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NURSING ART b y; Sewunet.S (BSC,MSC) 01/12/2023

Nursing is an art and science of caring and healing that promotes health. The art of caring is implemented through the nursing process. Nursing is the art and science involves working with individual, families, and communities to promote wellness of body, mind, and spirit spirit( saint Paula) . “It is the diagnosis and treatment of human responses to actual or potential health problems” ( ANA, 1980 ) NURSING ART 01/12/2023

The central focus in all definition of nursing is the person receiving care which includes physical, emotional, social & spiritual dimensions of the person. It is dynamics, therapeutic and educational process that serves to meet the health needs of the society, including its most vulnerable members Nursing Focuses not on illness but rather on the client’s response to illness. Nursing promotes health and helps clients move to a higher level of wellness 01/12/2023

It is impossible to specify a particular date at which nursing, was as we know today, and came in to begin; the same for medicine, But it can be assumed to be originated with primitive mother In the early ages, much of the practice of medicine was integrated with religious practices. As human needs expanded, nursing development broadened; its interest and functions through the social climates created by religious ideologies, economics , industrial revolutions, wars, crusades, and education. In this way modern nursing was born. Historical Background of Nursing 01/12/2023

The intellectual revolution of the 18th and 19th centuries led to a scientific revolution . The dynamic change in economic and political situations also influenced every corner of human development including nursing. It was during the time of Florence Nightingale that modern nursing developed . Cont … 01/12/2023

Florence Nightingale is considered the founder of modern nursing . She had always been interested in relieving suffering and caring for the sick Social mores of the time made it impossible for her to consider caring for others because she was not a member of a religious order the implementation of her principles in the areas of nursing practice and environmental modifications resulted in reduced morbidity and mortality rates during the war. 01/12/2023

Nightingale’s novel beliefs about nursing education were: • A holistic framework inclusive of illness and health • The need for a theoretical basis for nursing practice • A large education as a foundation for nursing practice • The importance of creating an environment that promotes healing • The need for a body of nursing knowledge that was distinct from medical knowledge ( Nightingale, 1969 ) Cont … 01/12/2023

Multi definitions of nursing, common themes are evident Holism caring teaching advocacy supporting promoting Maintaining and restoring health 01/12/2023

The four broad aim of nursing practice can be To promote health Health maintenance To prevent illness Rehabilitation Aim of Nursing 01/12/2023

Health promotion is” the process of enabling people to increase control over the determinants of health & there by improve their health”. Health maintenance is a systematic program or procedure planned to prevent illness, maintain maximum function, and promote health. It is central to health care, especially to nursing care at all levels (primary, secondary, and tertiary) and in all patterns (preventive, episodic, acute, chronic, and catastrophic). It includes early DX & RX to prevent disability and further complications. Illness prevention is the action taken prior to the onset of disease, which removes the possibility the disease will ever occur. 01/12/2023

Rehabilitation is a dynamic, health-oriented process that assists an ill person or a person with disabilities . Rehabilitation is the combined & coordinated use of medical, social, educational & vocational measures for training & retraining the individual to the highest possible level of functional ability . The nurse advocates of the holistic approach view all of the component with equal importance when identifying health need, planning and implementing care and evaluating the results 01/12/2023

Introduction of modern medicine was very late in Ethiopia. Health care of communities and families was by Hakim ( wogesha or traditional healers ). In 1908 Minlik II hospital was established in the capital of Ethiopia . The hospital was equipped and staffed by Russians In 1949 the Ethiopian Red Cross, School of Nursing was established at Hailesellasie I hospital in Addis Ababa. The training was given for three years. History of Nursing in Ethiopia 01/12/2023

In 1954 HailesellasieI Public Health College was established in Gondar to train health officer, community health nurses and sanitarians. During the regimen of ' Dergue ', the former bedside and community health nursing training was changed to comprehensive nursing. An additional higher health professional training institution was also established in 1983In Jimma . Cont … 01/12/2023

process is a series of steps or acts that lead to accomplishment of some goal or purpose The nursing process is the framework for providing professional, quality nursing care A systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness Nursing Process 01/12/2023

purpose T o identify a client’s health status, actual or potential health care problems or needs To deliver specific nursing interventions to meet those needs It helps nurses in arriving at decisions and in predicting and evaluating consequences. Used for applying a scientific approach or a problem solving approach to nursing pract ice 01/12/2023

Assessment Nursing Diagnosis Planning Implementation Evaluation Nursing Process step 01/12/2023

Is the foundation of the nursing process It is a continuous process carried out during all phases of nursing process. purpose All phases of the nursing process depend on the accurate and complete collection of data. To establish baseline information on the client. To determine the client’s normal function. To determine the client’s risk for diagnosis function. To determine presence or absence of diagnosis To provide data for the diagnostic phase ASSESSMENT 01/12/2023

Assessment include : Nursing history Physical examination Diagnostic & lab. test 01/12/2023

Data - Subjective vs O bjective Characteristics Complete Factual Accurate Relevant Incomplete or inadequate assessment may result in inaccurate conclusions and incorrect nursing interventions 01/12/2023

Sources of data: - Client Support people Client record Health care professional L iterature 01/12/2023

1. Comprehensive (initial assessment): performed with specific time after admission to a health care agency it includes history taking, physical examination, and laboratory test Purpose: - T o establish a complete data base for problem identification, reference, and future comparison Type of assessment 01/12/2023

2 . Focus or on going assessment :- Is on going process integrated with nursing care Purpose: to determine the status of a specific problem identified in an earlier assessment to identify new or over looked problem Assessment of client ability to perform self care while assessing the client to bathe 01/12/2023

3 . Emergency assessment :-is assessment during any physiological & psychological crisis of the client Purpose : To identify life-threatening problem E.g. Rapid assessment of the person’s air way, breathing status and circulations during a cardiac arrest 01/12/2023

4. Time-lapsed assessment : - is assessment long times after initial assessment Purpose To compare the client’s current status to base line data previously obtained E.g. reassessment of the client functional health pattern in a home care or out patient setting 01/12/2023

It is the process of identification of actual or potential health problem of the patient It is the process of making clinical judgments (nursing diagnose) about individual, , family, or community responses to potential or actual problem It is problem identification & gives meaning to the data . During this time the nurse sorts, clusters and analyze the data Nursing diagnoses guided planning and implementation of care Nursing diagnosis 01/12/2023

Nursing diagnosis A clinical judgment about individual, family, or community responses to actual and potential health problem. T ype Actual Risk Possible wellness Syndrome 01/12/2023

Actual nursing diagnosis : - is a judgment about a client response to a health problem that is present at the time of nursing assessment. A high risk diagnosis : - is a clinical judgment that a client is more vulnerable to develop the problem. It can be documented by using the two part statement. Does not have sign and symptom of the diagnoses Possible nursing diagnoses :- is one in which evidence about a health problem is unclear 01/12/2023

Wellness diagnoses; identify the individual or aggregate condition or state that may be enh anced by health promoting activities E.g. Readiness for Enhanced Community Coping and Readiness for Enhanced Spiritual Well-Being Syndrome nursing diagnoses usually are one part diagnostic statement with the contributing factors contained in the diagnostic predisposed Syndrome NANDA has five s diagnoses Rape trauma syndrome Disuse syndrome Post trauma syndrome Relocation stress syndrome Impaired environmental interpretation syndrome 01/12/2023

Planning D esigning basis for how some thing can be achieved Elements of planning Establishing priority Writing goals/expected out comes that determine the evaluation strategy Selecting appropriate intervention Communicating plan with other nurses participating in implementation 01/12/2023

Is the action phase of the nursing process Independent ‑ performed without order Dependent‑implementing orders Interdependent‑ incooperation with other health team members I ntervention Categories 01/12/2023

The way nurses determine whether a client has reached a goal It is the analysis of the client’s response Evaluation helps to determine the effectiveness of nursing care . Ongoing part of the nursing process Determining the status of the goals and outcomes of care Evaluation 01/12/2023

Components of the Nursing Process Assessment/data collection Evaluation NSG diagnosis Goals/ priorties /outcomes Planning/NSG prescriptions Intervention 01/12/2023

Wash your hands before and after any procedure Explain procedure to patient before you start Close doors and windows before you start some procedures like bed bath and back care Do not expose the patient unnecessarily General instructions for all nursing procedures 01/12/2023

5. Assemble necessary equipment before starting the procedure. 6. After completion of a procedure, observe the patient reaction to the procedure , take care of all used equipment and return to their proper place. 7. Record the procedure at the end 01/12/2023

BED MAKING UNIT- 2 01/12/2023

Learning Objectives At the end of this unit, the learner able to: Describe different types of bed making State the purposes of bed making in health care facilities Develop understanding about general instruction of bed making 01/12/2023

Bed making It is a scientific way of preparing a bed for the patient A clean, dry, smooth bed enhances patient feeling of well-being. If the linens are soiled, wet, or stained, they need to be changed. In most instances beds are made after pt receives certain care 01/12/2023

The bed is particularly important to people who are ill. It is essential the nurse keep the bed as clean and comfortable as possible. Physical Comfort Psychological comfort 01/12/2023

Open bed Closed bed Occupied bed Anesthetic bed Amputation bed Fracture bed Cardiac bed Types of bed 01/12/2023

It is one which is made for an ambulatory pt Are made in the same way with closed, but the top covers of an open bed folded back to make it easier to get in OPEN BED 01/12/2023

It is prepared for a newly admitted patient Top sheet, blanket and bed spread are drawn up to the top of the bed and under the pillow A closed bed is not being used CLOSED BED 01/12/2023

Anesthetic bed: is a bed prepared for a patient recovering from anesthesia Purpose : to facilitate easy transfer of the patient from stretcher to bed Amputation bed : a regular bed with a bed cradle and sand bags Purpose : to leave the amputated part easy for observation Fracture bed: a bed board under normal bed and cradle Purpose: to provide a flat, unyielding surface to support a fracture part Cardiac bed: is one prepared for a patient with heart problem Purpose : to ease difficulty in breathing 01/12/2023

Make sure the wheels on the bed are locked before you begin to make the bed Use good body mechanics at all times Follow standard precautions wash your hands before handling Bring enough linen into the person’s room Always keep clean linen covered Never put dirty linens on the floor or Roll dirty linen away from your body when removing it. RULES FOR BEDMAKING 01/12/2023

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 and Non sterile gloves 01/12/2023

Wash hands and collect necessary materials Place the materials to be used on the chair. Positions bed flat, raises to working height, lowers side rails. Folds and places clean bed spread and/or blanket on clean area. Removes all sheets and pillowcases; places in laundry bag or hamper without contaminating uniform Does not place linen on the floor Making Unoccupied Bed 01/12/2023

Removes and replaces linens on one side of the bed at a time Does not “shake” or “fan” linen flat bottom sheet, allows at least 10 inches to hang over at top and sides for tuck-in Smoothest wrinkles from bottom sheet If there is a draw sheet, tucks it and draws it tight. Replaces waterproof pad if one is being used. Places top sheet and bed spread along one side of the mattress; tucks them in at the same time, using a mitered corner. Then moves to opposite side of the bed 01/12/2023

14. after making both sides of the bed, at the head of the bed, folds sheet down over bedspread. 15. At foot of the bed, makes a small pleat in the top sheet and bedspread. 16. folds top sheet and bed spread back to the foot of the bed. 17. Changes pillowcases: grasps middle of closed end of pillowcase 18. Assists client back to bed 19. Places call signal within reach. 20. Places bed side table and over-bed table so they are accessible to the client 21. Document your actions and the client’s response during the procedure 01/12/2023

Purpose: to provide comfort, cleanliness and facilitate position of the patients Essential equipment: Two large sheets Draw sheet Pillow case Pajamas or gown, if necessary Occupied Bed 01/12/2023

Mattress pad Antiseptic solution, washcloth, and towel Linen bag hamper outside the room Non sterile gloves Cont … 01/12/2023

Equipment is the same as for unoccupied bed If a full bath is not given at this time, the patient’s back should be washed Nurse must use initial touch to the patient and explain the procedure Wash hands and collect equipment Carry all equipment to the bed and arrange in the order it is to be used Make sure the windows and doors are closed Make the bed flat, if possible Making occupied bed 01/12/2023

1 . Prepares the environment, as needed 2. Dons protective gloves if necessary 3. Positions the bed flat if possible, and raises to the appropriate working height 4. Disconnects the call device and removes patient’s personal items from the bed 5. Checks that no tubes are free in the bed linens 6. Leaves the side rail down only on the side of the bed where the nurse is standing Making Occupied bed 01/12/2023

. 7.Removes blanket and/or bedspread; if clean, folds and places on a clean area. Does not place clean linen on another patient’s bed or furniture. 8. Covers patient with a bath blanket, if available, or leaves the top sheet over patient. 9. Positions patient; Slides patient to the far side of the bed; places in a side-lying position facing the side rail 10. Rolls or tightly fan-folds the soiled linens toward patient’s back; tucks the roll slightly under patient 11. Covers any moist areas of the soiled linen with a water proof pad . 01/12/2023

Removes soiled gloves; performs hand hygiene; and dons clean procedure gloves Places a clean bottom sheet and draw sheet on near side of the mattress, with the center vertical fold at the center of the bed. Fan folds the half of the clean linen that is to be used on the far side, folding it as close to patient as possible and tucking it under the dirty linen Tucks the lower edges of clean linen under the mattress. Smoothest out all wrinkles. Rolls patient over dirty linen and gently pulls patient toward the nurse so patient rolls onto the clean linen 01/12/2023

17. Raises the side rail on the clean side of the bed 18. Moves pillows to the clean side of the bed; positions patient side-lying near the bed rail on the clean side 19. Moves to opposite side of bed; lowers the bed rail 20. Pulls soiled linen away from patient 21. Does not put soiled linen on the floor or other surfaces. 22. Removes soiled gloves, performs hand hygiene, and dons clean procedure gloves . 23. Pulls linens stiff, starting with the middle section 01/12/2023

24. Assists patient to a supine position close to the center of the mattress. 25. Places the top sheet and bedspread along one side of the mattress; removes the bath blanket 26. Tucks sheet and blanket in at the same time, then moves to the opposite side of the bed 27. After making both sides of the bed, at the head of the bed, folds sheet down over the bed spread 01/12/2023

28. At the foot of the bed, makes a small toe pleat in the top sheet and bedspread; then tucks in the bottom of the sheet and bedspread Changes pillowcases Returns the bed to a low position, raises side rails, and attaches the call light within patient’s reach Positions the bedside table and over bed table within patient’s reach. 01/12/2023

Bed making : Occupied Bed 01/12/2023

bed position when completed, bed is lowered Call light Side rails Unit organized Personal belongings are within reach When finished evaluate 01/12/2023

GENERAL CARE OF THE PATIENT UNIT -3 01/12/2023

Hygiene is the science of health. Hygienic care promotes cleanliness , provides for comfort and relaxation, improves self-image, and promotes healthy skin. Client hygiene is an extension of providing client safety and protecting the client’s defense mechanisms. The type of hygienic care provided depends on the client’s ability, needs, and practices. Personal Hygiene 01/12/2023

Personal hygiene and skin care Bathing It is a bath or wash given to a patient who is unable to care for himself or her self Purpose To prevent infection, secretions , excretion To stimulate circulation To produce a sense of well being To promote relaxation, comfort, & cleanliness To prevent or eliminate unpleasant body odors To prevent pressure sores 01/12/2023

TYPE The type of bath provided will depend on the purpose of the bath and the client’s self-care ability. The two general categories of baths based on purpose are cleaning and therapeutic . Cleaning Baths It is provided as routine client care The purpose is personal hygiene Sub classified as: Shower(stand up/sit down ) Tub Bath Self-help , or assisted bed bath Complete bed bath, and partial 01/12/2023

Clients frequently prefer and enjoy tub baths. A tub bath permits washing and rinsing in the tub Tub baths can also be therapeutic. Clients with limited physical ability should be assisted with entering and exiting the tub. A complete bed bath is provided to dependent clients confined to bed. Cont … 01/12/2023

Therapeutic Bath It require an order by stating type of bath, T ° of water, body surface, type of medicated/solutions to use Hot- or warm-water tub baths are used to reduce muscle spasms , soreness, and tension It may classified as: hot or warm water cool or tepid water soak, sitz , or sodium bicarbonate 01/12/2023

A soak can include the entire body or be limited to only one body part. A soak consists of applying water, with or without a medicated solution, to reduce pain,swelling , or irritation or to soften or remove dead tissue Sitz baths cleanse and reduce inflammation in the perineal and anal areas . Sitz baths are commonly used for hemorrhoids or anal fissures and after perineal or rectal surgery . 01/12/2023

Back care ( Massage ) It includes the back area from shoulder to lower buttocks Purpose To relieve muscle tension To promote physical and mental relaxation To promote muscle and skin functioning To relieve insomnia To provide a relive from pain To prevent pressure sores To enhance circulation 01/12/2023

Oral care It is important to maintain dental health of hospitalized client, begins with a good oral hygiene evaluation Rationale: Help to assess clients oral health status To remove pathogen, unpleasant tastes & odours To provide comfort for the client To enhance client’s feeling well being & appetite 01/12/2023

Common problems of oral cavity are : • Bad breath ( halitosi s) • Dental caries ( cavities ) • Plaque • Periodontal disease • Gingivitis • Stomatitis 01/12/2023

Poor oral hygiene and loss of teeth may affect: A client’s social interaction Body image Nutritional intake Preventive oral care consists of fluoride rinsing, flossing , and brushing . 01/12/2023

Flossing Flossing should be performed daily in conjunction with brushing of teeth. Flossing prevents the formation of plaque , removes plaque between the teeth, and removes food debris. Dental caries and periodontal disease can be prevented by regular flossing. Flossing is best performed after tooth paste is applied to the teeth but before brushing 01/12/2023

Brushing Brushing of teeth should follow flossing. Teeth should be brushed after each meal. Brushing should be performed using a dentifrice (toothpaste) that contains fluoride to aid in preventing dental caries Brushing removes plaque and food debris and promotes blood circulation of the gums. Dentures should be brushed using the same brushing motion as that used for brushing teeth. 01/12/2023

Brushing and Flossing Denture Care Tooth brush Denture brush Tooth paste Denture cleaner Emesis basin Emesis basin Towel Towel Cup of water Cup of water Non sterile gloves Non sterile gloves Dental floss Tissue Dental-floss holder Denture cup Mirror Lip moisturizer 01/12/2023

1 . Assemble articles for flossing and brushing 2. Provide privacy. 3. Place client in a high-Fowler’s position. 4. Wash hands and don gloves. 5. Arrange articles within client’s reach 6. Assist client with flossing and brushing as necessary. Position mirror and emesis basin near client for use during activity Flossing and Brushing 01/12/2023

7 . Assist client with rinsing mouth 8. Reposition client, raise side rails, and place call button within reach. 9 . Rinse, dry, and return articles to proper place. 1 0. Remove gloves, wash hands, and document 01/12/2023

Clients at Risk for or with an Alteration of the Oral Cavity Bleeding Infection Ulcerations 01/12/2023

Assemble articles for flossing and brushing Provide privacy Wash hands and don gloves Place the client in a lateral position, head turned toward the side. Use a floss holder and floss between all teeth. Moisten tooth brush , apply small amount of tooth paste , and brush the teeth If Unconscious (Comatose) Client 01/12/2023

After flossing and brushing, rinse mouth with syringe and perform oral suction Dry the client’s mouth. Apply lip moisturizer. Leave the client in a lateral position with head turned toward side for 30 to 60 minutes after oral hygiene care. Remove the towel from under the client’s mouth and face. 01/12/2023

Dispose of any contaminated items in a biohazard bag and clean, dry, and return all articles to the appropriate place. Remove gloves, wash hands, and document care . 01/12/2023

Specimen collection Taking vital signs Unit 4 Observation and Lab diagnosis of patient 01/12/2023

Learning Objectives; At the end of the unit the learner will be able to : Assist the patient in laboratory finding Collect specimen with accuracy as indicated Take vital signs and interpret the finding Give appropriate care based on the finding 01/12/2023

It refers to collecting various specimens (samples) General consideration for specimen collection Get request & identify type of specimen and patient wear gloves to protect self from contact with fluids Give adequate explanation to the pt about the purpose, type of specimen being collected Specimen- collection 01/12/2023

Assemble and organize all the necessary materials and clearly labeled with time and date Due to specimen collection pt name, age, card number, the ward and bed number(if in patient) should be check All the specimens should be sent quickly Cont … 01/12/2023

S pecimen collection -include Blood Stool Urine Other body fluids or tissues, for diagnostic or therapeutic purposes. 01/12/2023

Blood specimen collections Venous blood is most commonly used for blood tests It can be obtained by means of a venipuncture Arterial blood is less commonly assessed; it can be obtained with arterial puncture or through an indwelling arterial catheter for blood gas measurements Capillary blood is obtained using lancet 01/12/2023

Purpose :- Specimen of venous blood is taken for complete blood count, which includes; Hemoglobin Erythrocyte (RBC) count Leukocytes (WBC) count 01/12/2023

Purpose ; For laboratory diagnosis, such as microscopic examination, culture and sensitivity tests . The amount of stool specimen to be taken depends on the purpose, but usually takes. 3.5cm sample from formed stool 15.30 ml sample from liquid stool Collecting Stool Specimen 01/12/2023

Collecting urine specimen Types of urine specimen collection 1. Clean voided urine specimen 2. Timed urine specimen Short period – 1-2 hours Long period – 24 hours Purpose; for some tests of renal functions and urine composition 3 . Sterile urine specimen – To diagnostic urinary workup - Routine laboratory analysis, culture and sensitivity tests 01/12/2023

01/12/2023

Anuria Anuria means absence of urine or a volume of 100 ml or less in 24 hours. It indicates that the kidneys are not forming sufficient urine. Oliguria Oliguria , urine output less than 400 ml per 24 hours, indicates inadequate elimination of urine. Residual urine , The amount of urine that remains in the bladder after voiding (~50 ml) Abnormal Urinary Elimination Patterns 01/12/2023

Polyuria Polyuria means greater than normal urinary volume and may accompany minor dietary variations. For example, consuming higher than normal amounts of fluids, especially those with mild diuretic effects e.g ., coffee, tea, or taking certain medications can increase urination. Incontinence T he inability to control either urinary/stool after a person is toilet-trained. 01/12/2023

Nocturia N ight time urination; is unusual because rate of urine making is normally reduced at night Dysuria Is difficult/uncomfortable voiding and a common symptom of trauma to urethra or a bladder infection 01/12/2023

Collecting sputum specimen Sputum is the mucus secretion from the lungs, bronchi, & trachea The best time for sputum specimen collection is in the morning. It should be collected early in the morning, before the client’s teeth are brushed. Have the client rinse the mouth with water before coughing, to reduce contamination of the sputum sample with oral flora Do not obtain it immediately after a meal 01/12/2023

Purpose For culture and sensitivity test Cytological examination Acid fast bacillus (AFB) test Assess the effectiveness of the therapy 01/12/2023

Objectives Define v/s Describe the instruments used to measure v/s Identify normal and abnormal values of v/s List contraindications of oral, axillaries, and rectal site in taking body temperatures. Identify the sites for assessing the v/s. MEASURING VITAL SIGNS 01/12/2023

Vital signs are fundamental to physical assessment (the first step in the physical examination) to establish baseline values of the client’s cardiorespiratory integrity Baseline values establish the norm against which subsequent measurements can be compared Vital Signs 01/12/2023

Are important indicators of body’s response to physical, environmental/psychological stressors. Part of a routine physical assessment and are not assessed in isolation. A baseline set of V/S are important to identify changes Vital Signs 01/12/2023

When to take vital signs On a client’s admission Institution’s policy or standard of practice During home health visit Before & after a surgical or invasive procedure Before & after the administration of medication When the client’s physical condition changes Before, after & during nursing interventions When client reports symptoms of illness 01/12/2023

Temperature Pulse Respirations Blood pressure Vital signs must be measured, reported, and recorded accurately VITAL SIGNS INCLUDE 01/12/2023

Illness Emotions – anger, fear, anxiety, pain Exercise and activity Age, Sex, Environment - weather Food and fluid intake Medications Time of day – ↓ in the morning, ↑ in the afternoon/evening FACTORS AFFECT V/S 01/12/2023

REPORT THE VITAL SIGNS IF; Any v/s is changed from a previous Vital signs are above/below normal range 01/12/2023

It is the balance between the amount of heat produced and lost Heat is produced by : The contraction of muscles during exercise The breakdown of food during digestion The environmental temperature change Heat is lost through : Urine, Feces, Respirations & perspiration BODY TEMPERATUR 01/12/2023

Two Types of Body Temperature Core Temperature Temperature of the deep tissues Relatively constant unless exposed to severe extremes temperature Assessed by using a thermometer 01/12/2023

Surface Temperature Temperature of the skin May vary a great deal in response to the environment Assessed by touching the skin The body’s tissues & cells function best between the range from 36 deg C to 38 deg C 01/12/2023

Oral – within the mouth or under the tongue. Axillary – in the arm pit Tympanic – in the ear canal. Rectal – through the anus, in the rectum. Most temperatures are taken orally Rectal temperatures are the most accurate Axillary temperatures are the Less accurate TEMPERATURE MEASUREMENT SITES 01/12/2023

SITE NORMAL RANGE ORAL 98.6 ° 97.6 °-99.6 ° RECTAL 99.6 ° 98.6 °-100.6 AXILLARY 97.6 ° 96.6 - 98.6 ° TYMPANIC 98.6 ° 98.6 ° TEMPORAL 98.6 ° 98.6 ° NORMAL BODY TEMPERATURE 01/12/2023

Thermometer is an instrument used to measure body temperature 3 - type 1. Glass Thermometers Mercury expands or contracts in response to heat Mercury rises in a glass tube until its level matches the temperature 01/12/2023

The scale is marked from 94° to 108° The long lines represent one degree The short lines represent two tenths of a degree GLASS THERMOMETER 01/12/2023

Battery operated Have an oral probe and a rectal probe Disposable probe cover is placed on the probe The temperature registers in about 30 seconds Measure through a probe at the end of the device. Hold as close as possible to the area where you wish to measure the temperature . 2.ELECTRONIC THERMOMETER 01/12/2023

Accurate, fast, easy to read Comfortable for the patient use a disposable cover 3. DIGITAL THERMOMETER 01/12/2023

Measures the temperature in the tympanic membrane (eardrum) Fast and accurate - 1 to 3 seconds Infants – pull the ear straight back Adults and children over one year -Pull the ear up and back TAKING tympanic thermometer 01/12/2023

Lubricate the thermometer before inserting Place the person in a side-lying position Insert the thermometer 1 inch into the rectum Hold the thermometer in place for 2 minutes Remove the disposable cover and read the thermometer T aking a rectal temperature 01/12/2023

Taken only when no other site can be used sure the underarm is clean and dry The arm is held close to the body hold the thermometer in place while the temperature is being taken in place for 10 minutes T aking an axillary temperature 01/12/2023

Oral Posterior sublingual pocket – under tongue No hot or cold drinks or smoking 20 min prior to temp. Must be awake & alert. Not for small children (bite down) Leave in place 3 min Axillary Bulb in center of axilla Lower arm position across chest Non invasive – good for children. Less accurate Leave in place 5-10 min. Measures 0.5 C lower than oral temp. Rectal Side lying with upper leg flexed, insert lubricated bulb (1-11/2 inch adult) (1/2 inch infant) When unsafe or inaccurate by mouth (unconscious, disoriented or irrational) Side lying position – leg flexed Leave in place 2-3 min. Measures 0.5 C higher than oral Ear Adult - Pull pinna up & back Child – pull pinna down & back Rapid measurement Easy assessibility 2-3 seconds 01/12/2023

T he pulse is beat of the heart felt at an artery as a wave of blood passes through the artery A pulse is felt every time the heart beats More easily felt in arteries close to skin Should be the same in all pulse sites of body PULSE 01/12/2023

In some types of cardiovascular diseases heartbeat and pulse rate differs. Client's heart produces very weak or small pulses that are not detectable in a peripheral pulse far from the heart. Peripheral Pulse: is a pulse located in the periphery of the body e.g. in the foot, and or neck Apical Pulse (central pulse): it is located at the apex of the heart 01/12/2023

THE PULSE IS AFFECTED BY MANY FACTORS Age , fever, Exercise, fear Anger, anxiety, heat, Position, pain. Medications 01/12/2023

PULSE SITES 01/12/2023

Most common site Can be taken without disturbing or exposing person Place the first two or three fingers against the artery The radial artery is on the thumb side of the wrist Do not use your thumb to take a person’s pulse Use gentle pressure Count the pulse for 30 seconds and multiply by two RADIAL PULSE 01/12/2023

Taken with a stethoscope Counted by placing over the heart Apex of heart 5 th intercostal space directly below center of left clavical Counted for one full minute The heart beat normally sounds like l ub -dub Each lub -dub is counted as one beat Do not count the lub as one & dub as another Is taken for pts who have heart disease APICAL PULSE 01/12/2023

The apical and radial pulse rates should be equal Sometimes the heart beat is not strong enough to create a pulse in the radial artery this cause the radial less than the apical pulse One person counts the apical while the other counts the radial. The difference in pulses is called the pulse deficit APICAL vs RADIAL PULSE 01/12/2023

Electronic devices Blood pressure machines Pulse oxymetry Infrared light measures pulse & oxygen levels Report oxygen level below 92% not improved by deep breathin g 01/12/2023

Age Heart Rate (Beats/min) Infants 120-160 Toddlers 90-140 Preschoolers 80-110 School agers 75-100 Adolescent 60-90 Adult 60-100 Normal Heart Rate 01/12/2023

Respiration(r) It is the act of breathing Observe the client’s chest movement upward/outward for a complete minute Chest rises during inspiration & falls during expiration Count each time the chest rises Count for 30 seconds and multiply two Do not let person know you are doing 01/12/2023

Two types of breathing 1. Costal (thoracic ) Involves the external muscles and other accessory muscles Observed by the movement of the chest up ward and down ward. Commonly used for adults 2. Diaphragmatic (abdominal ) Involves the contraction & relaxation diaphragm Observed by the movement of abdomen Common in men young children 01/12/2023

Assessing Respiration Rate breathing cycles/minute (inhale/exhale-1cycle) 12-20 breaths/min – adult Abnormal increase – tachypnea [RR>20] Abnormal decrease – bradypnea [RR<12] Absence of breathing – apnea Depth Amount of air inhaled/exhaled normal (deep & even movements of chest) shallow (rise & fall of chest is minimal) Rhythm Regularity of inhalation/exhalation Normal (very little variation in length of pauses b/w I&E Character Dyspnea – difficult or labored breathing 01/12/2023

1 inhalation + 1 exhalation = 1 respiration Respiratory rate – indication of how well the body provides oxygen to the tissues Check by watching movement 01/12/2023

Normal Respiratory Rates 26-40 ) 20-30 18-24) 16-24 ) 12-20) ( 12-24) 01/12/2023

Is the pressure created when the force of blood pumped against the walls of the arteries Two types Systolic pressure – measure of pressure when left ventricle contracts or the first sound. Diastolic pressure : Measure of pressure when ventricle relaxes Minimum pressure exerted against the artery walls at all times Blood Pressure 01/12/2023

Arterial blood pressure : it is a measure of pressure exerted by the blood as it flows through the arteries. Physiologic factors determining arterial blood pressure are blood flow and peripheral resistance Arterial blood pressure = Blood flow X Peripheral resistance Blood flow = Cardiac output = Stroke volume X HB Stroke volume – the amount of blood pumped from each ventricle with each heart beat Resistance to blood flow – caused by friction among the cells and other blood components and between the blood and the vessel walls 01/12/2023

NORMAL BLOOD PRESSURE Average adult systolic range – 90 to 139 Average adult diastolic range – 60 to 89 ABNORMAL BLOOD PRESSURE Hypertension Hypotension 01/12/2023

Age – blood pressure increases as a person grows older Gender – women usually have lower blood pressure than men Blood volume – severe bleeding lowers the blood pressure Stress – HR & B/P increase as part of body’s response to stress Pain – increases blood pressure FACTORS AFFECT B/P 01/12/2023

Exercise – increases heart rate and blood pressure Weight – blood pressure is higher in overweight persons Race – black persons generally have higher than white persons Diet – a high-sodium diet increases the fluid volume in the body which increases blood pressure Medications – can be taken to raise or lower blood pressure Position – blood pressure is lower when lying down Cont … 01/12/2023

Methods of measuring BP; BP can be assessed directly or indirectly Directly (invasive) with a catheter placed in an artery provides a continuous reading of BP and is used in critical care setting, in anesthesia. it is highly accurate . Indirectly (non – invasive ) using inflatable cuff to temporarily occlude arterial blood flow through one of the limbs . 01/12/2023

Equipment Sphygmomanometer Inflatable cuff Pressure bulb or other device for inflating cuff Types of sphygmomanometers Aneroid Electronic Mercury 01/12/2023

Aneroid sphygmomanometers Circular gauge for registering pressure Each line 2 mmHg Very accurate Must be checked and calibrated every 3 to 6 months 01/12/2023

Electronic sphygmomanometers Provides a digital read out of the B/P Maintain equipment according to manufacturer’s instructions No stethoscope is needed Easy to use 01/12/2023

Mercury sphygmomanometers A column of mercury rises with an increased pressure as the cuff is inflated If in use, must be checked, serviced, and calibrated every 6 to 12 months 01/12/2023

Stethoscope Amplifies body sounds Earpieces Chest piece Diaphragm – high-pitched sounds Earpieces Binaurals Rubber or plastic tubing Bell Chestpiece Diaphragm 01/12/2023

Measuring blood pressure Place cuff on the upper arm above the brachial pulse site Inflate the cuff to 30 mmHg above the estimated systolic pressure or approximately 180 mmHg to 200 mmHg Release the air in cuff and listen for the first heartbeat (systolic pressure) and the last heartbeat (diastolic pressure) Record results with systolic as the top number and diastolic as the bottom number. 01/12/2023

Special considerations in adults Post exercise, ambulatory disabilities, obese, known blood pressure problems Anxiety or stress Proper cuff size – improper size results in inaccurate reading Avoid measurement in an arm if: Injury or blocked artery is present History of mastectomy on that side Implanted device is under the skin 01/12/2023

Is the introduction of fluid into rectum and sigmoid colon for cleansing, therapeutic or diagnostic purposes Purpose For emptying (cleanse the lower bowel)– soap solution enema For diagnostic purpose (to assist in the evacuation of stool) Unit-5 Enemas 01/12/2023

Enemas can be classified as large or small depending on their purpose. Large-volume enemas ; Contains 500 to 1000 ml fluid Are administered to cleanse the bowel. Small-volume enemas ; Are used for the purpose of evacuating stool or instilling medications in the lower bowel. Usually found as prepackaged solutions which contain 150 to 240 ml fluid 01/12/2023

Equipment's Enema bag Bedpan, toilet Towel and wash cloth Solution per physician’s order Water-soluble lubricant Clean gloves 01/12/2023

Introduce yourself and explain procedure Prepare the solution, assure temperature within range of 99° to 102°F by using a thermometer or placing a few drops on your wrist Wash hands and don gloves Assist patient to left side-lying position, with right knee bent Hang bag of enema solution 12 to 18 inches above anus Procedure 01/12/2023

Lubricate 4 to 5 inches of catheter tip Place bedpan, robe and slippers within easy reach Separate buttocks, insert catheter tip into anal opening, slowly advance catheter approximately 4 inches. Slowly infuse solution via gravity flow; bag height may be increased but not to exceed 18 inches above anal opening Procedure 01/12/2023

10. If client complains of increased pain or cramping or if fluid is not being retained, stop procedure, wait a few minutes, then restart 11. Clamp tubing when fluid finishes infusing; remove catheter tip 12.Assist client to bedpan, toilet 13.Discard equipment in proper place 14.Remove gloves and wash hands. 15.Instruct client to call for assistance when finished eliminating Procedure 01/12/2023

Procedure fig 01/12/2023

Urinary Elimination The urinary system consists of the kidneys, ureters, bladder, and urethra. These major components, along with some accessory structures such as the ring-shaped muscles called the internal and external sphincters, work together to produce, collect and excrete urine . Urinary elimination (the process of releasing excess fluid and metabolic wastes), or urination, occurs when urine is excreted The consequences of impaired urinary elimination can be life-threatening Unit 6 01/12/2023

General measures to promote urination : Providing privacy, Assuming a natural position(sitting for women, standing for men), Maintaining an adequate fluid intake, and Using stimuli such as running water from a tap to initiate voiding. 01/12/2023

Is the introduction of a tube (catheter) through the urethra into the urinary bladder Strictly a sterile procedure Catheter is a tube with a hole at the tip Types of Catheter Straight (plain or Robinson) Retention (Foleys, indwelling) Condom catheter Catheterization 01/12/2023

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Appropriate catheter length is determined by the clients gender For adult male – 40 cm catheter For adult females – 22 cm Catheter Select appropriate balloon size 5 ml – for adults 3 ml – for children 01/12/2023

STRAIGHT CATHETER Purpose To relieve discomfort due to bladder distention To obtain a urine specimen To empty the bladder prior to surgery 01/12/2023

Indwelling Catheter Retention (Foley) Catheter contains a second, smaller tube through out its length On the inside this tube is connected to a balloon near the insertion tip. 01/12/2023

Purpose To manage incontinence To provide for intermittent or continuous bladder drainage and irrigation To prevent urine from contacting an incision after perineal surgery (prevent infection) To measure urine out put needs to be monitored hourly 01/12/2023

The condom catheter is a device that resembles a condom with a large-caliber connector at its distal end This is connected to a drainage bag via a leg bag or bedside container for urinary containment The ideal device adheres to the penile skin without producing irritation condom catheter 01/12/2023

Sterile Kidney dish Galipot Gauze Towel Solution Lubricant Catheter Syringe Specimen bottle Gloves Forceps Equipment for catheterization II. Clean Waste receiver Rubber sheet Flash light Measuring jug Screen 01/12/2023

Provide for privacy and explain procedure to client Set the bed to a comfortable height to work, and raise the side rail on the side opposite you Assist the client to a supine position with legs spread and to a side-lying position with upper leg flexed. Drape client’s abdomen and thighs. Ensure adequate lighting of the perineum Performing Urinary Catheterization: Female Client 01/12/2023

6 .Wash hands, don disposable gloves, and wash perineal area 7 . Remove gloves and wash hands 8 . Prepare a sterile field, apply sterile gloves, and connect the catheter and drainage system 9 .Separate the perineum and using forceps cleanse the periurethral mucosa with iodine or other antimicrobial cleanser 01/12/2023

10. Generously coat the distal portion of the catheter with water-soluble, sterile lubricant 11. Gently insert the catheter into meatus until urine is noted. Continue inserting for 1 to 3 additional inches 12.Inflate the retention balloon using manufacturer’s recommendations or according to physician orders. 13 . Instruct the client to immediately report discomfort or pressure during balloon inflation; if pain occurs, discontinue the procedure 14.Gently pull the catheter until the retention balloon is snuggled against the bladder neck 01/12/2023

15.. Secure the catheter to the abdomen or thigh . 16. Place the drainage bag below the level of the bladder 17. Remove gloves, dispose of equipment, and wash hands 1 8.Help client adjust position 19.Assess and document the amount, color , odor , and quality of urine 01/12/2023

Learning objectives At the end of this lesson learners will be able to: Define the key terms and abbreviations frequently used in medication administration. Describe the clinician’s responsibilities in preparation and administration of medications Locate the different sites of parenteral drug administration . Calculate appropriate dosage of medications UNIT -7 Administration of medication 01/12/2023

BID Two times a day C/I Contraindication D/S Detrose in Saline solution D/W Dextrose in water solution IM Intramuascular IV Intravenous IU International Unit Kg Kilogram Mg Milligram Ml Milliliter P.O Per Os (mouth) PRN As required QD Once a day QID Four times a day S/E Side effect TID Three times a day ABBREVIATIONS 01/12/2023

Types/ forms of drugs preparations Pills Powders Liquids for drinking or injection Suppositories Creams Ointments And inhalants are some of them 01/12/2023

Sources of drugs Minerals : liquid paraffin , magnesium sulfate, etc Animals : insulin, thyroid extract, heparin, etc Plants : morphine, digoxin, atropine, etc Synthetic sources : aspirin, sulphonamides Microorganisms :- penicillin, streptomycin 01/12/2023

Calculating medication orders Medication orders are usually written in metric units of measure, and present/supplied in the same way. But, rarely liquid medications or commonly used oral medications may be ordered in apothecary or house hold units of measure. In this case, calculate the amount of medication needed in the measurement system is needed 01/12/2023

Several formulas may be used by the nurse when calculating drug doses. One formula uses ratios based on the dose on hand and the dose desired Example1, the health care practitioner orders heparin (anticoagulant) 10,000 units SC; the dose on hand is 40,000 units/ml: 40000IU/1ml=10000/Xml X=0.25ml 01/12/2023

Example-2:- Amoxicillin 625 mg po is ordered. It is supplied as liquid preparation containing 250 mg in 5ml. How much would you administer. 625mg/X=250mg/5ml 250mgX=625mg5ml X=12.5ml 01/12/2023

Calculation of Flow Rate The flow rate is the volume of fluid to infuse over a set period of time as prescribed by the health care practitioner The health care practitioner will identify either the amount to infuse per hour (such as 125 ml per hour or 1000 ml over an 8-hour period 01/12/2023

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Types of medication orders There are four common medication orders 1. Stat order:- medication given immediately and once Epinephrine (adrenaline) would be carried out immediately for a client experiencing anaphylactic drug reaction (shock). 2. Single order or one-time order is for medication to be given once at a specified time 3. Standing order:- this order may or may not have termination date may be specified number of days. Ex:- Amoxicillin 500 mg TID 4. P.R.N order (when ever necessary ) 01/12/2023

Components of a drug order Name, age, sex of the client Name of the medication(generic /trade name) Forms of the medication Route of administration Amount/dose of the medication Frequency of the medication Duration of the medication Date and time of prescription was written And signature of prescriber 01/12/2023

Maintaining safety when administering medications When you administer drugs, you must follow certain safety procedures or rules, which are also known as ‘ the five rights’. Right medication Right dose/amount Right route/ method Right time Right client: Never administer a medication that has been prepared by someone else 01/12/2023

Calculate flow rate 2000ml NS in 4hrs?(2pt) Write five rights during medication administration?(1pt) the health care practitioner orders heparin 5,000 units SC; the dose on hand is 25,000 units/5ml:how many ml are administer?(2pt) quiz 01/12/2023

ROUTES OF DRUG ADMINISTRATION Route of administration is the path by which a drug, fluid , or other substance is brought into contact with the body. include : Oral Paranteral Topical Rectal Vaginal In halation 01/12/2023

Oral Route Most drugs are administered by the oral route because it is the safest, most convenient, and least expensive method. By swallowing. It is intended for systemic effects resulting from drug absorption through the various epithelia and mucosa of the gastrointestinal tract 01/12/2023

Advantages: Convenient - portable, no pain, easy to take. Cheap - no need to sterilize Variety - tablets, capsules Disadvantage Sometimes inefficient - low solubility drugs may suffer poor availability Not suitable for unconscious patient May cause irritation to gastric mucosa Effect too slow for emergencies 01/12/2023

Parantral Intradermal Subcutaneous Intramuscular Intravenous Other parenteral routes include : Intrathecal or intraspinal -into the spinal canal Intrapleural Intraperitoneal -injection into the peritoneum Intra-arterial, into an artery Intracardiac , into the heart muscle Intraosseous , into the bone 01/12/2023

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Administeringintradermalinjections (15 ) Is an injection given into the outer layer of the skin placed just below the epidermis Purpose 1. For diagnostic - TB screening ( Mantoux test) - Allergic tests 2. Therapeutic Local anesthesia Vaccination After administration of medication check for the immediate reactions of the skin 10-15 minutes for TAT,20-30 minutes for penicillin and72 hrs for TB 01/12/2023

Administering subcutaneous Injections Is depositing medication in to the loose connective tissue underlying the dermis SQ tissue is not richly supplied with blood vessels. Drugs commonly given in SQ includes- insulin, heparin, and allergic medications. Purpose To obtain quicker absorption than oral When it is impossible to give medications in other 01/12/2023

Administering Intramuscular (IM) medications IM injection: - is an introduction of a drug into a body’s system via the muscles. Purpose: - To obtain quicker action To avoid irritation It is more vascular so large volume of drug (up to 5ml) can be injected into develop muscles of adults Older infants and children under 2 years should no receive more than 1 ml of medication 01/12/2023

Intramuscular site selection When selecting an IM site, determines if the area is free of infection , necrosis , bruising & abrasions select safe site away from blood vessels , large nerves/sciatic and bones Unless it result in [common complication]: Abscesses Necrosis Nerve injuries Persistent pain 01/12/2023

These common sites include: Ventrogluteal site: Involves gluteus medium & minimums muscles in hip area Recommended for age over seven months. Provides the greatest thickness of gluteus muscle, doesn’t have nerves & blood vessels penetrating It is also clean and away from bone 01/12/2023

Dorsogluteal site Common site for administering IM injections Because of potential accidental injury to sciatic nerve , presence of major blood vessels & bone near the site; This site should not be preferred/used Studies confirmed that the exact location of the sciatic nerve varies from one person to another. If a needle hits the sciatic nerve, the client may experience permanent paralysis of the involved leg 01/12/2023

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Vastus lateralis site (Anterior lateral thigh ) Recommended if ventrogluteal site can’t be used Preferred site for infants under 7 months of age The thigh is divided into three horizontally and vertically. The injections are given in the outer middle third . This space provides large number of injection sites 01/12/2023

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Deltoid Muscle site Located in the lateral aspect of the upper arm Damage to the radial nerve and artery is a risk Land marks: Lower edge of the acromion process A triangle is formed at the midpoint in line with the axilla on the lateral aspect of the upper arm. Hepatitis B-virus vaccine should be given only in the deltoid muscle in adults 01/12/2023

Intravascular ( IV ) Placing a drug directly into blood stream May be - Intravenous (into a vein) Advantages Precise, accurate and immediate onset of action. When the given drug is irritating to the body tissue through other route Disadvantages Risk of embolism Infection. Infection can occur at the injection site. ... Damage to veins and injection site. The most dangerous route 01/12/2023

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Ways of IV medication administration May be added to the patient’s infusion Intravenous bolus or push Intermittent intravenous infusion 01/12/2023

Sites for IV injections Medicines or fluids may be given through an intravenous (IV) tube inserted into a vein. The IV is most often placed in the back of the hand, on the forearm, or on the inside of the elbow Dorsal venous network Radial vein Ulnal vein 01/12/2023

vein cut down Venous cut down is an emergency procedure in which the vein is exposed surgically and then a cannula is inserted into the vein under direct vision. It is used for venous access in cases of trauma, and hypovolemic shock when the use of a peripheral venous catheter is either difficult or impossible. 01/12/2023

Purpose when vein puncture is difficult /collapsed or inaccessible when prolonged, continuous infusion is needed when a secure infusion is essential when rapid infusion is important 01/12/2023

common sites for peripheral venous cut downs include The inner arm above the elbow The inner thigh and The inner ankle 01/12/2023

Potential complications of the venous cut down technique include Infection Failed cannulation Hemorrhage Nerve injury, and air embolism 01/12/2023

Topical Route Topical applications are those applied to: A circumscribed surface area of the body Or immediately beneath, the point of application Routes for topical applications include : Dermatologic -applied to the skin Instillations & irrigations- applied into body cavities/ orifices such as: Urinary bladder, Eyes, ears, nose, rectum and vagina 01/12/2023

Applying Topical Medications Purpose To have local effect To produce systemic effect Drugs Ointments - provide prolonged contact of a medication with the skin and soften the skin Powders used to promote drying & prevent friction skin Creams and oils lubricate and soften the skin 01/12/2023

Administering Ophthalmic Medications : It is application of a medications to the eye Purpose To treat local eye infections To dilate pupil for diagnostic purpose To aid in controlling intraocular pressure 01/12/2023

Drugs : - To administer an eye medication, gently press the lower lid down and have the client look upward while instilling into the lower conjuntival sac Eye drops/ Ointments - instilled in lower conjuctival sac 01/12/2023

Eye irrigation :- Purpose: -To remove secretions/foreign bodies -To cleanse /soothe or reduce pain the eye -To remove chemicals that may burn the eye Large amount tape water should be used to remove chemicals like acids. Irrigation should continue for at least 15 mint 01/12/2023

Contra indication of eye irrigation Eye perforation is suspected Eye examination can be done. If the cornea may have a deep injury or foreign body, 01/12/2023

Administering Ear medications : Instillation of a drug into the auditory canal Purpose : - For local effects - To soften the wax - To relieve pain - To destroy organisms /insects Prepare client for instillation by positioning on side, with the ear treated to the upper most Warm medication bottle in your hand to body 01/12/2023

Infant draw earlobe gently down & backward Adult: lift auricle upward and backward. Instill medication drops, holding dropper slightly above ear. Instruct client to remain on side for 5 to 10 min following instillation. Ear Irrigations : - Is flushing of external auditory canal Purpose: - To cleanse (using normal saline) - To apply heat 01/12/2023

Nasal Instillations : Administration of drugs into the nose Purpose : - To treat sinus infections - To treat nasal congestion s 01/12/2023

Rectal instillations : Administering drugs rectally Adivantage : - For local effect on GI mucosa (promoting defection) For systemic effects (provide analgesia, relieve nausea) By-pass liver - Some of the veins draining the rectum lead directly to the general circulation, thus by-passing the liver. Reduced first-pass effect Unable to take drugs orally(unconscious, children) Disadvantage Erratic absorption - Absorption is often incomplete Not well accepted 01/12/2023

Intravenous Fluids Crystalloids Colloids Blood/blood products and blood substitutes 01/12/2023

It is the giving of blood to a patient through a vein why blood transfusion is needed? Improvement of oxygen transport Restoration of red cell mass Correction of bleeding caused by platelet dysfunction Correction of bleeding caused by factor deficiencies BLOOD-TRANSFUSION 01/12/2023

BLOOD-TRANSFUSION Blood is a specialized organ that differs from other organs in its existences in a fluid state The volume of blood in humans is approximately 7 to10% of the normal body weight Blood is composed of plasma & various types of cells Plasma The main role of plasma is to take nutrients, hormones, and proteins to the parts of the body that need it It is the fluid portion consists about 55% It contains various serum proteins, such as: Albumin, globulin 01/12/2023

Cellular part Around 45% of the blood’s volume Has three types of cell : • Red blood cells (erythrocytes) • White blood cells (leukocytes) • Platelets(thrombocytes) 01/12/2023

White blood cells are part of the body's immune system. They help the body fight infection and other diseases. WBC's are composed of granulocytes (neutrophils, eosinophils , and basophils) and non-granulocytes (lymphocytes and monocytes) granulocytes, specifically neutrophils, help the body fight bacterial infections. The number of granulocytes in the body usually increases when there is a serious infection The granulocytes and monocytes are responsible for phagocytosis (cells engulf and dispose of foreign bodies . 01/12/2023

Platelets It maintain hemostasis and blood coagulation Blood coagulation is a comprehensive, sequential process of body’s response to injury Prothrombin (factor II) is a plasma protein, formed in the liver It is activated when blood vessels are damaged. Prothrombin activator causes the conversion of prothrombin into thrombin, which then causes fibrinogen to form clothing with in 10-15 seconds 01/12/2023

Purpose of platelet To counteract sever hemorrhage and replace the blood(to restore blood volume) To prevent circulatory failure in operation when there is blood loss(loss is considerable) To provide plasma in sever burns To increase hemoglobin in chronic anemia To provide clothing factors 01/12/2023

Type/group and Cross match Blood type and cross match is a lab test that identifies the client’s blood type and determines the compatibility of blood b/n donor & recipient There are four basic blood types: A, B, AB, and O that are determined by the presence or absence of A or B antigens Antigen is a foreign substance that enters your body. This can include bacteria, viruses, fungi, allergens, and other various toxins. Antibody is a protein produced by your immune system to attack and fight off these antigens 01/12/2023

Blood types are also classified as either positive or negative based on presence/absence of the Rh factor Rh factor refers to antigen found on the RBC Rh positive means the antigen is present Rh negative means the antigen is absent 01/12/2023

BASIC BLOOD TYPES • A positive A negative • B positive B negative • AB positive AB negative • O positive O negative 01/12/2023

Cross match determines the compatibility of the donor’s blood with that of the recipient In the laboratory, a sample of the recipient’s blood is mixed with that of possible donor If the blood sample is compatible, the mixed sample does not agglutinate 01/12/2023

People with A positive blood can receive donations from: A positive donors A negative donors O negative donors O positive donors 01/12/2023

Administrating blood transfusion Is the infusion of whole blood or blood component such as: Plasma Packed red blood cells Platelets from the healthy person to recipient 01/12/2023

Precaution of blood transfusion Before initiating the transfusion check the blood group of the doner with the recipant’s All doner’s blood should be checked weather free from infection/hepatitis “B”, syphilis & HIV 01/12/2023

Administrating blood transfusion Equipment Bottle containing blood, with the patient name, blood group and Rh . Factor. • Blood giving set • Sterile forceps in a sterile jar • Sterile syringes and needle • Alcohol swabs • Sterile gauze • Rubber sheet and towel • Tourniquet • Adhesive tape • Receiver for dirty swabs • I.V pole (stand) • Patient's chart. 01/12/2023

Before blood transfusion is administered the nurse has to check the blood group & RH- factor, if cross match of the donor's & the recipient’s blood is done and is compatible Prepare the tray with necessary items Take it to the pt's room Explain procedure to patient Hang the bottle & remove the air from the tubing Put pt. in a comfortable positio n. Procedure 01/12/2023

Place rubber & towel under the arm Check the vital signs before administering Choose the vein Apply tourniquet Clean the skin & feel for a distended vein & clean again . Puncture the vein with the needle After you make sure that you are in the vein release tourniquet &open the lamp. The drop/minute at the beginning should be very slow 01/12/2023

Watch patient closely for any reaction If there is no reaction from the patient regulate the rate of flow according to the patient's conditions & the order Remove the equipment you have used, wash and return to its proper place . Record the time you started the blood & any other pertinent information . 01/12/2023

Pre-operative Assessment Intra-operative care Post-operative care UNIT-8 PERI-OPERATIVE NURSING 01/12/2023

At the end of the unit students will be able to ; Identify phases of Perioperative period List the common nursing diagnoses during each phases of Perioperative period Discuss the responsibility of Perioperative time Learning Objective 01/12/2023

P erioperative :-is a term used to describe the entire span of surgery, including what occurs before, during and after the actual operation. S urgery is performed to correct an anatomical or physiological defect or to provide therapeutic interventions. Surgeries are categorized according to the degree of urgency (timely intervention of surgery) PERIOPERATIVE CARE 01/12/2023

Emergency surgery : requires immediate intervention to tolerate life. Urgent surgery: dictates intervention as necessary to maintain health in situations that are not life-threatening. Elective surgery: is usually performed at a time convenient to the client, with the delay presenting no physiological harm Categories of surgery according to the degree of urgency 01/12/2023

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Diagnostic : Performed to determine the origin of presenting symptoms and extent of a disease process Reconstructive: Performed to correct a disease process or improve cosmetic appearance Curative surgery : Repair or remove a diseased organ or restore normal physiologic functioning Palliative surgery: Decrease the spread of the disease process to prolong life or to reduce pain Transplant : Remove diseased tissue or organ and replace with functioning tissue or organ Surgical Interventions Based on Expected Outcomes 01/12/2023

Effective perioperative management is directed by a multidisciplinary team in accordance with recognized standards of care and individualized expected client outcomes Each member of the health care team (surgeon, anesthetist, and nurse) has a specific role and responsible PERIOPERATIVE MANAGEMENT OF CARE 01/12/2023

Perioperative nurses perform critical functions that vary with specific surgical procedures and the unique needs of individual clients to achieve positive client outcomes The three guiding principles for implementing care based on professional standards are: Maintain client safety Provide effective care and Provide care as efficiently Nurse Responsibilities 01/12/2023

Preoperative (before surgery) refers to the time interval that begins when the decision is made for surgery until the client is transferred to the operating room (OR) Head to toe examination of assessment should have to be performed(General systems review). Vital signs the morning of surgery (any deviation ) Results of all preoperative diagnostic tests recorded Preoperative phase 01/12/2023

Anxiety Ineffective coping Decisional conflict Deficient knowledge Possible Nursing Diagnosis pre operative phase 01/12/2023

T he nurse develops goals with client-focused expected outcomes based on relevant nursing diagnoses Demonstrates physical preparation for surgery Provides informed consent for the surgery Psychosocial and spiritual support systems and community resources Nursing Planning during pre operative phase 01/12/2023

Surgical Consent Form : Before surgery, the client must sign a surgical consent for any procedure that requires anesthesia and has risks of complications. Nurses can identify problems with consent when the client; Cannot explain the procedure or identify the risks Signed the form more than 30 days before surgery Had an unauthorized person sign the consent form Did not sign the consent form Nursing interventions during pre operative phase 01/12/2023

Nurses should verify that consent has been obtained before treatment begins. Consent is given only for the extent of action documented on the informed consent If an adult client is confused, unconscious, a family member or guardian must sign the consent form. If the client is <18 years of age, a parent or legal guardian must sign the consent form. Cont … 01/12/2023

Pt . must sign informed consent in front of witness 3 conditions of informed consent: Adequate disclosure of risks & benefits Pt demonstrates clear understanding & comprehension of information provided Consent must be given voluntarily Cont … 01/12/2023

In an emergency, the surgeon may have to operate without consent. Health care personnel, however, makes every effort to obtain consent by telephone or fax. Clients must sign the consent form before receiving any preoperative sedatives. The signed consent form is in the client’s chart before the client goes to the operating room 01/12/2023

Physical Preparation Skin preparation Elimination Food and fluids clothing/ grooming Preoperative Preparation 01/12/2023

Psychosocial Preparation. Careful preoperative teaching can reduce fear and anxiety of the clients . Provide preoperative teachings Administer medications Assist with psychosocial preparation Complete the surgical checklist 01/12/2023

Nursing activities are usually designated by time intervals: “night before surgery” and “day of surgery.” Time designations help to prevent surgical delays that can increase the client’s anxiety and the agency’s costs. The nurse prepares the client’s medical record the day before the patient arrives OR. Preoperative Checklist 01/12/2023

The risks of surgical complications are decreased when the client knows what to expect and receives instruction in postoperative exercises The nurse plays a major role in relieving the client’s anxiety This is by facilitating communication between surgeons and the client and family Client Teaching 01/12/2023

To prepare the patient emotionally, mentally and physically for surgery. To prevent any complication before, during and after surgery Purpose preoperative care 01/12/2023

Begins when the patient is transferred onto the operating room and ends with his admission to the post anesthesia recovery room (PARR ). The goal of nursing care during this phase is to ensure client safety INTRAOPERATIVE PHASE 01/12/2023

Risk for Injury related to physical Risk for Infection related to: Invasive procedure Hypothermia related to: Exposure to cool environment and/or Decreased metabolic rate Common nursing diagnosis during IOP includes; 01/12/2023

Scrub nurse Preparation of supplies and equipment on the sterile field Maintenance of patients safety and integrity Observation of the scrub bed team for breaks in the sterile fields Delivery of appropriate sterile instrumentation, sutures, and supplies; sharps count. Handling instruments to the surgeon, threading needles, cutting sutures, assisting with withdrawal and suction, and handling specimen. Nursing intervention during IOP 01/12/2023

Circulating Nurse opening sterile packs, delivering supplies and instruments to the sterile team , delivering medications to sterile nurse Responsible for creating a safe environment Managing the activities outside the sterile field Documenting intra operative nursing care Communicating relevant information to individual outside of the OR, such as family members The circulating nurse must be registered nurse. 01/12/2023

Begins with the admission of the patient to the PACU or PARR and ends with a follow–up evaluation in the clinical setting or at home. The immediate postoperative period refers to the first 24 hours after surgery. Assessment of the Post anesthesia Client should cover Airway, Vital signs , Cardiac monitoring, Peripheral vascular assessment , LOC, Fluid and electrolytes , GI system, Integumentary system and Discomfort/pain POSTOPERATIVE PHASE 01/12/2023

Immediate postoperative period assessment Airway patency Effectiveness of respiration Presence of artificial airways Mechanical ventilation, or supplemental oxygen Circulatory status, vital signs Wound condition, including dressings and drains Fluid balance, including IV fluids, output from catheters and drains and ability to void Level of consciousness and pain 01/12/2023

Later postoperative period ongoing assessmen t Respiratory function General condition Vital signs Cardiovascular function Fluid status Pain level Bowel and urinary elimination Dressings, tubes, drains, and IV lines 01/12/2023

Ineffective Airway Clearance Ineffective Breathing Pattern Deficient Fluid Volume Urinary Retention Acute Pain Risk for Infection Deficient knowledge of wound or drainage Situational Low Self-Esteem Common Nursing diagnosis in post o perative period 01/12/2023

Ensures a patent airway Endotracheal tube Nasal or oral airways and Suctioning when needed Helps maintain adequate circulation Passive range of motion and The application of anti embolism tube Nurses innervation in post operative phase 01/12/2023

Maintaining Neurologic Status Strict bed rest for 24 to 48 hours Adequate hydration with intravenous saline Maintains proper position and function of drain tubes and IV infusion Monitor for potential complications Comforting the patient 01/12/2023

Extremes in age Malnutrition Obesity Smoking Diabetes Cardiopulmonary disease Drug and alcohol abuse Low hemoglobin and red cells Pregnancy Factors that increase Perioperative complications 01/12/2023

Definition of wound wound classification Wound Dressing Suturing Removing Sutures UNIT-9 Skin integrity &wound healing 01/12/2023

The skin is the body’s largest organ and is the primary defense against infection Regulates body temperature Prevents loss of essential body fluid Protection of the body from harmful effects of radiation Excretes toxic substances with sweat Mechanical support. Immunological function Vitamin D synthesis from its precursors under the effect of sunlight FUNCTIONS OF THE SKIN 01/12/2023

A loss of continuity of the skin or mucous membrane which may involve soft tissues, muscles, bone and other anatomical structure Any disruption to layers of the skin and underlying tissues due to multiple causes including trauma, surgery, or a specific disease state Definition of wound 01/12/2023

Wound classification may be based on The cause of the wound The status of skin integrity B y depth of skin loss Based on degree of contamination Descriptive qualities of the wound such as color Wound classification 01/12/2023

Depending on the causes of wound ; Intentional wounds : Occur during treatment or therapy. These wounds are usually made under aseptic conditions. E.g , surgical incisions and vein punctures. Unintentional wounds : Are unexpected and often the result of trauma or an accident. These wounds are created in an unsterile environment & pose a greater risk of infection. 01/12/2023

Based on skin continuity : Open wound:- is when there is a break in the skin or mucous membrane, c losed wound :- is when there is injury to the underlying tissue without breaking in the skin or mucous membrane. 01/12/2023

C lassification by depth of skin loss ; Superficial epidermal (first degree) : Are confined to the epidermis layer Partial-thickness (first to second degree) : Involves the epidermis and upper dermis, which is the layer of skin under the epidermis. 01/12/2023

Deep (second degree) : Involves the epidermis and deep dermis. Full thickness (third degree) : Refers to skin loss that extends through the epidermis and the dermis, and into subcutaneous fat and deeper structures. Fourth degree : Are deeper than full-thickness loss, extending into the muscle and bone. 01/12/2023

Clean wounds: are intentional wounds that were created under conditions in which no inflammation was encountered and the respiratory, alimentary, genitourinary, and oropharyngeal tracts were not entered. ( expected infection rate: 1% to 5%) 2. Clean-contaminated wounds are intentional wounds that were created by entry into the alimentary, respiratory, genitourinary, or oropharyngeal tract under controlled conditions . ( infection rate: 8% to 11%) Based on degree of contamination ; 01/12/2023

3. Contaminated wounds are open, traumatic wounds or intentional wounds in which there was a major break in aseptic technique, leakage from the gastrointestinal tract, or incision into infected urinary or biliary tracts. have acute non purulent inflammation present. ( infection rate: 15% to 20%) 4. Dirty and infected wounds are traumatic wounds with retained dead tissue or intentional wounds created in situations where purulent drainage was present. ( infection rate: 27% to 40%) 01/12/2023

This classification assist the nurses in assessing the wound surface color. The three color system is a tool to direct treatment of open wounds With each color corresponding to specific therapy needs The RYB Wound Classification System 01/12/2023

Red wounds :. Are the color of normal granulation tissue and are in the proliferative phase of wound repair. These wounds need to be protected and kept moist and clean. How to protect red wounds : Gentle cleansing Applying a topical antimicrobial agent. Appling a transparent film/hydrocolloid dressing. Changing the dressing as in frequently as possible 01/12/2023

2. Yellow wounds Characterized primarily by liquid to semiliquid ”slough” that is often accompanied by purulent drainage. The clinician cleanses yellow wounds to absorb drainage Applying wet-to- wet dressing ; irrigating the wound; using absorbent dressing material such as impregnated no adherent, hydro gel dressing topical antimicrobial to minimize bacterial growth. 01/12/2023

3 . Black wounds : Covered with thick necrotic tissue or scar . Required debridement . When the scar is removed, the wound is treated as yellow, then red 01/12/2023

Since there are many types of wound, there are also many ways of caring for wounds depending on the type of wound. Ex :- clean wounds, septic wounds wound with drainage tube, wound that need irrigation . Open method :- refers to the care of wound with out dressing. Closed method:- is the care of wound with dressing Care of wounds 01/12/2023

History: Helpful to elicit information regarding medical conditions or disease processes that are often associated with delayed or disrupted healing Chronic illnesses Infections Assessment of a wound 01/12/2023

History should include ; When and how the wound occurred The initial location, size and general appearance. All associated symptoms such as pain and itching. The aggravating and alleviating factors, such as radiation at the site of the wound, which can influence the healing process. Any allergies to tape, latex, medications or other substances Laboratory data- culturing result of the wounded areas 01/12/2023

Should be examined to identify among t hree common types of ulcers. Vascular ulcers Evaluate the skin, nails, hair color, capillary refill, temperature, pulses, edema of the extremity, and in the per ulcer area Arterial ulcers Weak or absent pulses, thin skin and lack of hair on the affected extremity Neuropathic ulcers : Use of the Wagner scale to evaluate diabetic ulcers Wagner Scale provides a structure to determine the severity of a wound by examining its depth and extent Physical Examination 01/12/2023

From the assessment data the following nursing diagnosis can be expected Impaired Tissue Integrity Risk for Infection Pain related to inflammation, infection Disturbed Body Image related to changes in body appearance secondary to scars, drains, removal of body parts Deficient Knowledge related to lack of exposure to information, misinterpretation Nursing diagnosis 01/12/2023

Nursing management Cleanse the Wound The goal of cleansing the wound is to remove debris and bacteria from the wound with little trauma to the healthy granulation tissue as possible. Choice of cleansing agent depends on the physician’s prescription as well as agency protocol. It is recommended that isotonic solutions such as normal saline used to preserve healthy tissue. 01/12/2023

Antiseptics used for wound care Iodine 1%:- for small, dry and clean wounds Hydrogen peroxide3%:- to clean septic wound normal saline 0.9% for wound irrigation Ointments Petroleum (Vaseline gauze ) is used to protect tissue from drying It prevent dressing adherence to the wound create an air tight scar (used for burns ) 01/12/2023

Irrigating a wound ; is the washing a wound Purpose To remove excess drainage with sloughing tissue To facilitate healing. To apply antiseptic solution To cleanse and maintain free drainage of infected wound 01/12/2023

Dressing: - It is covering the wound with sterile material after cleaning with an antiseptic solution to provide the conditions necessary for healing . 01/12/2023

Purpose To keep wound clean To prevent the wound from injury and contamination To keep in position drugs applied locally To apply pressure To keep edges of the wound together by immobilization Dressing of a Clean Wound 01/12/2023

Pick up forceps kidney dish Sterile cotton balls Sterile swab Sterile gauze Three sterile forceps Rubber sheet with its cover Antiseptic solution as ordered Adhesive tape or bandages Scissors Ointment or other types of drugs as needed Receiver Benzene or ether Dressing equipment 01/12/2023

Explain procedure to the patient Clean trolley or tray; assemble sterile equipment on one side and clean items on the other side . Drape and put patient in comfortable position. Place rubber sheet and its cover under the affected side. Remove the outer layer of the dressing Remove the inner layer of the dressing using the first sterile forceps and discard both the soiled dressing and the forceps Procedure 01/12/2023

Take the second sterile forceps. Clean wound with cotton balls soaked in antiseptic solution, starting from inside to the outside. Again use the second forceps to clean the skin around and remove adhesive with benzene or ether. Apply medication if any and dress the wound with sterile gauze. Solutions or powder can be applied direct on the wound. Make sure that the wound is properly covered. Fix dressing in place using adhesive tape or bandage. Leave patient comfortable and orderly Record status of wound 01/12/2023

purpose Absorb materials being discharged from the wound Apply pressure to the area Apply local medication Prevent pain, swelling and injury Equipment and procedures are the same for both clean and septic wound Dressing of Septic Wound 01/12/2023

Explain procedure to the patient Clean trolley or tray and assemble sterile equipment on one side and surgically clean items on the other Drape patient and position comfortably. Place rubber sheet and its cover under the affected part First remove the outer layer of the dressing Wear gloves if necessary. Use, forceps to remove the inner layer of the dressing smoothly and discard there for caps. Observe wound and check if there is drainage rubber or tube Take specimen for culture or slide if ordered Procedure 01/12/2023

Start cleaning wound from the cleanest part of the wound to the most contaminated part using antiseptic solution. Discard cotton ball used for cleaning after each rap over the wound. Cleanse the skin around the wound to remove the plaster exudate with benzene or ether Use cotton balls for drying the skin around the wound properly Dress the wound and make sure that the wound is covered completely Fix dressing in place with adhesive tape or bandages Leave patient comfortable and neat Discard soiled dressings properly to prevent cross infection in the ward 01/12/2023

Suturing 01/12/2023

Sutures are a surgical means of closing a wound by stitching, connecting, or clipping the edges of the wound together. When placed deep within the tissue layers, sutures made of absorbable material are used so that the sutures will not need to be removed but rather can dissolve into the tissue . For surface closures, steel staples or sutures made of wire, nylon, cotton, or other materials are used; these need to be removed as the wound heals . Do not suture deep wound Suturing 01/12/2023

To approximate wound edges until healing occurs To speed up healing of wound To minimize the chance of infection C osmetic appearance Purpose of suturing 01/12/2023

Sutures are of two types: 1. Absorbable sutures 2. Non absorbable sutures Types of sutures material 01/12/2023

ABSORBABLE SUTURES Absorbable sutures are also known as catgut. A hard thin cord made from the treated and stretched intestines of certain animals, especially sheep This type of suture are commonly used to suture the inner structure of the body such as: Walls of the organs Rectal sheath Muscles Subcutaneous tissue Peritoneum 01/12/2023

Non absorbable sutures These types of sutures are not absorbed . used for closing or suturing outer surface of the body such as skin . Is cheaper ,easy to handle and to sterile ,have smooth surfaces & knot securely with the ends cut short But these kind of sutures are liable to cause stitch infection The infection can be prevented by only removing the stitch . For this reason sutures on the superficial surface of the skin should always be interrupted suture & never be continuous suture . Because the disadvantage of the continuous suture is when infection occurs on one site it is difficult to remove the infected stitch from the site without removing the rest of the stitch. 01/12/2023

stitches should not be too tight because extremely tight stitches may cause ischemia of the tissues that may lead to delayed healing. Also for the interrupted & continuous stitches the distances between stitches should be equal & all the bulges in the interrupted stitches are placed at the one side of the surgical wound . Methods of suturing 01/12/2023

1 . Continuous sutures :- are made with one thread, tied at the beginning and end of the suture line. 2. Intermittent sutures :- Each sutures are tied individually Methods of suturing 01/12/2023

01/12/2023

Tray or trolley covered with a sterile towel Sterile needle holder Sterile silk Sterile catgut Sterile tissue forceps Sterile scissors Sterile cotton swabs Sterile solution for cleaning Sterile dressing forceps Sterile gauze Suturing Equipment 01/12/2023

Explain procedure to patient Adjust light Wash your hands Clean the wound thoroughly Wash your hands again Put on sterile gloves Drape the Wound with the hold sheet Infiltrate the edges of the wound to be sutured with local anesthesia Procedure 01/12/2023

Approximate the edges of the fascia with the help of the tissue forceps and using the round needle and cat gut . Using the cutting needle and silk, suture the outer layer of skin approximating the edges with the help of the tissue forceps. Clean with iodine and cover with sterile gauze . Remove the hole Sheet Make patient comfortable Remove all equipment, wash & return to its proper place or send for sterilization . 01/12/2023

During the removal of suture use aseptic technique Sutures may be removed all at a time or may be removed alternatively Do not cut stitches in more than one place as a part of it may be left behind and may cause infection Suture is lifted slightly by the knot to allow scissors to go under and one part of the suturing from the cleanest part of the wound to the most contaminated part . After the completion of the removal the area needs to be cleaned and dressed Keep patient comfortable Record the state of the wound Removal of the Stitch 01/12/2023

Learning Objectives : After this chapter students will be able to: Describes signs of unconsciousness Management of unconsciousness patient Hospice Care for terminal illness Unit 10 Care of the terminally illness and unconscious patient 01/12/2023

Care of the terminally illness and unconscious patient Terminal illness: progressive, irreversible illness that despite cure-focused medical treatment will result in the patient’s death Coma : apply repeated painful stimuli to a comatose patient, the patient un arousal and no evident response to inner need or external stimuli Unconsciousness is a state of unawareness and loss of response to meaningful external stimuli Hospice is a type of care for the terminally ill. 01/12/2023

Trauma Stroke Infection Meningitis Subdural Hematoma I ntracranial Hemorrhage Drug over dose Poisoning Causes of Unconsciousness 01/12/2023

is unaware of his or her surrounds and not respond to sound Make no purposeful movement Dose not respond to question or touch Inability to speak or move parts of his or her body Loss of bowel or bladder control(Incontinence) Stupor drowsiness 01/12/2023 Sign and symptom unconsciousness

GCS (motor +verbal +eye opening) Vital sign Pupil –size and reaction Limb movement and tendon reflex 01/12/2023 Assessment of unconscious

Level of consciousness is degree of responsiveness of the patient to stimuli in the environment (internal and external). It assessed in the following ways; The Glasgow comma scale ; is a standard assessment tool change in consciousness. The eye opening Verbal responses Best motor responses 01/12/2023

GCS … The value in this scale range from 3 the deepest coma to 15 the fullest alertness The value for the three different response are listed below with respect to different stimuli A score of 7 or less is accepted as coma and requires the appropriate nursing management 01/12/2023

Eye opening Spontaneously =4 To speech =3 To pain =2 No response at all=1 01/12/2023 GCS…

Verbal responses Oriented =5 Confused conversation =4 Inappropriate words =3 Incomprehensible sound =2 No response = 1 01/12/2023 GCS…

Nursing Diagnoses Ineffective airway clearance related to i ncreased production of secretions evidenced by Changes in depth and rate of respirations Fluid volume deficit related to disturbances of consciousness and hormonal dysfunction Altered nutrition, less than body requirements, related to metabolic changes, fluid restriction, and inadequate intake 01/12/2023

Planning Goals : The patient's goals may include Achievement of a patent airway Achievement of fluid and electrolyte balance Achievement of adequate nutritional status Improvement of cognitive function 01/12/2023

Nursing Interventions 1. Airway Maintenance . Keep the unconscious patient in a position that facilitates drainage of oral secretions, with the head of the bed elevated about 30 degrees to decrease intracranial venous pressure . Establish effective suctioning procedures- (Pulmonary secretions produce coughing and straining, which increase ICP .) Monitor the patient on mechanical opening 01/12/2023

2. Environmental stimuli should be kept to a minimum by keeping the room quiet, limiting visitors, speaking calmly, and providing frequent orientation information 3. Adequate lighting may prevent visual hallucinations. 4. The patient's sleep-wake cycles should not be interrupted. 5. The skin is lubricated with oil or cream lotion to prevent irritation due to rubbing against the sheet. 6. Improved Cognitive Functioning 01/12/2023

Ventilation support Oxygen therapy Manage blood pressure Manage fluid balance Manage of seizures Manage increase ICP DVT prophylaxis Manage of elimination 01/12/2023 Medical and nursing management for Unconsciousness

Pressure sore Respiratory embolism DVT Weakness Constipation Anxiety and depressio n 01/12/2023 Complication of immobility

Hospice Care Hospice, a type of care for the terminally ill It is founded on the concept of allowing individuals to die with dignity and be surrounded by those who love them. Clients enter hospice care when aggressive medical treatment is no longer an option or When the client refuses further aggressive medical treatment The emphasis is on palliative care (control of the symptoms rather than cure) 01/12/2023

Interdisciplinary team is essential for delivering quality, compassionate care Home Care: Home care is an alternative for the dying client, if the family members are physically and emotionally able to provide care. Ideally, health care providers should share the responsibility of home care of the dying with the family. This sharing could include respite time and frequent visits 01/12/2023

Death presents a threat not only to one’s physical existence but also to psychological integrity Spend as much time as possible with the dying client Encourage verbalization of feelings Listen in nonjudgmental manner. Answer all questions in an honest, factual manner Provide explanation of all procedures. Encourage family and friends to spend time with client Psychosocial Needs 01/12/2023

In times of crisis, such as death, spirituality may be a sources of comfort and support for the client and family. Spiritual and religious beliefs often determine the appropriate course of action. Nurses play a major role in promoting the dying client’s spiritual comfort. The nurse can serve as a sounding board for the client who expresses values and beliefs related to death. Spiritual Needs 01/12/2023

The following are therapeutic nursing interventions that address the spiritual needs of the dying Communicating understanding Playing music Using touch Praying with the client Contacting the clergy if requested by the client Reading religious literature aloud at the client’s request 01/12/2023

Support for the Family Family members need to be involved in the care of their dying loved one. Unrealistic guilt is increased by feelings of powerlessness, thus it is important to involve family members in the care giving. Families facing the impending death of a loved one require much support from nurses and other caregivers. The nurse’s presence, just being there with the family, is extremely important 01/12/2023

Encourage client to verbalize presence of pain . Discuss pain relief options with client and family . Administer medication on a regular schedule instead of PRN to ensure maximum pain relief . Assist client and family to identify the stressors that influence pain. Teach non invasive pain relief measures Nursing management for terminally ill client 01/12/2023

Definition of death Stages of dying Post mortem care UNIT- 11 POST-MORTEM CARE 01/12/2023

Is a natural part of life and comes to all beings . Is the end of life and all the vital processes. Legal death is the total absence of brain activities as assessed and pronounced by the physician It is one of the two life events that all humans share, the other being birth. Death 01/12/2023

In her classic works, Dr Ross identified five possible stages of dying experienced by clients and their families dying as a normal process including the social and cultural context of death. Do not leave a dying patient alone. He may appear unconscious but he may hear and understand all that is being said Every person does not move in order through each stage . Stages of Dying 01/12/2023

1. First stage: Denial It is an immediate response to loss experienced by most people, is a useful tool for coping. It is an essential and protective mechanism that may last for only a few minutes or may manifest itself for months, E .g . Verbal : “This can’t be happening to me 01/12/2023

2. Second stage: Anger The client has no control over the situation and thus becomes angry in response to this powerlessness. The anger may be directed at self, God and others. E.g. Verbal : “Why me?” 01/12/2023

3. Third stage: Bargaining The anticipation of the loss through death brings about bargaining through which the client attempts to postpone or reverse the inevitable. The client promises to do something (such as be a better person, change lifestyle) in exchange for a longer life. E.g. Verbal : Client prays, “Please, God, just let me live long enough to see my grandchild graduate.” 01/12/2023

4. Fourth : Depression When the realization comes that the loss can no longer be delayed, the client moves to the stage of depression. E.g. Verbal : “Go away. I just want to lie here in bed. What’s the use?” 01/12/2023

5. Fifth stage: acceptance Most dying persons eventually accept the inevitability of death. Many want to talk about their feelings with family members Verbalization of emotions facilitates acceptance. With acceptance comes growing awareness of peace and contentment. The feeling that all that could be done has been done is often expressed during this stage. Verbal : “I feel ready. At least, I’m more at peace now.” 01/12/2023

Proficient nursing care during the final stage of life requires a unique knowledge base and skills. Areas that are often problematic for the terminally ill client are nutrition, respiration, elimination, comfort and mobility Promoting Comfort: The primary activities directed at promoting physical comfort include pain relief, keeping the client clean and dry and providing a safe, nonthreatening environment 01/12/2023 Nursing care of the dying patient

This is the care given to the body after death It is also called post-mortem care Nursing care includes maintaining privacy and preventing damage to the body . Purpose To show respect for the dead To prevent spread of infection To show kindness to the family CARE AFTER DEATH 01/12/2023

Equipment for post mortem care Basin for water, wash cloth and towel Cotton Gauze Dressings and tape if necessary Clean sheet Stretcher Forceps Name tag Gloves, if necessary 01/12/2023

Note the exact time of death and chart it If the doctor is present call him to pronounce death If the family members are not present, send for them Wash hands and wear clean gloves according to agency policy Close doors of the room or pull screen Raise bed to comfortable working level (when necessary) Arrange for privacy and prevent other patients from seeing in to room Procedure 01/12/2023

Close patient's eyes and nose if necessary Remove N.G. tubes and other devices from patient's body Place patient in supine position Replace soiled dressing with clean ones when possible Bath patients as necessary Brush or comb hair Apply clean gown Cont … 01/12/2023

Care for valuable and personal belongings Allow family to view patient and remain in room Attach special level if patient had contagious disease Remove gloves and wash hands Document the procedure 01/12/2023

g astric aspiration ; is withdrawal of fluid/gas from gastric by suction. Purpose To prevent or relieve distention following abdominal operation To remove the stomach or gastric contents incase of gastro intestinal obstruction To aspirate the stomach contents for diagnosis To keep the stomach empty before an emergency abdominal operation UNIT- 12 Gastrointestinal disorders therapeutic and diagnostic 01/12/2023

Types of gastric aspiration Intermittent aspiration :- suction is done as condition is required/ordered. Continuous aspiration :- attached to a drainage bag ways of suction The continues method is indicated when it is absolutely necessary and desirable to keep the stomach and duodenum empty 01/12/2023

Equipment Aspiration tube Aspiration syringe if this method is used Gallipots with lubricant Gauze swabs in a bowl Sodium bicarbonate solution or saline to clean the nostrils Litmus paper Water in a galipot to test the right position of the tube in the stomach Two test tubes and laboratory forms of necessary Saline or plain water in a galipot to be injected, in case the stomach content is too thick to come out through the syringe. Rubber mackintosh and towel to protect the patients chest. Receiver for sailed swabs 01/12/2023

Explain procedure to patient Prop up in an upright position with help of back rest and pillow Cleanse and lubricate the nostrils Lubricate the aspiration tube with water Insert the tube as directed in nasal feeding and ask the patient to swallow as the tube goes down . Instruct patient to open her or his mouth to make sure the tube is in the stomach Procedure 01/12/2023

7. After being sure that the tube is in the right position, inject about 15-20 cc. of saline or water in to the stomach 8. Draw plunger back to with draw the fluid collect specimen, If needed 9 . If the aspiration tube is to be left in site then a stopper or clamp is used to close the end, but if it is for one aspiration and to be removed immediately, it should be withdrawn very gently to avoid irritating the mucous lining. 01/12/2023

N.B Special care of the nose and mouth to prevent dryness should be considered Always measure the amount withdrawn accurately noting color, contents and small Record on the fluid chart properly Report any change in patient condition regarding pulse, Temperature, B.P , fluid out put. 01/12/2023

I nstillation of drops : to administer an eye medication, gently press the lower lid down and have the client look upward while instilling into the lower conjuntival sac. Unit-13 Eye , ear , and nose disorders therapeutic and diagnosis procedures 01/12/2023

Procedure Assists patient to a high Fowler’s position with head slightly tilted back Dons procedure gloves If needed, cleans the edges of the eyelid from the inner to the outer canthus Holding the eyedropper, rests the dominant hand on patient’s forehead With the nondominant hand, pulls the lower lid down to expose the conjunctival sac Positions eyedropper 1.5–2.0 cm above patient’s eye; does not let the dropper touch the eye Asks patient to gently close and move the eyes 01/12/2023

Eye irrigation : Large amount tape water should be used to remove chemicals like acids. Irrigation should continue for at least 15mint Purpose : -To remove secretions/foreign bodies -To cleanse /relax the eye -To remove chemicals that may burn the eye 01/12/2023

Ear instillation of drops is a drug into the auditory canal Purpose: For local effects - To soften the wax - To relieve pain - To destroy organisms /insects Prepare client for instillation by positioning on side, with the ear treated to the upper most Warm medication bottle in your hand to body lift auricle upward and backward. Instill medication drops, holding dropper slightly above ear. Instruct client to remain on side for 5 to 10 min following instillation . 01/12/2023

Assists patient to a low-Fowler’s position (if possible), with head tilted toward the affected eye Places a towel and basin under patient’s cheek Checks pH by gently touching pH paper to secretions in the conjunctival sac Instills ocular anesthetic drops, if ordered. Follows agency protocol . Connects IV solution and tubing; primes the tubing Holds IV tubing about 2.5 cm from the eye; does not touch the eye . Separates eyelids with thumb and index finger Directs flow of the solution over the eye from inner to outer canthus Rechecks pH and continues to irrigate the eye as needed . Procedure 01/12/2023

Procedure Warms the solution to be instilled and gently shakes the bottle before using the drops Assists patient to a side-lying position, with the appropriate ear facing up . Cleans the external ear with a cotton tipped applicator if needed . Clears the dropper with the correct amount of medication . Straightens the ear canal Instills the correct number of drops along the side of the ear canal Does not touch the end of the dropper to any part of the ear Gently pulls on the external ear after drops are instilled. Instructs patient to remain on his side for 5–10 minutes . Places cotton loosely at the opening of the auditory canal for 15 minutes . 01/12/2023

Ear irrigation is flushing of external auditory canal Purpose To cleanse (using normal saline) To apply heat 01/12/2023

procedure Warms the irrigating solution to body temperature Assembles irrigator, if necessary, and places a clean disposable tip on it Assists the client into a sitting or lying position with the head tilted away from the affected ear Dons gloves; puts on headlight . Drapes the client with a plastic drape and places a towel on the client’s shoulder on the side being irrigated Has the client hold an emesis basin under the ear Straightens the ear canal 01/12/2023

8. Instructs patient to indicate if any pain or dizziness occurs during the irrigation 9. Explains to patient that he may feel warmth, fullness, or pressure when the fluid reaches the tympanic membrane . 10. Places the tip of the needle about 1 cm above the entrance of the ear canal and directs the stream of irrigating solution gently along the top of the ear canal toward the back of patient’s head. 11. Does not obstruct the ear canal with the needle 12. Instills the solution slowly 01/12/2023

Nasal Instillations : Administration of drugs into the nose Purpose To treat sinus infections To treat nasal congestions 01/12/2023

procedure Explains to patient that the medication may have an unusual taste or cause some burning Dons gloves Asks patient to blow his nose . Determines head position depending on patient’s ability to assume the position Asks patient close one nostril and exhale, then inhale deeply through the mouth Administers spray or drops while patient is inhaling through the mouth. Does not touch the dropper to the sides of the nostril . Repeats steps 5 and 6 on other nostril If nose drops are used, asks patient to stay in the same position for 1–5 minutes Instructs patient not to upset his nose for several minutes 01/12/2023

Good luck Read more!!! ! 01/12/2023

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