is the gait a person assumes on crutches by alternating body weight on one or both legs and the crutches. The five standard crutch gaits are the four-point gait, three-point gait, twopoint gait, swing- to gait and swing through gait. The gait used depends on the following individual factors (d) The ability to take steps (e) The ability to bear weight and keep balance in a standing position on both legs or only one and (f) The ability to hold the body erect A physiotherapist or a physician usually decides which crutch gait is best for the client. Nurses may participate in decision making and teaching the technique some times. Clients also need instructions about how to get into and out of chairs and go up and down stairs safely. All these crutch skills are taught best before the client is discharged and preferably before clients surgery. Crutch stance (tripod position): Before crutch walking is attempted, the client needs to learn facts about posture and balance. The proper standing position with crutches is called the tripod (triangle) position. Four-point alternate gait This is the most elementary and safest gait, providing at least three points of support at each time, but it requires coordination. It does not require much space. To use this gait the client needs to be able to bear weight on both legs. Three-point gait to use this gait the client must be able to bear entire body weight on the unaffected leg. The two crutches and the unaffected leg beat weight alternatively. Two- point gait This gait is faster than the four-point gait. It requires more balance because only two points support the body at one time. It also requires at
least partial weight bearing on each foot. In this gait arm movement is with the crutches are similar to the arm movements during normal walking. Swing-to gait The swing-to gait are used by clients with paralysis of the leg and hips. Prolonged use of this gait results in atrophy of the unused muscles. The swing-to gait is the easier of these two gaits. Swing through gait This gait requires considerable skill, strength and coordination Getting into a chair Chairs that have armrests and are secure or braced against a wall are essential for clients using crutches. Going up stairs During this crutch walking the nurse, stand behind the client and slightly to the affected side of if needed. Going down stairs For this procedure, the nurse stands one step below the client on the affected side if needed.
UNIT FIVE BED MAKING

Types of bed making
Bed making is the most important part of hospital and hospitalization. To Know how to prepare various types of bed is the responsibility of the nurse. clean, smooth and dry bedding provide psychological and physical comfort as well as to prevent complication. There are different types of bed making based on the patient conditions. Nursing diagnosis in bed making include -High risk for altered skin integrity -High risk for infection related to socked linen with body discharge.
Closed bed: is a smooth, comfort and clean bed which is prepared for new patient. 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 provide a clean comfortable bed -To give the bed a good appearance -To keep ready for the next patient Equipment -Two large sheet
-Cotton draw sheet -Rubber draw sheet (water proof sheet) -Blanket -Bed spread -Pillow case -Linen hamper -Bed side chair Procedure -Wash hands and collect the necessary materials - place the materials to be used on the chair. Turn mattress and arrange evenly on the bed - place bottoms sheet with correct side up, center of sheet on center of bed and then at the head of the bed. -tuck sheet under the mattress at the head of bed and miter the corner -remain on one side of bed until you have completed making the bed on that side - tuck sheet on the sides and foot of bed, mitering the corners -tuck sheet smoothly under the mattress, there should be no wrinkles -place rubber draw at the center of the bed and tuck smoothly and tightly -place cotton draw sheet on the top of rubber draw sheet and tuck. The rubber draw sheet should be covered completely -place top sheet with wrong side up, center of bed, tuck at the foot of beds and miter the corner -fold top sheet over blanket -place bed spread with right side up and tuck it.
Open bed: is one of which is made for ambulatory patient are made in the same way but the top covers of an open bed are folded back to make it easier for a client to get in. Equipment The same as closed bed. Procedure The same as closed bed but in open bed procedure the top bedding is folded to the center of the bed.
Occupied bed: is a bed prepared for a week patient who is unable to get out bed. Purpose -To provide comfort and facilitate movement of the patient -To conserve patients energy and maintain current health status Equipment The same as open and closed bed add pajamas (gown) if necessary and 2 blankets if available. Procedure -Explain the procedure to the pt and wash your hands -Assemble the equipment and arrange in order of its use -Carry equipment to the bed side; make sure the windows and door are closed -Remove extra pillow and have pt. flat if possible
-Loosen all bedding at the foot of the bed and remove the spread the blanket and place it over the chair -Place the bath blanket if available over the pt. if it is not used leave the top sheet in place -Assist the pt to turn towards the opposite side of the bed and reposition the pillow under the pts head -Loosen all bottoms linen from the head and sides of the bed -Fanfold soiled linen as close as to the pt as possible -Place the bottom sheet on the bed, tuck it under the near half the head of the bed, miter the sheet at the top corner and tuck under the side of the mattress -Place the rubber draw sheet and cotton draw sheet on the bed and tuck it under side of the mattress -Assist the pt to roll over the folded linen in the middle of the bed towards the other side -Move to the other side of the bed -Loosen and remove all bottom linen place these in the hamper -Pull and secure the bottom sheet under the head of the mattress, miter corners. Pull the side of the sheet and tuck under the mattress. repeat these with draw sheet. -Assist the pt to turn to the centre of the bed, remove the pillow and change the pillow case before replacing. -Apply top sheet over the pt, have pt hold on to the top edge linen so the bath blanket or top sheet can be removed
-Complete the top bedding, loosen top bedding over the pts feet by grasping them in the area of the feet -Leave the room clean and in order Anesthetic bed: is a bed prepared for patient recovering from anesthesia. Purpose: to facilitate easy transfer of the patient from stretcher to bed with a minimum of time and movement. Equipment the same as closed bed but add: -towel -paper and pencil(pan) -v/s equipment -tongue blade -hot water bottle -syringe and needle -IV stand -emesis basin -oxygen -receiver -emergency drug -bed block -tissue paper or gauze -swab Procedure -Make the bottom sheet, rubber and cotton draw sheet as usual. -Place a small rubber and cotton draw sheet at the end of the bed -Place the top bedding as usual but do not tuck it under the mattress -Fan fold top bedding to one side of the bed -Place hot water bottle in the middle of the bed -Place pillow on chair or at the head of the bed b/n the bed and the mattress -Place v/s equipment, emesis basin, and tongue blade on bed side stand
Amputation bed: a regular bed with a bed cradle and sand bags Purpose: -To leave the amputated part easy for observation -To allow to do repeated procedure Equipment -One bottom sheet -Two set of top bedding -One large rubber draw sheet -One large cotton draw sheet -Tourniquet -Bed cradle Two sand bag with its cover -Safety pin Two blanket if available Procedure -Make the bottom bedding as usual -Spread bath blanket next to the pt body , make bottom half of the bed -Fold sheet cross wise at the centre of the bed at bottom tuck in and make a corner -To make the upper half of bed fold the sheet in a half. Fold back over the top bedding. The two halves should be overlap. Remove bath blanket -Use sand bag to keep the part in place
-Place the bed cradle over the affected part. Fracture bed: a bed board under normal bed and cradle Purpose: to provide a firm, a flat, unyielding surface to support a fracture part. Equipment: The same as closed bed and add -Fracture board -Bed cradle -Small rubber and draw sheet -Sand bag with its cover -Safety pin -Small blanket Procedure -Place a fracture board directly over the bed spring with the mattress on it -The procedure to make this bed is same as for and ordinary occupied bed -Fold back the top bedding at the foot of bed and over the injured limb with small blanket -Place the cradle over the injured part and adjust the cover over it. Cardiac bed: is one prepared for patient with heart problem. Purpose: - To ease difficulty in breathing (to relieve dyspnea) To provide comfort for the patient Equipment -Ordinary bed equipment
-Cardiac over bed table if available -Extra pillow -Back rest -Foot rest -Oxygen Procedure -Make bed the same as closed bed with the foot rest at the foot of the bed -Place the back rest at the pts back , make it comfortable with pillow -Place the cardiac table/over bed table/ in front of the pt. with pillow in it. -Leave your pt. comfortable in bed Order of bed covers 1. Mattress cover 2. Bottom sheet 3. Rubber sheet 4. Cotton ( cloth) draw sheet 5. Top sheet 6. Blanket 7. Pillow case 8. Bed spread
General instruction during bed making 1. Put bed coverings in order of use 2. Wash hands thoroughly after handling a patients bed linen. Linen and equipment soiled with secretion and excretion harbor microorganisms that can be transmitted directly or by hands uniforms 3. Hold soiled linen away from uniform 4. Linen for one client is never( even momentarily)placed on another client bed 5. Soiled linen is placed directly in a portable linen hamper or pillow case before it is gathered for disposal 6. Soiled linen is never shaken in the air because shaking can disseminate secretion and excretion and the microorganisms they contain 7. When stripping and making a bed, conserve time and energy by stripping and making up one side as completely as possible before working on other side 8. To avoid unnecessary trips to the linen supply area, gather all needed linen before starting to strip bed 9. Make a vertical or horizontal toe pleat in the sheet to provide additional room for the clients feet -Vertical make a fold in the sheet 5-10cm to the foot -Horizontal- make a fold in the sheet 5-10 cm across the bed near the foot
Page 207
-While tucking bedding under the mattress the palm of the hand should face down to protect your nails
NB- 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.
UNIT 11 ADMINSTRATING AND MONITORING MEDICATION There are different routes of drug administration, some of them are oral rectal parental vaginal -intradermal inhalation -subcutaneous topical -intramuscularly -intravenous NB. remember the 5Rs during medication administration -Right patient -Right medication -Right route -Right dose
-Right time Oral drug administration Oral medication is drug administered by mouth. Purpose: -when local effects are desired -when prolonged systemic action is desired -to safely and effectively administered by mouth Disadvantage and contraindication for oral drugs -For patient that can not swallow(pt with nausea, vomiting and unconscious) -When digestive juices inactivate the effect of the drug -When there is inadequate absorption of the drug that leads to inaccurate determination of the drug absorbed -When the drug is irritating to the mucus membrane of the alimentary canal causing vomiting or diarrhea and the desired effect is lost. Types of oral medication lozenges(troches):sweet medical tablet containing sugar that dissolve in the mouth so that the medication is applied to the mouth and throat. tablets: a small disc or flat round piece of dry drug containing one or more drug made by compressing a powered form of drugs capsules: small hollow digestible cause usually made of gelatin filled with a drug to be swallowed by the patient. syrups:sugar containing medicine dissolved in water tinctures:medical substances dissolved in water suspension: liquid medication with undissolved solid particles in it. pills and gargle: a small ball of variable size, shapes and color sometimes coated with sugar that contains one or more medicinal substances in solid form taken in mouth. effervescence: drugs given of small bubbles of gas
gargle: mildly antiseptics solution used to clean the mouth or throat. powder : a medicinal preparation consisting of a mixture of two or more drugs in the form of fine particles. Equipment -tray -a jag of water(boiled water) -towel -chart &medication card -a bowl of water for used medication cup -ordered medication -measuring spoon -straw if necessary Procedure -Explain the purpose of the procedure to the pt
-Wash your hands and dry -Prepare tray with necessary materials and take it to the pt room -Begin checking the order -Read the label 3 times -Place solution and tables in a separate container -Shake the bottle if the medication is suspension -Take it to the pt bedside -Keep the medication in site at all time -Identify the pt carefully using all precautions (the pt name, bed number) -Remain with the pt until each medicine is swallowed -Offer additional fluid as necessary unless contraindicated -Record the medication given refused or omitted immediately
Page 210
-Take care of the equipment and return them to their proper places -Wash your hands. Suppository Purpose: To produce a laxative effect.(bowel movement),suppository is used frequently instead of enema since it is inexpensive. To produce local sedative in the treatment of hemorrhoid or rectal abscess To produce general sedative effects when medications can not be taken by mouth To check rectal bleeding Equipment -suppository (as ordered) - gauze square - rectal glove or finger cot - toilet paper -receiver for soiled swabs -bed pan, if the treatment is in order to produce defecation - screen -mackintosh and towel Procedure -screen the patient -lie pt on left lateral position or if not possible on dorsal recumbent position - towel and mackintosh is placed under the buttock -fold back top linen to the opposite side thus exposing the buttocks only -put on the glove and insert the suppository into the rectum until it is felt to slip beyond the internal sphincter muscle - hold the buttock together for a few minutes until there is no longer desire to expel the suppository
- clean the anus with a toilet paper and place it in the receiver for used swabs -report the time ,type and the result of the treatment and the reaction of the patient to the treatment -wash and boil glove for 10 minutes and return to proper place Parental medication Intra-dermal medication: is an injection given into the dermal layer of the skin(corneum). Purpose:- for diagnostic purpose -Tine test(mantoux) -Allergic reaction -Therapeutic purpose Site of injection Inner part of the forearm(midway b/n the wrist & elbow upper arm, at deltoid area for BCG Equipment: -Tray -Syringe & needle (sterile) -Receiver -Drug (to be injected) -File alcohol swab -Marking pen -Water in bowl to rinse syringe and needle Procedure
Page 212
-Prepare and take the equipment to patient side after you have washed and dried your hands -Explain the procedures purpose to the pt - Get hold of the arm and locate the site of injection -Clean the skin with alcohol swab and inject the drug about 0.1-0.2 in to the epidermis -Check for immediate reaction of skin 10-25 minutes for tetanus,20-30 minutes for penicillin -If it is for tine test allergic test mark the area -Chart the date and time of administration -Take of the equipment -Read after 72 hours for tine test or tuberculin test Subcutaneous /hypodermic: is an injection of drug under the skin in the subcutaneous tissue(under the dermis) Purpose: -to obtain quicker absorption than oral administration -When it is impossible to give medication orally Site of injection -Outer part of the upper arm -the abdomen below the costal margin to the iliac crest -the anterior aspect of the thigh Equipment: the same as intra-dermal injection and add -sterile forceps in a container - disposing box Procedure
-Explain the procedures purpose to pt -Wash the hands and dry -Collect the necessary equipment and get ready -Clean the site (usually it is in upper arms, thighs or abdomen) -Grasp the area b/n your thumb and forefinger to tense it. -Insert the needle at about 45o-60o angle -Pierce the skin quickly and advance the needle -Aspirate to determine that the needle has not entered a blood -Inject the drug slowly -After injecting withdraw the needle and massage the area with alcohol swab -Chart the amount and time of administration immediately -Take care of the equipment -Watch for any undesired reaction NB: if repeated injection are given the nurse should rotate the site of injection so that each succeeding injection is about 5cm away from the previous one. Intramuscular injection: is an introduction of a drug into a bodys system via the muscles. Purpose: - to obtain quick action next to the intra venous route To avoid an irritation from the drug if given through other route Site for injection
Page 214
1.ventrogluteal: free from major blood vessels or nerves and less fat issue than the buttock area. The fastest for absorption and least painful site. 2. dorso-gluteal: common used site for adults and children. <3 years children are contraindicated because their gluteal muscle is not well developed and have a risk of gluteal artery and sciatic nerve injury. 3.vastus lateralis: rapid drug absorption site and preferred site for adults and children. Free from large vessels and nerves. 4. rectus femoris: this site can be used for occasional injections for infants and children and for adults when other site are contraindicated. Its chief advantage is for clients who administer their own injections can reach this site easily but a considerable discomfort may be present for some people. 4.deltoid muscle: the thickest area of the muscle that lies over midaxillary line and rapid absorption is obtained. It is not frequently used for IM injections because it is a small muscle. <18 month children are contraindicated and have a risk of radial artery and radial nerve injury. Equipments: The same as subcutaneous and intra-dermal injections Procedure 1. Prepare tray and take it to near bedside of the pt 2. Explain the procedure purpose to the pt 3. Prepare medication and draw it 4. Position pt 5. Work or locate the area of injection i.e. upper outer quadrant 6. Clean the area 7. Insert the needle by holding go degree 8. Check three time if the needle enters in to blood vessel. If there is bleeding remove and change the site
9. After you finished injection, remove and massage the site to enhance the absorption of the drug 10. Watch the reaction of pt 11. Chart the time, amount , type of drug and pt reaction 12. Take care of the equipment NB: the needle for IM injections should be long. strict aseptic technique should be used. Other site for IM injection is the deltoid muscle and the outer part of the thigh(quadriceps). Intravenous injection: is an introduction of a drug in a solution form into a vein. Often the amount is not more than 10ml at a time. It is the fastest way of drug administration. Purpose: When the given 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 When blood drawing is needed(exsanguinations) Equipment The same as intra-dermal and intramuscular injection and add -Towel and a rubber sheet -Tourniquet -Receiver (2) Procedure 1. Prepare tray and the necessary materials after you have washed and dried your hand. 2. Explain the procedure to the pt
3. Position the pt properly 4. Place rubber sheet and towel under arm 5. Expose the arm and apply tourniquet 6. Ask pt to open and close his fist 7. Palpate the vein and clean with alcohol swab the site of the injection (which is mainly the mid cubital vein of the arm) 8. Clean with a circular motion, proceed from centre of the site outward.
9.
Held the needle at about 45o angle in line with the veins
10. Puncture the vein and draw back to check whether you are in the vein or not. 11. Once you know that you are in the vein release the tourniquet gently, lower the angle of the needle until it is nearly parallel to the vein push the medication very slowly 12. Check the pts pulse in b/n any complaint from the pt should not be ignored 13. Apply pressure over the site after removing the needle to prevent bleeding tell pt to flex his elbow 14. Watch the pt for few minutes before leaving him 15. Remove your equipment 16. Put the pt in a comfortable position 17. Wash sterilize and place the equipment in order
18. Chart the medication given, the amount time and the reaction of the patient
NB: make the patient as well as your self comfortable before giving injection. Have a bowl of water to rinse the needle used immediate. Never recup a used needle. General precautions in drug administration 1.Never pour the medication back in to the bottle 2.Never use a drug when the label is not clear 3.Watch all pts for drug rxns. 4.Never leave medicine of bedside unless specified 5.Solution medication which have become discolored should not be given 6.Always give right medication to the right pt and the dosage at the right time 7.All poisonous drugs must be kept separately, in a separate cupboard if possible and the cupboard must remain locked. Intravenous therapy :is administration of large amount of fluid in to the system via vein. Purpose :- to rehydrate the patient -When it is desired to increase the volume of circulating fluid in the treatment of shock or hemorrhage by giving glucose, blood, plasma, etc -To restore acid and base balance -To maintain fluid and electrolyte -To introduce antibiotics via vein. Equipment -Iv fluid as ordered - sterile syringe and needle - rubber & towel
-Receiver - alcohol swabs -arm board -bandage &scissors -Tourniquet -adhesive tape - iv pole - medication chart Preparation of the patient Since an infusion therapy takes several hours to complete the patient should first be made comfortable. Procedure -Take equipment to the pts bed side -Explain to the chart. Be sure you have right patient -Remove air form the tubing -Place rubber and towel under the arm -Apply tourniquet about 3cm above the intended site of entry -Observe and palpate for suitable vein -Cleanse the skin with alcohol swabs thoroughly and place the swab used thumb the retract down the vein and soft tissue 4cm below the intended site of injection -Hold needle at 45 o angle line with the vein -Pierce the skin and puncture the vein -Check if you are in the vein by drawing back with the syringes(blood returns If you are in the vein) -Release the tourniquet gently -Start the flow of solution by opening clamp -Support needle with sterile gauss and sterile cotton balls -If necessary to keep it in proper position in the vein -Anchor the iv tubing with the adhesive tape to prevent pull on the needle -Place arm board or splint under the arm and bandage around -Adjust the rate of flow -Rate of flow is regulated by the following formula Number of ml *of sols number of drops in a ml
Number of hrs over which sol is to be administered *60min( 1ml=15 drops). For example calculate drops per minute of 1000ml normal saline over 6hrs. =1000ml * 15gtt/ml= 42drop/min 6hr*60min Note 1.The arm board should be long enough to extend beyond the wrist and elbow joint 2.Board should be padded 3.Infusion bottle should be labeled with the date time infusion is started drops per minute and any added medications. If more than one bottle as used in 24hrs it should be labeled as bag 1,2,3 and so on. 4.Extend the arm in the most comfortable position 5.Usual areas used for intravenous infusion are A .the median basilica vein on the inner surface of the arm. B. a vein on top of the foot C. in a infant the jugular vein and the scalp vein
Blood transfusion: is the giving of blood to a patient through a vein. Purpose: - to counteract sever hemorrhage and -To prevent circulatory failure in operation where blood loss is considerable.
-In sever burns to make up for blood lost by burning but only after plasma and electrolytes have been replaced -For sever anemia -To provide clotting factors normally present in blood which may be absent as a result of disease. Equipment : -Bottle containing blood with the patient name ,blood group and Rh factor -blood giving set - sterile forceps in sterile jar -sterile syringe and needle -alcohol swab -sterile gauze - rubber sheet and towel - tourniquet -arm splint - bandage and scissors -adhesive tape -receiver for dirty swabs -IV pole(stand) -patients chart Procedure Before blood transfusion is administered the nurse has to check the blood group &RH factor, if cross match of the donors and the recipients blood is done and is compatible. Also check for HIV Prepare the tray with necessary items Before taking it to the patients room check the patients name ,hospital number, bed number, blood group, RH factor and the expiration date with a 2nd nurse or a doctor Blood should be used within 21 days of its withdrawal date Take it to the patients room Explain procedure to patient
Hang the bottle and remove the air from the tubing Put patient in a comfortable position Place rubber and towel under the arm Check the vital signs before administering Choose the vein Apply tourniquet Clean the skin and feel for the distended vein and clean again Puncture the vein with the needle (the needle here should be short and wide so that it does not cause occlusion easily) After you make sure that you are in the vein release tourniquet and open the lamp The drop/minute at the beginning should be very slow Watch patient closely for any reaction If there is no rxn from the patient regulate the rate of flow according to the pts conditions and the order Splint the arm and position it comfortably Remove the equipment you have used, wash and return to its proper place Record the time you started the blood and any other pertinent information Check pt frequently Immediate reaction A. headache B. backache C. chills D. pyrexia E. rash of the skin (urticaria) late reaction A. dyspnea
B. renal shut down in sever cases C. heamaturia D. chest pain E. rigor (rigidity) F.cut down Note 1. always remember to have anti-histamine injection ready in case a pt has rxn from the blood 2.be familiar with the most usual symptoms of blood rxns.
Cut down: dissection of a vein for inserting IV cannula or needle. it is a procedure done by a doctor Purpose -when vein puncture is difficult -when prolonged, continuous infusion is needed -when secure infusion is important -when rapid infusion is important -when emergency situation combine these indications equipment: there are sterile and clean equipments sterile equipment -dressing forceps -cotton balls in a galipot - solution for cleansing
- gloves -hole sheet(fenestrated towel) -syringe and needle -scalpel (surgical knife) -Mosquito forceps(3) -aneurysum needle(1) -silk -intravenous cannula or vein flow(2) -small straight scissors(1) -small curved scissors(1) -needle holder (1) -round needle(1) -cutting needle(2) -tissue forceps(1) -gauze (slit at one end) -probe -fine dissecting forceps(1) -local anesthesia Clean equipment -receiver of dirty swab -stand light if available -adhesive tape(plaster) -dressing scissors Procedure -bring equipment to the bedside of the pt - explain procedure to the pt -shave the area, if needed -position the pt properly -the nurse will then open the set and pour the cleaning lotion into the galipot for the doctor -the doctor then scrub his hands, put on gloves, clean and drape the area ,he will insert the IV - the channel is securely tied with silk and skin is closed
-the nurse dresses the site and secure it with the site and secure it with adhesive tape -remove all equipment, wash and send for sterilization Inhalation: is the act of drawing in of gas vapor or steam into the lungs for therapeutic purpose it could be in dry, moist or vapour form. 1. oxygen administration Purpose: to provide and maintain a normal supply of o2 for blood and tissues o2 may be administered in 3 ways. 1. by mask 2. nasal catheter 3. tent 1. Giving o2 by mask There are many kinds of masks for o2 administration the common ones are 1. the venture mask 2. the B.L.B( Broothby. Lovelance &Bulbulain) The venture mask gives a controlled amount of o2 i.e. it is not high to cause respiratory depression and it is sufficient to relieve anoxia. It gives 24-35% of o2. The B.L.B mask provides an oxygen concentration of 90% with the flow meter set at 7 liters /minute. This kind of mask allows the patient to eat, drink and to expectorate. If the patient can not breath through his nose, the B.L.B mask should not be used. Equipment -a cylinder of o2 with a reducing value flow meter and pressure tubing to be connected with the o2 cylinder. - mask - safety pin to secure the tubing to the end linen - tissue paper to clean the nostrils with. If the pt is unconscious, a tray containing a galipot of saline or water, wooden applicator and receiver for soiled applicator is necessary in order to clean the nostrils. Procedure 1. the cylinder adjustments is turned on before bringing the cylinder to the bedside. 2. explain treatment to pt
3. bring equipment to the bedside 4. ask him to clean his nostrils to avoid obstruction(if well enough) 5. connect the mask to tubing and open the fine adjustments to the required rate of flow. Then apply the mask to the patients face making sure that it rests comfortably on the pt face. See that the tubing is secured to the bed linen by means of safety pin. Stay with the patient until he is reassured if it is his first time to be on oxygen therapy 2. Giving oxygen by nasal catheter There are different kinds of catheters A. a fine catheter B. a separate frame, which carries two, places of rubber tubing and is worn by the pt. C. two soft rubber catheter connected by Y shaped connection to the tube on oxygen apparatus. Equipment -oxygen cylinder with regulating valve and pressure tubing - wolfs bottle for water i.e. humidifier - glass connection/ flow meter - fine catheters, lubricant, plaster - safety pin - tray containing a galipot of saline or water. Receiver for soiled applications Procedure 1. procedure is the same as giving oxygen by mask 2. connect the fine catcher with the pressure tubing. Turn on the fine adjustments to the required rate of flow the maximum liter flow being 6-7 litter /minute 3. catheter is lubricated preferably with water and passed backward into pharynx until the tip of the catheter is opposite the uvula. The catheter can also be inserted by measuring the distance from the pts nose to his ear lobe. It is then taped in place. Never force catheter against an obstruction. Note Oxygen catheter are removed every 8 hrs and a clean catheter is inserted into the other nostril. Pts receiving oxygen by catheter
requires specials mouth and nose care since the catheter tends to irritate the mucous membrane. Oxygen dries and irritates mucous membrane, therefore it should be passed through water (humidified ) before it is administered by catheter. The advantage of administration of oxygen by catheter is the freedom of movement that id gives to patients receiving oxygen. By this method patient can obtain about 50% concentration of oxygen. 3. oxygen tent: Purpose to keep pt in high oxygenation environment -whenever the other means are not possible Equipment -transparent oxygen tent and its apparatus fitted with oxygen - ice if the apparatus is with out refrigerator device - hanger for the tent - room thermometer if needed - no smoking sign for the unit Procedure 1. remove all electrical appliances from the room as this may produce sparks. 2. post sign of no smoking on many places in the unit 3. prepare and check if the applicator is working properly 4 .bring the oxygen unit to the bedside and fix the tent on the hanger 5. close all appliances of the tent: place ice if the apparatus is with out refrigeration device 6. tuck the sides of the hold tent under the mattress as far as they will go 7. fill the tent wit h 12-15 liters of oxygen 40-60% concentration for the first half hour 8. after first half hour regulate the flow of oxygen to 6-10 liters or as ordered by the doctor until the treatment is completed 9. check temperature indicator frequently and adjust to 18oc 22oc 10. record state of pt and time started and the flow of the oxygen. Precaution to be taken when oxygen is used 1. oxygen supports combustion. Therefore it is essential for the pts safety there is no smoking with in 3 meters of oxygen equipment. Lighted
matches , cigarettes, electric lights, nylon clothing, electric pads , bells mechanical toys should be forbidden. 2. alcohol must not be applied to the pts skin 3. the catheter tip and the cylinder itself must not be lubricated with Vaseline or oil or any kind. 4. cylinder must be handled carefully as the oxygen is under pressure 5. the fine adjustments should always be closed when the main tab is tuned on. 6. check that there is no obstacle in the patients airway before firing oxygen in order to prevent patient from suffocation. 7. the doctor will order the rate of flow. A rate of 2-liters/minute is commonly used when is used in case of emergency instead of free air. In the case of asphyxia liter/min may be needed. Protect patient from asphyxia ion inspecting regularly pressure gauge and flow meter and noting pulse, respiration, color, mental status and necrosis from carbon dioxide. Steam inhalation: is the intake of steam alone or with medication through the nose and mouth. Purpose respiratory passage during cold, sinusitis, laryngitis, bronchitis etc. -To relieve spasm -To increase circulation in the lung by increasing or decreasing the secretions of the bronchi -To moisten secretion There are two types of inhalation 1.intermitent (interrupted) e.g. nelsons inhaler 2. continuous method e.g. steam tent 1.Nelsons inhaler Equipment -Nelson inhaler with the mouth piece -cover for the inhaler(blanket or towel) -face towel to wipe the face as pt requires
-gauze can be used around the mouth piece to prevent burning of the lips - a tray large enough to carry the inhaler to take it to the -a measuring jug with water which is 82co -the drug ordered might -graduated measure -sputum mug for the pt Procedure -Inhaler should be warmed and glass mouth piece boiled -Be sure about the drug as ordered -Pouring half pint (300cc)of boiling water into the inhaler then 5cc of the ordered drug then add another 300 cc water making sure that the temperature of water in the inhaler comes to 82oc. In order to have a good mixture of the drug -Fix the mouth piece firmly in the haler in direction opposite to the air inlet and cover the inhaler with blanket or towel ,close window. -Prepare the pt usually in a sitting position making sure that he is well supported. -Then put the inhaler on a saucepan on the tray -Place the tray on the over bed table or on his knees in such away that he can bond over the inhaler easily -Put the spout for the escape of steam away from him -Cover his head with blanket -The treatment can take from 5-10 minutes after which the patient should be kept warm and comfortable for some time -Take care of used equipment NB 1.when nelsons inhaler is not available a wide mouthed jug may be used. The mouth of the jug may be used with towel to make the opening small enough for the pt to put his nose and mouth. 2. for irritable helpless pt stay with them through out the procedure 3. report the amount and nature of any sputum or discharge.
Page 229
Topical medication: are applied on the surface of the skin. They affect only the area to which they are applied. Purpose: - to decrease itching (pruritus) -to lubricate and soften the skin -to cause local vasoconstriction or vasodilation - to increase or decrease secretions from the skin - to provide a protective coating to the skin - to apply an antibiotic or antiseptic to treat or prevent infection Dermatologic preparation include lotions, liniments, ointments, pastes and powders. Documenting & scheduling in drug administration Administration of medication should be documented to avoid confusion about missed doses &to prevent in advertent double dosing. Once the physician ordered the medication it should be carried out. The pt name, the bed number, the name of the ordered medication, the route, the dosage and the interval b/n each administration(Bid:2 times/day, tid:3 times/day,Qid:4 times/day, PRN: as needed, per day:1 time in a day) and the time of administration should be documented. Risk minimization in drug administration To avoid or minimize risk in administering drug is: to follow the 5 rights. -Right patient -Right medication -Right route -Right dose -Right time to follow the general precaution in drug administration to use barrier method(e.g. gloves)
Page 230
1------
Prone: The client lies face down . Arms may cushion the head or may be flexed An alternative pos is contraindicated after abdom inal surgery and in clien ts with r esDiratory or s pinal p roblems .
ition for an immobi lized client, the prone posit ion
Supine : The client lies flat on bac k. Pillows may be used un der the head. knees and calves to ra ise heels off the mattress. An alte rnative pos ition for a client on bed rest, the pr one position is used afte r spine surgery and some spin al anesth esia. It is not used f or cl ients "\llth dyspn ea or at risk for aspiration.
Fowler's: This sitting position raises the c lient's head 8o O-90 c Pillows can b e used unde r the hea d and arms and a f ootboard may a lso be used. The position improve s cardi:::c output. promotes ventliation and e ases eating , talking. and watching TV. It is not us ed after spine or bra in surgery. Side-lying : The client lies on the side w ith we ight on hip and shoulder . Pillows suppor t and st abilize uppermost leg. arm, head, an d back. A choice position for clients wi th pressure on bony prominences of the back and s acral pressure sor es, sid e-lying is no t used after hip r eplace'Ti(;nt and oth er orthopedic surgery.
\\
\
I
I
Sims' : In this se miprone position the client lies on the side with we ight distributed toward the a nterior il eum, humerus , and clavicle . Pillows s upport the flexed arms and legs. The po sition is contraindic ated by m any spine or or thope dic condit ions.
._--- ~ I
~I
Semi-Fowler 's: In this semi -sitting pos ition the client 's head is elevated 30 -45. This pos ition has the same ad vantages and contra lnc!lcations as Fowler's position.
L_ . _______ __ ______ _ . ___ __ ____ __ ___ __ ____ __ __ __ ___ __ __ ____ __ __ ___ __ __ __ __ __ __ __ ___ __ __ __ __ __ __ __ __ ___ __ __ __ __ __ __ __ __ ____ __ __ __ __ __ __ __ __ ___ __ __ __ __ __ __ __ __ ____ __ __ __ __ __ __ __ __ ___ __ __ __ __ __ __ __ __ ____ __ __ __ __ __ __ __ __ __ ~ __ __ . __ _ .
Page 231
(((lllliilU,_'di
_ __ _ --.--_ _ . --J
Figure
33-5 Common client posit ions. Among selected body positions, 1I1e prone, supine, Fowler's, semi-Fowler's,
side-lying, and Sims' positions are typically chosen for clients in heoll11core facilities, whereos the dorsal recumbent, lithotomy, knee-chest, and Trendelenburg POSitiOns are typically used durinl) certain tests and surgical ,()((>(edures
CATHETERIZATION
Def. Is removal of urine from the bladder by means of catheter. It can be: - Rubber, metal or glass catheter. N.B. This is strictly a sterile procedure; therefore the nurse should always follow aseptic technique. FEMALE CATHETERIZATION Purpose: 1. A. To empty bladder in case of retention of urine, occurring as a postoperative complication.
Page 232
B. In an obstruction due to the blockage of the urethra, therefore causing stricture. C. Where the retention is due to injury of the spinal cord. 2. To obtain a sterile specimen of urine for pathological examination. 3. To ensure that the bladder is empty before an abdominal or pelvic operation of abdominal paracentesis. 4. To keep an incontinent patient dry. 5. To avoid contamination after an operation of the vagina and perineum. 6. To empty bladder before irrigation or instillation. 7. To determine if residual urine is present in the bladder. N.B. when residual urine is to measured have the patient use the bed pan, then catheterize immediately. Equipment All equipment must be sterile. - 2 rubber catheters of different sizes. - A bowl for antiseptic lotion for cleaning. - A bowl for sterile swabs and gauze to separate the vulva. - A receiver with lid containing sterile dressing towel - A pair of forceps in a receiver. - Sterile gloves - Sterile specimen bottle - Receiver for urine - Scissors /if required/. - Measuring jug for urine - Specimen forms for pathological tests. - Receptacle for dirty swabs.
- Receiver for dirty forceps and catheter.

-
Rubber mackintosh to protect the bed linen.
- Flash light
Procedure
Prepare trolley and take to patients bed side. Explain the procedure and reassure the patient. Screen the unit. Fan fold top bedding to foot of bed. Place bath blanket over patient. Place patient in dorsal position with knees flexed and thighs apart, then put mackintosh under the patients buttocks. Wash your hands thoroughly under a running water Place the sterile towel in between her thighs under the buttocks and make sure the mackintosh is covered. Put receiver for urine near the vulva. Put on gloves and clean the vulva by swabbing with the antiseptic lotion using your forceps. Discard the forceps in the receiver for dirty instruments. When cleaning the vulva always clean using up to down motion and discard swab after one use. Separate the vulva with two pieces of gauze. Carefully pickup your catheter and introduce it right into the urethral orifices about 4 5cm A little pressure on the bladder above the symphysis pubis could be useful to ensure complete emptiness of the bladder. If laboratory test is prescribed, collect some amount of urine in the sterile specimen bottle straight from the catheter.
Discard the catheter, measure the amount of urine with the measuring jug. Swab the vulva and perineum dry with cotton wool, remove mackintosh and towel. Make patient comfortable by covering up properly. Take trolley away from the bed side and finally remove the screen. Take care of the equipment and send the specimen to the laboratory. MALE CATHETERIZATION The procedure is same as in a female patient. Clean the genital organ with antiseptic lotion.
Hold the penis at an angle of 90or in upright position then insert the catheter
bringing the penis to an angle of 60 or slightly bent until urine flows and the foreskin retracted /16 18cm/ N.B. 1. Avoid infection which might lead to cystitis by using sterile equipments and procedure. 2. Make sure the catheter remains sterile until used, it contaminated reboil. 3. Do not drain more than 1000ml of urine at once. Removing a greater amount can upset the patients body fluid balance. 4. Anesthetic lubricant should be used for a male patient, if available, as it prevents such pain. FOLEY CATHETER Also called indwelling or self retaining catheter Def- A catheter to be left in the bladder for a period of time, or permanently. Purpose - To prevent retention
- To prevent frequent catheterization in use where patient is unable to pass urine. - To prevent bed sore, if patient is incontinent. - To prevent infection, in case of operation Equipment Includes the complete set of catheterization In addition you need: - Foley catheter - Sterile water and syringe - Drainage bottle with a tube or bag Procedure Same as in catheterization, using Foley catheter. Test the ballon of the catheter by filling it with sterile water using syringe before insertion When the catheter is inserted, fill the syringe with proper amount of sterile water and inflate the ballon slowly.
Pull gently on the end of the catheter to be sure it will not leave the bladder.
Plaster and string
Attach the drainage tube to the end of the catheter and place the other end in the drainage bottle or bag. Tie the drainage tube loosely to the side of the bed using plaster to position it. N.B. 1 Make sure the catheter is in the bladder before inflating the ballon. If there is pain when inflating the ballon, then push the catheter further in to the bladder. 2 Use a long drainage tube, so that patient can move freely without pulling the tube out of the bottle.
3 The end of the drainage tube should not be submerged in the urine in the drainage bottle. 4 Inspect the opening of the tube leading ballon so that there is no leakage as this might pull the catheter out of place or position. MEDICATION EFFECTS OF DRUGS
Therapeutic effect also referred to as the desired effect, is the primary
effect intended, that is, the reason the drug is prescribed.

Side effect or secondary effect, of a drug is one that is unintended. Drug toxicity harmful effects of a drug on an organism or tissue results
from over dosage, ingestion of a drug intended for external use.

Drug allergy is an immunologic reaction to a drug. Allergic reactions can
be either mild or severe and can occur anytime from a few minutes to 2 weeks after the administration of the drug. A severe allergic reaction usually occurs immediately and is called anaphylactic reaction.
Drug tolerance exists in a person who has unusually low physiologic
activity in response to a drug and who requires increases in the dosage to maintain a given therapeutic effect.
Drug interaction occurs when the administration of one drug before, at the
same time as, or after another drug alters the effect of one or both drugs.
Iatrogenic a secondary condition arising from treatment of a primary
condition.
Iatrogenic disease disease caused unintentionally by medical therapy or
drug therapy. ADMINISTRATION OF MEDICATION

By 1 Mouth 2 INTRADERMAL 3 HYPODERMIC 4 INTRAMUSCULAR 5 INTRAVENOUS 6 INTRAVENOUS INFUSIONS 7 BLOOD TRANSFUSION 8 SETTING FOR CUT DOWN ON VEINS 9 ADMINISTRATION OF OXYGEN 10 STEAM INHALATION ORAL ADMINISTRATION /by mouth/ Def. oral medications are drugs administered by mouth. It is the most common, least expensive and most convenient route. Purpose A When local effects are desired. B When prolonged systemic action is desired. DISADVANTAGES AND CONTRAINDICATIONS 1. For a patient with nausea and vomiting. 2. If the patient is unconscious. 3. When the effect of the drug is inactivated by digestive juices. 4. When there is inadequate absorption of the drug, which leads to inaccurate determination of the drug absorbed. 5. When the drug is irritating to the mucus membrane of the alimentary canal. 6. The patient may not swallow the medicine. Types of oral medications - Lozenges
- Tablets - Capsules - Syrups - Tinctures - Effervescent - Powder - Oily medication etc. Equipment - Tray - Towel - A bowl of water for used medication cup - Measuring spoon - A jag of water and glass - Chart and medication card - Ordered medication - Straw if necessary Procedure - Prepare your tray and take it to the patients room - Begin by checking the order - Read the label 3 times - If suspension, shake the bottle before pouring - Take it to the patients bed side - Keep the medication insight at all time - Identify the patient carefully using all precautions. /patients name, card No. bed No, etc/ - Remain with the patient until each medicine is swallows
- Give more fluid as necessary unless contraindicated - Record the medication given, refused, time and amount immediately N.B. 1. Remember the 5Rs a. Right patient b. Right medication c. Right route d. Right dose e. Right time 2. Always keep the bottle tightly closed 3. Clean and keep the label of the bottle clear 4. Keep medication away from light. 5. Check their expired date 6. Give your undivided attention to your work while preparing and giving medications 7. Make sure that some potent drugs are checked by a graduate nurse 8. Never give medication from unlabeled container 9. Never return a medicine once poured to the bottle 10.Watch all patients for drug reaction 11.Iron should not be given after tea because iron plus tea is equal to ink 12.Clients receiving a series of injections should have the injection sites rotated 13.Drug errors must be reported immediately upon occurrence INTRADERMAL INJECTIONS Def. is the administration of a drug in to the dermal layer of the skin just beneath the epidermis /in to the dermis/
Purpose
- For diagnostic purpose
a. Tuberculin tests /mantoux test/
b. Allergic reaction - For therapeutic purpose Site of injection The inner part of the forearm /midway between the wrist and elbow/ Equipment - Tray - Syringe and needle - Receiver - Drug /to be injected/ - File and alcohol swabs - Marking pen Procedure - Take equipment to the patients side and explain procedure - Get hold of the arm and locate the site of inj. - Clean the skin with alcohol swab and inject the drug about o.1cc in to the dermis and the needle enters the skin at a 15 degree angle - Mark the area - Check for reaction /10 15min later for tetanus, 20 30 min later for penicillin/ - If it is for tine test /mantoux test/ chart the data and time of the administration of the drug - Take care of equipment and return to their places - Do not forget to do the reading after 48 72 hours if it is for tine test
SUBCUTANEOUS /HYPODERMIC/ INJECTION Def administration of a drug in to the subcutaneous tissue, just below the skin - Common sites for subcutaneous injections are the outer aspect of the upper arms and the anterior aspect of the thighs. - Usually small doses, not more than 2ml are given Purpose - To obtain quick absorption than oral administration - When it is impossible to give medicines orally Equipment - Tray - Syringe and needle - Medication - File and alcohol swabs - Medication chart - Receiver Procedure - Take equipment to the patients side and explain procedure - Draw your medication and expel the air from the syringe - Clean the site /usually upper arms, thighs or abdomen/ - Grasp the area between your thumb and forefinger to tense it - Insert the needle at about 45 angle - Aspirate by pulling back on the plunger - If blood appears in the syringe, withdraw the needle, discard the syringe, and prepare a new injection. If blood does not appear, continue to administer the medication.
- After injecting withdraw the needle and massage the site lightly with alcohol swab - Chart the amount and time of administration immediately - Take care of equipment wash, sterilize and return to its place - Watch for side effect of the drug etc. N.B. If repeated injections are given, the nurse should rotate the site of injection so that each succeeding injection is about 5cm away from the previous one. INTRAMUSCULAR INJECTIONS Def. administration of a drug in to a bodys system via the muscles - Best site of injection should be area upper, outer quadrant of buttocks /Gluteal muscle/ - Other site for IM (intramuscular) injection is the deltoid muscle and the outer part of the thigh /quadriceps muscle/ - The needle for IM injection should be long Purpose - To obtain quick action next to the intravenous route - To avoid irritation from the drug it given through other route Equipment - Tray - Medication - Syringe and needle - Alcohol swab - Receiver - File
- Chart - Bowl of water and forceps /if the syringe is reusable/. Procedure - Take equipment to the patients side and explain procedure - Prepare the medication and draw the medicine - Expel the air from the syringe - Choose the site of injection - Using the iliac crest as the upper boundary divided the buttock in to four. Clean the upper outer quadrant with alcohol swab. - Stretch the skin and inject the medicine - Draw back the piston to check whether or not you are in the blood vessel /if blood returns, withdraw and get a new one and reinject in a different spot,/ - Push the drug slowly into the muscle - When completed, withdraw the needle and massage the area with swabs gently to aid absorption - Place the patient comfortable - Take care of equipment and return to their places. - Chart the amount, time, route and type of the medicine - Check the patients reaction N.B. Insert needle with a 90 angle INTRAVENOUS INJECTIONS Def. It is the introduction of a drug into a vein often the amount is not more than 10ml at a time. Purpose
- When medication are too irritating to tissues to be given by other routes - When a rapid effect is required - When it is particularly desirable to eliminate the variability of absorption - When blood drawing is needed /IV inj/ - When it is desired to introduce a drug in to the circulation for diagnostic purposes E.g. IVP. Equipment - Tray - Towel and rubber sheet - Syringe and needle - Alcohol swabs - File - Medication - Tourniquet - Receiver - Treatment chart Procedure - Take equipment to the patients side and explain procedure - Position the patient properly - Place rubber and towel under his arm - Expose the arm and apply tourniquet - Ask patient to open and close his fist - Palpate the vein and clean with alcohol swab the site of the injection /which is mainly the mid cubital vein of the arm/ - Clean with a circular motion, start at the center and move outward - Hold the needle at about 45 angle in line with the veins
- Puncture the vein and drawback to check whether you are in the vein or not. /blood returns/ - Once you know that you are in the vein release the tourniquet gently, lower the angle of the needle until it is nearly paralleled to the vein and instill the medication slowly unless there is an order to give it fast. - Check the patients pulse in between. Any complaint from the patient should not be ignored - Remove the needle and apply, pressure over the site and tell patient to flex his elbow to prevent bleeding - Watch patient for few min before leaving him - Remove your equipment - Put patient in a comfortable position - Wash, sterilize and place the equipment in order - Chart the medication given, amount, time and reaction of the patient N.B. 1. immediately 2. giving injection INTRAVENOUS THERAPY /INFUSION/ Def. It is the administration of a large amount of fluid into the system through a vein. Purpose - To maintain fluid and electrolyte balance - To introduce medication particularly antibiotics
Always have a bowl of water to rinse the needle used Make yourself as well as the patient comfortable before
Equipment - IV fluid as ordered /with IV set/ - Rubber and towel - Receiver - Alcohol swabs - Arm board - Bandage and scissors - Tourniquet - IV pole - Adhesive tape - Medication chart Procedure - Take equipment to patients side and explain procedure - Refer to the chart. Be sure you have the right patient - Remove air from the tubing - Place rubber and towel under the arm - Apply tourniquet about 3cm above the intended site of entry - Cleanse the skin thoroughly - Use thumb to retract down the vein and soft tissue 4cm below the intended site of injection - Hold needle at 45 angle line with the vein pierce the skin and puncture the vein - Check if you are in the vein by drawing back with the syringe /blood returns if you are in the vein/ - Release the tourniquet gently - Start the flow of solution by opening the lamp
- Support needle with sterile gauze or sterile cotton balls if necessary to keep it in proper position in the vein - Anchor the needle and IV tubing with the adhesive tape to prevent pull on the needle - Place arm board or splint under the arm and bandage around - Make patient comfortable - Adjust the rate of flow - Rate of flow is regulated by the following formula Number of ml of sol x number of drops in a ml Number of hours over which sol is to be administered x 60min 1ml = 15drops E.g. if 1000 ml of 5% D/W is to run for 24hrs how many drops per minutes should it run? 1000ml X 15 drops = approx. 10 drops/min 24hrs X 60min N.B. The arm board should be padded and long enough to extend beyond the wrist and elbow joint. - Infusion bottle should be labeled with the date, time, drops per min and any added medications. If more than one bag is used in 24hrs, it should be labeled as bag 1, 2, 3 and so on. - Usual areas for IV infusion are median basilica vein on the inner surface of the arm, vein on top of the foot. In infant the scalp vein and dorsal foot veins used. Jugular vein also can be used - Extend the arm in the most comfortable position BLOOD TRANSFUSION Def. Is the introduction of whole blood or components of the blood /E.g. Plasma/ in to the venous circulation
Purpose - To counteract severe hemorrhage and replace the blood loss - To prevent circulatory failure in operation their blood loss is considerable - In severe burns to make up for blood lost by burning but after plasma and electrolytes have been replaced - For severe anaemia from cancer, malaria and similar condition. - To provide clotting factors normally present in blood which may be absent as a result of disease Equipment - Bottle containing blood, with the patients name, blood group and Rh factor - Blood giving set - Alcohol swabs - Emergency drug with syringe and needle - Sterile gauze - Rubber sheet and towel - Tourniquet - Arm splint - Bandage and scissors - Adhesive tape - Receiver for dirty swabs - IV stand - Patients chart - Vital sign tray Procedure
- Before taking it to the patients room check the patients name, hospital number, bad number, blood group, Rh factor and the expiration date of the blood with a 2nd nurse or a doctor. N.B. Blood should be used within 21 days of its with drawl date - Before blood transfusion is administered the nurse has to check the blood group and Rh factor if cross match of donors and the recipients blood is done with is compatible. - Prepare the tray with necessary items - Take it to the patients room and explain procedure - Check vital sign for baseline data - Put patient in a comfortable position - Place rubber and towel under the arm choose the vein and apply tourniquet - Clean the skin and feel for distended vein and clean again - Puncture the vein with the needle /the needle should be short and wide so that it does not cause occlusion easily/ - After you make sure that you are in the vein release tourniquet and open the lamp - The drops/min at the beginning should be very slow. /about 20 drops/min/ - Watch patient closely for any reaction - If there is no reaction regulate the rate of flow according to the patients conditions and Drs order - Splint the arm and position it comfortably - Remove the equipment, wash and return to its proper place - Record the time you started and any other pertinent information
- Check V/S and patient condition frequently

N.B. - Always remember to have antihistamine injection ready
- Most adults can tolerate receiving one unit of blood in 1 to 2 hours. Do not transfuse a unit of blood for longer than hrs. - To decrease the risk of bacterial growth, a blood transfusion should be started within 30 min after it is received from the blood bank. RBC deteriorate when stored at room T - The potential for bacterial growth increase if the blood is allowed to hang for a longer period of time - Donors blood must be tested for syphilis, HIV and malaria - Be familiar with the most usual sign and symptoms of blood reactions IMMEDIATE REACTION - Headache - Backache - Chills - Pyrexia - Rash on the skin /urticaria/ LATE REACTION - Dyspnea - Renal shut down in severe cases - Haematuria - Chest pain - Rigor /rigidity/
Page 251
Page 252

Basicnursig Hidar2003

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Basicnursig Hidar2003

Uploaded by

Copyright:

Available Formats

Basic nursing care

Ruman Abdurashid- Menilik H.S.College

Basic nursing care

care of equipments after use.

Ruman Abdurashid- Menilik H.S.College

Basic nursing care

General instruction for all nursing procedures

Ruman Abdurashid- Menilik H.S.College

Basic nursing care

UNIT ONE Learning objective

INTRODUCTION TO BASIC NURSING ART

Basic nursing care

maintenance, and health restoration.

Ruman Abdurashid- Menilik H.S.College

Basic nursing care

A nurse should be:

Ruman Abdurashid- Menilik H.S.College

Basic nursing care

Define patient, patient unit and cleaning.

Ruman Abdurashid- Menilik H.S.College

Basic nursing care

Cleaning patient bath room, toilet utility-room, floor & walls

Cleaning patient unit

Ruman Abdurashid- Menilik H.S.College

Basic nursing care

General rules /principles for cleaning

Basic nursing care

Ruman Abdurashid- Menilik H.S.College

Basic nursing care

EQUIPMENT Basin of water Closes for cleansing

Disinfectant solution Floor mop Broom Dirty container PROCEDURE

Bed should be stripped (take used linen)

Ensuring Ventilation & lighting of the patient room

Ruman Abdurashid- Menilik H.S.College

Basic nursing care

Techniques of room ventilation & lighting

Ruman Abdurashid- Menilik H.S.College

Basic nursing care

Carrying for nursing equipments

tubes should be flushed with 0.5% chlorine solution.

The inside of the tube should flushed and rinsed well

should be taken not to be bend or kink tubes

tubing are sterilized for 15 minutes on autoclaving

Basic nursing care

Types of gloves available in Ethiopia

Before performing invasive medical procedures.

Before handling contaminated surfaces.

General principles for gloves use

What type of gloves to use

Basic nursing care

Sterile surgical gloves should be used when performing surgical procedures.

When to double glove

Removing and discarding or reprocessing gloves

Basic nursing care

gloves are to be discarded, briefly immerse them in 0.5% chlorine

1.4 Rubber sheet

Place forceps in a jar & cover them.

Care should be taken not to contaminate tip of forceps.

Ruman Abdurashid- Menilik H.S.College

Basic nursing care

2.2 Care of the sterile container

Care should be taken not to contaminate the inside of the lid.

Instruments are sterilized by boiling, dry heat or by immersing into disinfectant.