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Vital signs including temperature, pulse, respiratory rate, and blood pressure are essential for nursing assessment and monitoring patient health. Proper technique and equipment are required to accurately measure each vital sign. Nurses must be aware of normal ranges and know when to re-assess based on patient condition or procedures. Urine and other specimen collection are also important for diagnostic testing and monitoring the effects of treatment.

Healthcare
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UNIT ONE Essential Assessment Components Nursing Art for Health Officer
Vital Signs Vital sings are signs that reflect changes in the functions of the body. • The “taking of vital signs” refers to measurement of the client’s body temperature (T), pulse (P) and respiratory (R) rates, and blood pressure (BP). • Vital signs are fundamental to physical assessment (the first step in the physical examination) to establish baseline values of the vital signs. • The sequence for recording vital signs measurement in the nurses’ notes is T-P-R and BP.
Cont….. Types of v/s There are five v/s 1. The Blood pressure 2. The temperature 3. The pulse rate 4. The respiratory rate 5. The weight and Height
Cont… Times to Assess vital signs • On admission – obtain baseline date • When a client has a change in health status • According to a nursing or medical order • Before and after the administration of certain medications • Before and after surgery or an invasive diagnostic procedures • Before and after any nursing intervention that could affect the v/s
FACTORS INFLUENCING VITAL SIGNS • Several factors can cause changes in one or more of the vital signs: age, gender, lifestyle, environment, medications, pain, and other factors such as exercise and anxiety and stress, postural changes.
Cont… Purpose • To determine the condition of the patient • To aid in diagnosis • To monitor changes • To give medication • To provide appropriate care • To pronounce death  Equipment The measurement of the client’s vital signs requires the appropriate instruments. All pieces of equipment should be maintained to function accurately.
Thermometer- Glass 1. Oral- Slim tip 2. Axillary 3. Rectal- Stubby, pear-shaped tip 4. Electronic Battery-powered display unit with a sensitive probe (blue for oral and red for rectal) covered with a disposable plastic sheath for individual use 5. Disposable -Thin strips of plastic with chemically impregnated dots that (chemical), change color to reflect temperature single-use 6. Tympanic- Battery-powered display unit with disposable speculums and infrared-sensing electronics. (Courtesy, The Gillette Company.)
1. Blood pressure is the force exerted by the heart on the blood to pump it through the arteries & around the body.  In blood pressure there are the systole & the diastole. A. The systole: - is the period when the heart pumps the blood out into the arteries or contraction of ventricle. When if forces the blood in to the aorta. B. The diastole: - is the phase during which heart is filling with blood in preparation for the next pumping action.
• Blood pressure can be measured by an instrument called sphygmomanometer • Blood pressure is recorded in mmHg • normal B.P of adult is 100-120 mmHg systolic • normal B.P of adult is 80-90mmHg diastolic
Stethoscope  Acoustic- Closed cylinder that prevents dissipation of sound waves and amplifies the sound through a diaphragm. Flat-disc diaphragm transmits high- pitched sounds, and the bell-shaped diaphragm transmits low-pitched sounds.  Sphygmomanometer 1. Mercury Wall or portable unit that contains a mercury-filled glass manometer column, calibrated in millimeters; the mercury rises and falls in response to pressure created when the cuff is inflated.
2. Aneroid manometer Portable unit with a glass-enclosed gauge containing a needle to register millimeter calibration and a metal bellows within the gauge that expands and collapses in response to pressure variations from the inflated cuff.
Equipments..
Cont…. Positions of patients to take blood pressure • The blood pressure can be checked with the patient in the lying, sitting, or standing positions. Sites for measuring Blood pressure Upper arm- Using brachial artery Thigh around – Poplital artery Fore-arm – Using radial artery  Leg – using posterior tibia or dorsal pedis
Cont…. So:- - The patients arm should be slightly bent and relaxed - Do not applies the cuff too tightly the last beat.
• Procedure • Explain the procedure to the patient • If the patient is ambulatory place him in a sitting position. • If a bed patient places him in dorsal if up on recumbent of fowler’s position. • Roll patients sleeve above elbow, or slip sleeve off if convenient. • Have patients extend arm; support if up on the bed or a small pillow or table. • Apply cuff of sphygmomanometer smoothly & not too tightly or too loose. • Be sure there is no pressure on the arm
• Sit down if possible, so that your eye is on a level with the scale on the blood pressure apparatus, avoids the scale from the line of vision of the patient. • Palpate the brachial artery & place the stethoscope over pulsating vessel. Do not press too hard. • Close air value screw, pump bulb & inflate cuff until pulse disappears or mercury column should reach about the 150 more or more up to 200. • Open value screw slightly, releasing the air slowly in the cuff. (the mercury column should not fall faster) • Note read the scale until the first beat is heard. This is the systolic B/P. • Continue letting air out very slowly until last dull beat is heard or until the sound disappear this is the diastolic reading.
• Repeat the procedure & check the B.P to be sure. • Remove cuff & roll it up • Make the patient comfortable • Chart the blood pressure & any observations • Return the equipment you used to its proper place. • Ear pieces & the diaphragm should be clean with alcohol swab after use • Wash hands
Measuring patient pulse rate The pulse is the heart beat conveniently felt at the wrist & at any point Where an artery passes superficially over a bone. Site for taking pulse rate This pulse may be observed readily over the following arteries – Radial- the radial artery is palpated in wrist just below the thumb. – Temporal – the temporal artery is palpated immediately in front of the ear or the end of the eye brow. – Carotid – is palpated at the front of the neck on either side.
Cont…. – Brachial- the brachial artery at anterior & inner aspect of the elbow joint. – Femoral- the femoral artery is palpated on either sides of the groin. – Popliteal- the popliteal artery is palpated at the back of the knee • Do not make to great pressure • Do not use thumb to feel pulse • Note rate, regularity, skipped beats & force
Types of pulse The pulse may be classified according to; • Rate– means the rate at which heart is beating. • Normal rate is considered to be between 60- 80b/m, average is 72b/m. • Rhythm - is a regularity with which the heart beats. • Normal or regular rhythm; is a regular pattern of beats & intervals. • Volume- strength of the pulse
Cont…. Procedure •Explain the procedure to the patient •Place the patient in a comfortable position lying or seated with the arm resting across the chest •Usually you can count the pulse while the day thermometer is in place. •Place two or three fingers over the radial artery •The thumb should not be used over the area, it may cut off the circulation & the pulse cannot be felt. •The pulse is commonly taken over the radial artery, but it can be taken at other arteries. •If the pulse is irregular count it for a full one minute.
Cont… • If it is regular count 30 sec. & multiply by 2. • Chart the pulse rate & report any abnormal The normal pulse rate; • Infant age have 120-140 beat/min • children ( 1-5 age) have 100 beat/min • Elderly people (> 60 yrs age) usually have 50- 60beat/min
Cont…. Taking patient’s respiratory rate measurement Respiration - defined as the process of inhaling air in to the lungs & exhaling co2 from the lungs . • Respiration is controlled by the respiratory centre in the brain.
Cont…. Normal respiration rate • Normally the respiration number about 14- 20b/min at rest time. • Infant 28-40/min – children 20-28/min – adult 16-18/min – Old people 12-14/min Equipment • Watch with second hand & paper & pen or pencil
Procedure • respiration are counted while taking the pulse • After counting the pulse leave fingers on the wrist & count the respiration by watching the rise & fall of the chest or abdomen • The patient should not be aware that you are counting his respiration as he might control his breathing • Count respiration for all min • Observe the rate & depth of respiration & report any symptoms • Chart procedure time & observation.
Measuring patient’s body Temperature • Body temperature-degree of bodily heat, as measured by clinical thermometer. • Normal temperature is the balance maintained in the body between the heat produced & the heat lost. • Anything which interferes with this balance interferes with the function of the whole body. • The clinical thermometer is an instrument used for measuring the temperature of the bodily heat or cold.
Cont… • Measurement of Height and Weight • Measuring height and weight is as important as assessing the client’s vital signs. Routine measurement provides data related to growth and development in infants and children and signals the possible onset of alterations that may indicate illness in all age groups. • Height • Measurement of height is expressed in inches (in.), feet (ft), centimeters (cm), or meters (m). See the accompanying display for conversion equivalents from one system to another.
Site for taking body Temperature 1. Oral/mouth 2. Rectum 3. Axilla or Groin 4. Ear Normal temperature A/ by mouth – 98.6 oF or 37 oC B/ by rectum- 99.6 oF or 37.9 oC one degree higher than by mouth C/ by auxiliary – 97.6 oF or 36.4 oC one degree lower than by mouth.
• Calculations from oF to oC ,oC or oC to oF • When changing Fahrenheit to centigrade temperature the formula is as follows. Example C = oF – 32o x5/9 = 99oF – 32ox5/9 = 99 – 32 = 67x5/9 = 37.2oC
• Example 2 101.4oF – 32x5/9 = 99 – 32 = 67x5/9 = 38.5oC  When changing centigrade to Fahrenheit use the following formula:- F = C x 9/5 Example 1) 100oC x 9/5 + 32 = 180o + 32
= 212oF • Example 2 = 37oC x 9/5 + 32oC = 66.6o + 32 = 98.6oF
1- Procedure for oral Temperature • The nurse must wash her hands • Place the thermometer try on the locker between two patients. • Explain the procedure to new patients • Ask patient if he/she has taken any thing by mouth. • If so wait for ten minutes • Remove the thermometer from its tube, rinse in water & wipe from bulb to stem in circular movement. • Read & shake down mercury to below 95oF or 35oC
• Instruct the patient to open his mouth, and then place the thermometer under his tongue. Warm he to keep his lips closed, to avoid taking & closing teeth on the thermometer. • It must be left in place for 1-2 minutes to allow registering fully. • Place the second thermometer in the next patient’s mouth in the same way while waiting for the first. • Return to the first patient & count his respiration record temperature, in book or on chart. • Remove thermometer, wipe with swab from stem to bulb, read the thermometer, wash in soap solution, wipe again, clean swab & return to test tube, record temperature in temperature book or on chart.
• Wash the hands after all the temperature have been taken. • Change solutions & cotton after taking morning and evening temperature, twice daily, unless a separate thermometer is used for each patient. • Be sure equipment is clean before putting it a way in its proper place. Equipment is locked up after thermometers are counted • Chart accurately, in the right day, right patients chart use a ruler when drawing lines on graphic chart.
Procedure • Measurements must be taken each day at the same time and under the same conditions • Daily weights are usually taken each morning after the pt voids and before breakfast • The pt must wear the same amount and type of clothing at each weighing • Allow the pt to stand on the scale • Look at the measurements on the scale carefully • Report the weight or record on the pt’s chart • Make the pt comfortable after the procedure • Wash hands
Taking patient height measurement Body height – is a measurement from base to top or head to foot. Patient position when taking height - For a child or adult who is unable to stand place the child/adult lying on his back on a firm surface (by horizontal measuring board). - A tall board is made to stand upright against the wall, and the patient’s removes the shoes, and stands on the floor with his or her back to the measuring board, and stands in up right against the wall (by standing measuring board).
Measuring patients body weight Body weight- is the load of a body. • The unit measurement is kg  Essential equipment • Scale • Pencil and pt chart
Cont… Weighing a Client on a Standing Scale
1.2 Diagnostic tests procedure Collecting patient’s specimen  Specimen mean a sample of urine, stool, any discharge blood & sputum, which is send to laboratory for investigation. • Specimen is sent to the laboratory on time & all specimens should be fresh collection. • Purpose- If necessary – Collect a specimen for examination – To determine the prognosis of the patient out put. – To know the effect of any treatment
General instruction for collecting specimen • give the right specimen bottle • Identify the right patient, time & collect in the right specimen bottle • every specimen must have a label with the patients full name, room no., ward no., & hospital no. & nurses signature with date & time. • Orders or types of tests are written on laboratory request form. • Specimen must be placed on the specified place in the laboratory specimen shelf.
• Kinds of specimen – blood – urine – stool – sputum – body fluid
Taking urine specimen Urine Is a fluid formed in the kidney and excreted through the urinary organs. It is clear and straw yellow and composed of 95% of water and 5% solids an average out put of urine is 1.5 liters per day. Urine specimen :- A routine urine specimen is collected for a test called a urinalysis. a complete test includes a study of color and degree of cloudiness, PH, specific gravity, tests for glucose and protein (albumin). Addition shows the presence of blood; pus or casts.
 Types of urine specimen • Random/routine urine specimen • Mid-stream urine /sterile urine • Timed specimen /24hrs urine specimen Purpose – For routine screening of pt’s status • Equipment Specimen bottle Bed pan or urinal Request form Tissue paper
Procedure • instruct the patient about the procedure & tell him not to pass the stool in the same bed pan • pour 100-150ml of urine in specimen bottle • make a label with all necessary information • send in to laboratory with its request form Sterile urine specimen - It is only taken by catheterization.
Twenty four hours urine specimen; Purpose • to know the amount of urine passed in 24hr • for diagnosis & to know the effect of the drug  Equipment • Large container • Label for bottle • Request form Procedure • label container with correct information
• inform the patient & staff the 24hrs urine is in progress • start in early morning, after that each time patient voids, pour the urine in to the same container & keep it covered • measure the total amount & then take the laboratory properly labelled • Total amount urine should be noted on chart. N.B- Oliguria – decrease formation of urine –Polyuria – increase or formation of excess urine –Anuria – failure to secrete urine
Taking blood specimen Blood: - is the only fluid tissue circulating through out the body, carrying Nutrients and oxygen to the tissues and removing wastes and carbon dioxide.  Purpose of taking blood specimen • To detect infectious agent such as bacteria….. • To diagnose non-infectious d/s such as leukemia • To investigate anemia and monitor response of a pt to treatment • To demonstrate abnormal amount of the normal constituents or blood such as glucose and immunoglobulin
Types of method of taking blood specimen 1. Capillary puncture 2 .Vein puncture  Sites of taking blood specimen Capillary puncture – Lateral side of ring finger – Ear lobe for children and adults – Planter surface of the big toe or the heel for infantes
Vein puncture • Forearm/anticubital fosse • Wrist or ankle • External jugular vein for infant • Femoral vein for infant Precaution • Do not apply the tourniquet too tightly or to long a period b/c this will cause venous stasis leading to a concentration of substances in the blood such s hemoglobin and plasma proteins • Do no collect the blood from an arm in to w/c an intravenous (IV) infusion is being given. • Follow a safe technique and wear protective gloves when collecting and handling blood specimens .
Necessary materials • Lancet • Alcohol swab with its container • Gloves • Request form • Slide • Libeling marker
Procedure • The puncture site should be warmed to assure good circulation of bd. If it is cold, apply warm water (38-400c) for few mints • The site to be punctured, is first rubbed with 70% alcohol socked swab to move dirty materials • While making a finger puncture apply gentle pressure to the puncture site to hold the skin tightly. • Make a quick, firm, swab (3-4mm) • The 1st drop of blood should be wiped away before specimen is taken • The blood must not be squeezed out since this dilutes it with fluid from the tissue • After the desired specimen has been collected on the slide have the pt hold sterile dry gauze over the wound until bleeding stops.
 Obtaining blood specimen by vein puncture • Venous blood is used when more than 100ml blood is require • The method may need anticoagulants (e.g. Trisodiumcitrate ,heparin)  Necessary materials • Sterile syringe and needle, Tourniquet • Test tube bottle, Alcohol swab with container • Gloves, Labeling marker, Request form • Dry cotton
Procedure • Place an identifying label on the blood collecting bottle/test tube. • Remove sterile syringe and attain the needle • Cheek to be sure that the syringe works smoothly and that the needle is not plugged • Place the tourniquet around the pt’s arm above the elbow tightly enough w/c make the vein more prominent • Instruct the pt at open and close the fist several times to ↑ increase circulation • By inspection and palpation locate the desired vine • Cleanse the skin over the selected vein must use 70% alcohol swab
Shortly • Place the tourniquet on pt arm • Clean the area and make a puncture • Release the needle before unknot the tourniquet • Collect the blood in the appropriate test tube
Taking sputum specimens Sputum; - is a mucous substance expelled by clearing the throat or by coughing.  This matter may come from the lungs or bronchi the tubes entering the lungs.  Sputum may consists of a discharge from the nasal or throat area depending on the pt’s disease, sputum may consist of pus, blood, mucus, and micro organisms
• The pt, should be instructed to cough deeply in order to bring up material from the bronchi and lungs. Other wise, the specimen consists only of saliva and nose and mouth secretions. • The specimen may be collected at any time the pt is able to produce the sputum. • Sometimes a 24-hr collection of sputum may be ordered. • The amount of sputum, the appearance (consistency and color) and the odor are significant Purpose :- Sputum specimen aids the doctor in diagnosing problems in the respiratory system
Precaution - Wear a mask when collecting the sputum to protect your self from droplet infection. - Wash your hands carefully after handling the container. • Amount • Appearance- Containing pus/yellow/ -Gray or black -A rusty color or streaks of red blood -Green-colored • Odor • Equipment • Sputum mug , Request form, Labeling marker
 Procedure • Cheek doctor’s order, and explain procedure to the pt. • give specimen bottle to pt • Have pt clean her/his mouth well and encourage pt to cough and expectorate in to specimen bottle, explain that the pt should cough deeply and bring up the sputum from deep in the lungs • Should be collected early in the morning before the pt gets out of bed • Label container and send to the lab with a request form if the pt is suspected of having TB he/she should not cough in front of other pts and should at least cover the mouth when coughing
• NB- When pulmonary Tuberculosis is suspected, up to three specimens (morning spot) should be collected to detected AFB (Acid fast bacilli)
UNIT TWO Selected Clinical Nursing Therapeutics
2.1 Asepsis • Asepsis is the absence of microorganisms. • Providing nursing care using aseptic technique decreases the risk and spread of nosocomial infections. • Aseptic technique is the infection control practice used to prevent the transmission of pathogens. • Two types of asepsis are medical and surgical.
Medical Asepsis • Medical asepsis uses practices to reduce the number, growth, and spread of microorganisms. • Medical asepsis also referred to as “clean technique.” • Objects are generally referred to as “clean” or “dirty” in medical asepsis. • Clean objects are considered to have the presence of some microorganisms that are usually not pathogenic. • Dirty (soiled) objects are considered to have a high number of microorganisms, with some that are potentially pathogenic.
• Common medical aseptic measures used for clean or dirty objects are:-  hand washing  gloves changing linens daily  cleaning floors and hospital furniture daily.
Surgical Asepsis • Surgical asepsis, or sterile technique, consists of those practices that eliminate all microorganisms and spores from an object or area. • Surgical asepsis refers to :-  hand washing  the donning of surgical attire (caps, masks, and eyewear)  handling of sterile instruments and equipment  establishing and maintaining sterile fields.
• Common nursing procedures that require sterile technique are: All invasive procedures, intentional perforation of the skin such as:- injections,  insertion of intravenous needles  catheters or entry into a bodily orifice (tracheobronchial suctioning, insertion of a urinary catheter)
2.2 Hand washing • Hand washing is the rubbing together of all surfaces of the hands using a soap or chemical and water. • Hand washing is a component of all types of isolation precautions and is the most basic and effective infection control measure that prevents and controls the transmission of infectious agents. • The CDC (2000) commends vigorous scrubbing with warm, soapy water for at least 15 seconds to prevent the transfer of germs.
• The three essential elements of hand washing are soap or chemical, water, and friction • Hand washing should be performed after arriving at work, before leaving work, between client contacts, after nurseries, usually require about a 2-minute hand wash. Equipment • Soap Paper or cloth towels • Sink Running water
Procedure 1. Remove jewelry, Wristwatch may be pushed up above the wrist (midforearm). Push sleeves of uniform or shirt up above the wrist at midforearm level. 2. Assess hands for hangnails, cuts or breaks in the skin, and areas that are heavily soiled. 3. Turn on the water. Adjust the flow and temperature. Temperature of the water should be warm. 4.Wet hands and lower forearms thoroughly by holding under running water. Keep hands and forearms in the down position with elbows straight. Avoid splashing water and touching the sides of the sink.
5. Apply about 5 ml (1 teaspoon) of liquid soap. Lather thoroughly. 6. Thoroughly rub hands together for about 10 to 15 seconds. Interlace fingers and thumbs and move back and forth to wash between digits(Figure A). Rub palms and back of hands with circular motion. Special attention should be provided to areas such as the knuckles and fingernails, which are known to harbor organisms(Figure B).
Fig. A . Interlace fingers to wash between the digits Fig B. Provide special attention to washing knuckles and fingernails
7. Rinse with hands in the down position, elbows straight. Rinse in the direction of forearm to wrist to fingers. 8. Blot hands and forearms to dry thoroughly. Dry in the direction of fingers to wrist and forearms. Discard the paper towels in the proper receptacle. 9. Turn off the water faucet with a clean, dry paper towel (see Figure C).
Fig. C Turn off faucet with a clean, dry paper towel. NURSING ALERT Handwashing Wash hands before and after every client contact. The most common cause of nosocomial infections is contaminated hands of health care providers.
2.3 Donning Sterile Gloves • There are two methods for applying sterile gloves: open and closed. • The open method is used most frequently when performing procedures that require the sterile technique, such as dressing changes. • The closed method is used when the nurse wears a sterile gown.
Donning Surgical Attire • Surgical nurses are required to wear a surgical mask and a clean cloth or paper cap that covers all of the hair. • After the cap is applied, the nurse positions the mask to cover the nose and mouth Protective eyewear (glasses or goggles) is worn during all procedures that pose a threat of splashing body fluids into the eyes.
Procedure- Performing Open Gloving and Removal of Soiled Gloves 1. Wash hands 2. Read the manufacturer’s instructions on the package of sterile gloves; proceed as directed in removing the outer wrapper from the package, placing the inner wrapper onto a clean, dry surface. 3. Identify right and left hand; glove dominant hand first.
4. Grasp the 2-inch- (5-cm-) wide cuff with the thumb and first two fingers of the non dominant hand, touching only the inside of the cuff. 5. Gently pull the glove over the dominant hand, making sure the thumb and fingers fit into the proper spaces of the glove (see Figure A). • With the gloved dominant hand, slip your fingers under the cuff of the other glove, gloved thumb abducted, making sure it does not touch any part on your non dominant hand (see Figure B).
Fig. A Pull the glove over the dominant hand. Fig B. Slip the fingers under the cuff of the glove for the nondominant hand and abduct the thumb.
7. Gently slip the glove onto your on dominant hand, making sure the fingers slip into the proper spaces. 8. With gloved hands, interlock fingers to fit the gloves onto each finger. If the gloves are soiled, remove by turning inside out as follows: 9.Slip gloved fingers of the dominant hand under the cuff of the opposite hand or grasp the outer part of the glove at the wrist if there is no cuff (Figure C).
Fig . C. Insert gloved fingers under the cuff of the other glove. Fig. D Pull the glove down to the fingers and turn inside out.
10. Pull the glove down to the fingers, exposing the thumb (see Figure D). 11. Slip the uncovered thumb into the opposite glove at the wrist, allowing only the glove-covered fingers of the hand to touch the soiled glove. 12.Pull the glove down over the dominant hand almost to the fingertips and slip the glove onto the other hand. 13. With the dominant hand touching only the inside of the other glove, pull the glove over the dominant hand so that only the inside (clean surface) is exposed. 14. Dispose of soiled gloves according to institutional policy and wash hands.
2.4 Medication Administration  A drug is a chemical substance intended for use in the diagnosis, treatment, cure, or prevention of a disease.  When a drug is given to a client, there is an intended specific effect.  An assumption made by nurses before administration of any medication is that the drug will be safe for the client to consume if the dose, frequency, and route are within the therapeutic range for that drug.
DRUG NOMENCLATURE • The terms drug, medication, and medicine are often used interchangeably by health care providers and laypersons. • Drugs can be identified by their chemical, generic, official, or trade names. • The chemical name is a precise description of the drug’s composition (chemical formula). • The nonproprietary, or generic, is the name assigned by the manufacturer who first develops the drug.
• When the drug is approved, it is given an official name that may be the same as the non proprietary name (Lehne, 1994). • When pharmaceutical companies market the drug, they assign a proprietary name, also called a trade, or brand, name; therefore, one generic drug may have several trade names based on the number of companies marketing the drug. • For example, ibuprofen is a generic name; common trade names for this drug are Advil, Excedrin IB, Motrin
DRUG ACTION • Drug action refers to a drug’s ability to combine with a cellular drug receptor. Depending on the location of different cellular receptors affected by a given drug, a drug can have a local effect, systemic effect, or both. • For example, when diphenhydramine hydrochloride (Benadryl) cream is applied to the skin, it elicits only a local effect; however, when this drug is administered in a tablet or injectable form, it causes both systemic and local effects.
Preparation and Route • Drugs are available in many forms for administration by a specific route such as ;- • Oral Solids( Tablets, Capsule, Powder and granules, Troches, lozenges and Enteric-coated) • Topical (Ointments) • Inhalants • Solutions (Suspensions, Syrups, Optic (eye) and otic (ear) solutions) • The route refers to how the drug is absorbed: oral, buccal, sublingual, rectal, parenteral (hypodermic routes), topical, and inhalation.
1. Oral Route • Most drugs are administered by the oral route because it is the safest, most convenient, and least expensive method. • When small amounts of drugs are required, the buccal (cheek) or sublingual route is used. • Drugs administered through these routes act quickly because of the oral mucosa’s thin epithelium and large vascular system, which allows the drug to quickly be absorbed by the blood.
2. Parenteral Route  parenteral means introduction of a medication by any route other than the oral- gastrointestinal route. • Sterile technique is always used for any medication injection. • The four routs that nurses commonly use to administer parenteral medications are: IV, IM, SC and ID
• Intradermal (ID) is an injection into the dermis. • Subcutaneous (SC or SQ) is an injection into the subcutaneous tissue. • Intramuscular (IM) is an injection into the muscle. • Intravenous (IV) is an injection into a vein. 3. Topical Route • Most topical drugs are given to deliver a drug at, or immediately beneath, the point of application. Although a large number of topical drugs are applied to the skin, other topical drugs include eye, nose and throat, ear, rectal, and vaginal preparations.
4. Inhalants • Inhalants such as oxygen and most general anesthetics deliver gaseous or volatile substances that are almost immediately absorbed into the systemic circulation. • The inhalants are delivered into the alveoli of the lungs, which promote fast absorption.
FACTORS INFLUENCING DRUG ACTION • Individual client characteristics such as  genetic factors age  height and weight physical and mental conditions can influence the action of drugs on the body.
Guidelines for Medication Administration • To protect the client from medication errors, nurses have traditionally used as a guideline the “five rights” of drug administration. 1. Right drug 2. Right dose 3. Right client 4. Right route 5. Right time
1. Administering an Oral Medication(procedure) Equipment • Medication administration record (MAR) Medication cup, Medication cart or tray Medication properly labeled, Glass of water or juice Straw 1. Assess the client for potential problems (e.g., absence of a gag reflex). 2. Check the MAR against the health care praxis practitioner’swritten orders.
3. Check for drug allergies. 4. Wash your hands. 5. Prepare the medications for one client at a time:. Check for drug allergies. Wash your hands • Prepare the medications for one client at a time: Prepare liquids by placing the label side of the medicine bottle against the palm of your hand and pouring the liquid at eye level (Figure). • Liquids should be measured at fluid level at the surface or the meniscus not the edges. • Recheck medications prepared with MAR.
• Check MAR to make sure all medications to be administered have been prepared.Place on the tray or medication cart. 6. Check client’s armband before administering the medications. 7. Identify the drug for the client and its therapeutic purpose. 8. Perform any assessment required before the administration (such as apical pulse rate befor administration of digoxin.) 9. Assist client to a sitting position.
10. Offer liquids before and during ingestion; encourage the patient to drink 5–6 oz of water. • If the client is unable to hold the medication cup, assist the client by using the medication cup to introduce the pills to the person’s mouth one at a time. • If a medication falls on the floor, discard the pill and start over.
11. Remain with the client until all medications have been swallowed. 12. Wash your hands. 13. Record the administered medications on the MAR. 14. Observe the client for side effects or adverse reactions.
Fig. A. Check the client’s mouth to ensure that medications have been swallowed.
2. Administer Parenteral Drugs Equipment • Nurses use special equipment such as syringes(hub, barrel, or outside part and plunger ), needles, ampules, and vials when administering parenteral medications. • Angle of Injection The angle of insertion depends on the type of injection.
Figure A. Angles of Insertion for Parenteral Injections.
Intradermal Injection • Intradermal (ID) or intracutaneous injections are typically used to diagnose tuberculosis, identify allergens, and administer local anesthetics. • The drug’s dosage for an ID injection is usually contained in a small quantity of solution (0.01 to 0.1 ml).
Figure B. Intradermal Injection Sites: A. Inner Aspect of the Forearm; B. Upper Chest; C. Upper Back
Equipment • Medication administration record (MAR), Medication,Sterile tuberculin syringe and short bevel, 25 to Alcohol swab and sterile 2 × 2 gauze pad, 27 gauge, 3/8- to 1/2-inch needle, Disposable gloves Procedure 1. Check with the client and the chart for any known allergies. 2. Wash hands, and Follow the five rights. 4. Prepare the medication from an ampule or vial; refer to Procedure 29-2 or 29-3 as appropriate. Take the medication to the client’s room and place on a clean surface.
5. Check the client’s identification armband. 6. Explain the procedure to the client. 7. Place the client in a comfortable position; provide for privacy. 8. Wash hands and don nonsterile gloves. 9. Select and clean the site. • Assess the client’s skin for bruises, redness, or broken tissue. • Select an appropriate site using appropriate anatomic landmarks
• Cleanse the site with an alcohol wipe using a firm circular motion; cleanse from inside to outside; allow alcohol to dry. 10. Prepare the syringe for injection. • Remove the needle guard. • Express any air bubbles from the syringe. • Check the amount of solution in the syringe. 11. Inject the medication. Hold the syringe in dominant hand. • With nondominant hand, grasp the client’s • dorsal forearm and gently pull the skin taut • on ventral forearm(Figure C).
Figure C. Spread the skin taut for an intradermal injection.
• Place the needle close to the skin, bevel side up. Insert the needle at a 10° to 15° angle until resistance is felt, and advance the needle approximately 3 mm below the skin surface; the needle’s tip should be visible under the skin. • Administer the medication slowly; observe the development of a bleb (large flaccid vesicle that resembles a mosquito bite). If none appears, withdraw the needle slightly. • Withdraw the needle.
• Pat area gently with a dry 2 × 2 sterile gauze pad. • Do not massage the area after removing the needle. 12. Discard the needle and syringe in a sharps container. 13. Remove gloves, dispose of in appropriate receptacle, and wash hands. 14. Observe for signs of an allergic reaction. 15. Draw a circle around the perimeter of the bleb with a ball point pen. 16. Document medication and site of injection on the MAR.
Subcutaneous Injection • Subcutaneous (SC or SQ) injections are commonly used in the administration of medications. • SC injections place the medication into the subcutaneous tissue, between the dermis and the muscle. • Clients who administer frequent subcutaneous injections should rotate sites regularly. • The amount of medication given varies but should not exceed 1.0 ml;
Figure D. Subcutaneous Injection Sites: A. Abdomen; B. Lateral and Anterior Aspects of Upper Arm and Thigh; C. Scapular Area on Back; D. Upper Ventrodorsal Gluteal Area.
Equipment • Medication administration record (MAR) 2 alcohol swabs, Sterile syringe and 5/8-inch needle Medication as prescribed, Disposable gloves 1. Check with client and the chart for any known Allergies, Wash your hands. 3. Follow the five rights. 4. Prepare the medication from an ampule or vial; refer to Procedure 29-2 or 29-3 as appropriate. Take medication to the client’s room and place on a clean surface.
5. Check the client’s identification armband. 6. Explain the procedure to the client. 7. Place the client in a comfortable position; provide for privacy. 8. Don nonsterile gloves. 9. Select and clean the site. • Assess the client’s skin for bruises, redness hard tissue, or broken skin. • Cleanse the site with an alcohol swab; cleanse from inside outward. 10. Prepare for the injection.
• Remove the needle guard and express any air bubbles from the syringe; check the dosage in the syringe. • With dominant hand, hold the syringe like a dart between your thumb and forefingers. • Pinch the subcutaneous tissue between the thumb and forefinger with the nondominant hand. If the client has substantial subcutaneous tissue, spread the tissue taut. 11. Administer the injection. • Insert the needle quickly at a 45° or 90° angle
• Release the subcutaneous tissue and grasp the barrel of the syringe with nondominant hand. • With dominant hand, aspirate by pulling back on the plunger gently, except when administering an anticoagulant injection. • If blood appears, remove needle and discard in a sharps container. • Inject medication slowly if there is no blood present. • Remove the needle quickly and lightly massage area with alcohol swab; do not massage the injection site after the administration of an anticoagulant.
• Do not recap the needle; discard the needle in a sharps container. 12. Position client for comfort. 13. Remove gloves and wash hands. 14. Record on the MAR the route, site, and time of injection. 15. Observe the client for any side or adverse effects and assess the effectiveness of the medication at the appropriate time.
Intramuscular Injection • Intramuscular (IM) injections are used to promote rapid drug absorption. COMMON INTRAMUSCULAR INJECTION SITES AND MUSCLES Site Muscle Dorsogluteal Gluteus maximus Ventrogluteal Gluteus medius Anterolateral aspect of thigh Vastus lateralis Upper arm Deltoid
Equipment • Medication administration report (MAR) Medication as prescribed Sterile 3-ml syringe and long bevel, 20 to 22 gauge, Alcohol swab 1- to 2-inch needle (average-sized, adult client Nonsterile gloves receiving a drug in an aqueous solution), Sterile 2 × 2 gauze pad
Procedure 1. Check with client and the chart for any known allergies, Wash hands. 2. Follow the five rights. 3. Prepare the medication from an ampule or vial; refer to Procedure 29-2 or 29-3 as appropriate. • Add 0.1 to 0.2 ml of air to the syringe. • Take medication to the client’s room and place on a clean surface. 4. Check the client’s identification armband. 5. Explain the procedure to the client; provide for privacy
6. Place the client in an appropriate position to expose the site. • Deltoid: sitting position. • Ventrogluteal: • Side-lying: flex the knee, pivot the leg forward from the hip about 20° so it can rest on the bed. • Supine: flex the knee on the injection side. • Prone: point toes inward toward each other to internally rotate the femur. 7. Don nonsterile gloves.
8. Select and clean the site. • Assess the client’s skin for redness, scarring, breaks in the skin, and palpate for lumps or nodules. • Select site using the anatomic landmarks. • Cleanse the area with an alcohol swab, cleanse from inside outward using friction; wait 30 seconds to allow to dry. 9. Prepare for the injection. • Remove the needle cap by pulling it straight off, and expel any air bubbles from the syringe.
• Pull the skin down or to one side (Z-track technique) with nondominant hand. 10. Administer the injection. • Deltoid: quickly insert the needle with a dartlike motion at a 90° angle (Figure D). • Ventrogluteal: quickly insert the needle using a dartlike motion and steady pressure at a 90° angle to the iliac crest in the middle of the V (Figure D). • Aspirate by pulling back on the plunger, and observe for blood. • If blood appears, remove the needle and discard.
• If blood does not appear, inject the medication slowly, about 10 sec/ml. • Wait 10 seconds after the medication has been injected, then smoothly withdraw the needle at the same angle of insertion. • Apply gentle pressure at the site with a dry, sterile 2 × 2 gauze; do not massage the injection site. Swab using gentle pressure. • Discard the needle and syringe in a sharps container; do not recap the needle.
11. Position client for comfort; encourage client receiving ventrogluteal injections to perform leg exercises (flexion and extension). 12. Remove gloves, wash hands. 13. Record on the MAR the dosage, route, site, and time. 14. Inspect the injection site within 2 to 4 hours and evaluate the client’s response to the medication.
Figure D. Administering Intramuscular Injection into the Deltoid Muscle E. Grasp and pull the muscle laterally before injecting medication
Intravenous Injections • The intravenous (IV) route is used when a rapid drug effect is desired or when the medication is irritating to tissue. Equipment • Medication administration record (MAR) Secondary administration set Prepared and labeled medication 50-ml solution Needle-less locking cannula • bag from pharmacy • Alcohol swab
Procedure 1. Gather prepared equipment (medication labeled with the client’s name, and time tape for fluids to infuse per hour). 2. Wash hands. 3. Check the client’s armband. 4. Explain the procedure to the client. 5. Assess the puncture site. • Observe for redness and puffiness. • Palpate for tenderness. 6. Check patency of infusion site.
• Observe fluid infusing. • Remove IV container from the pole and lower the container below the level of infusion site. • Observe for backflow of blood into the hub of the venous access device. • Replace container on IV pole. 7. Secure medication bag prepared and labeled by pharmacy and check health care practitioner’s prescription and the MAR. 8. Check the client’s chart for allergies, and check the drug compatibility chart. 9. Hang the secondary bag on IV pole.
10. Add the administration set to the secondary bag and prime the tubing. 11. Affix a needle-less locking cannula to the end of tubing (Figure F). 12. Cleanse needle-less Y–site injection port of primary IV tubing closest to infusion site with an alcohol swab; allow to dry. 13. Insert needle-less locking cannula of secondary bag set into Y–site injection port of primary set and secure in place with tape (Figure 29-29B). 14. Affix the extension hook to the primary bag on the IV pole so that the primary bag hangs below the level of the secondary bag.
15. Open clamp of secondary tubing and adjust drip rate to desired infusion rate. • Slowly close the regular clamp while observing the drip chamber until the fluid is dripping at a slow, steady pace (Figure 29-29C). • Count the drops for a 15-second interval and multiply by 4 (e.g., if the drop factor of
Figure E. Administering Medications by IV Piggyback. Connect a needle-free locking cannula to a secondary infusion line. Figure F. Monitor the infusion rate.
Types of Syringe Types of Syringes. A. Hypodermic B. Standard U-100 Insulin. C. 1-ml Tuberculin D. Disposable Plastic
Length of syringe Various Lengths and Gauges of Needles. Gauge from left to right: 18, 20, 22, 25.
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. Total fluid volume × drop factor = drops/min Total time (minutes)
• For example, if 1000 ml is to infuse over 8 hours with a tubing drop factor of 10 drops per milliliter: 1000 ml × 10 drops/ml =10,000 drops = 20.8 or 21 8(60) min 480 min  21 drops/min
3. Administer Topical Medications • Topical medications may be administered to the skin, eyes, ears, nose, throat, rectum, and vagina. • The medication generally provides a local effect but can also cause systemic effects. • Drugs directly applied to the skin to produce a local effect include lotions, pastes, ointments, • creams, powders, and aerosol sprays. The rate • and degree of the drug’s absorption are determined by the vascularity of the area.
UNIT THREE ACTIVITY and EXERCISE
1. Self care and hygiene Giving bed bath • A bed bath is a cleaning sponge bath given to a patient in bed patients. Types of bed bath • There is two type of bed bath Complete bed bath and partial bath:- – Complete bed bath -Partial bath
1. Complete bed bath: - Taking a bath of whole body. 2. Partial bath: - The face, arms, hands and back are washed; a complete daily bath is not advisable for all pts. Elderly pts have a decrease in production of perspiration and natural oils w/c keeps the skin moist as a result, these pts. Need not wash as frequently. • Purpose – To cleanse the body – To prevent multiplication of bacteria on the skin – To stimulate circulation – To improve general muscle tone
– Give a good opportunity to observe his condition & establish friendly communication with him. . – Teach the patients the essentials of health – To keep the skin surface dry, thus helping to prevent bed sores. Precaution and contra indication • Change the water frequently whenever it is dirty/cold • Do not go to opposite side of bed during bath, as all work can be done from one side
• Put up screen to protect the pt’s privacy • Close the door and the window to prevent draft • Report to ward supervisor any undesirable symptoms, such as rash, swelling, pressure sores or discoloration. Equipment • Two wash clothes, Two bath towels, Two linen cloths, One draw sheet & rubber sheet if necessary, Two basins & jug with water, Soap with soap dish, Pyjamas as night clothes, Comb, Back care tray, Mouth care tray & Scissors for nail care
• Screen, Bed pan or urinal, Toilet paper and Waste receiver Procedure for complete bed bath -Wash hands& collect the equipment -Greet the patient & explain the procedure -Bring the necessary articles to the bed side. -Close the door & window -Screen the unit -Offer bed pan or urinal empty & clean before preceding with bath, wash hands. -Loosen top bed covers at sides & foot
-Remove bed spread & blanket & place them on a chair. Leaving the top sheet to cover the patient & remove gown or pyjama. -Prepare the water & check the temperature of the water the back of your hand, water at temp. of 105- 115*F(41-46*C) -Place towel under the chin, wash face, eyes, ears& neck. -Ask the patient if he likes to have his face washed with soap or with out soap. -First wash eyes from inner to outer corners, then the for head, down the face to the neck, then rinse& dry well.
-Place the towel under the arm further away from the nurse. -Place your hand under the arm to give support. -Soap the wash towel, wash & rinse the arm & hand, repeat the other arm. -Cover the chest with both towel & turn blanket down to abdomen, put the towel under the patient, wash, rinse& dry well. -Re cover the chest -Re covers the abdomen, protect the matters wash rinse& dry the abdomen. -Observe the patient & communicate during the bath.
-Uncover far leg & drape with bath blanket arranging bath towel under the foot. Flex knee, wash leg, rinse& dry well. -Repeat the same with near leg. -Change water now & whenever it is dirty or becomes cold -Turn patient on side, with back to wards you. Wash back & dry well. Rub the back with oil. Observe condition of skin, especially over pressure points. -Put towel under the hip & give him the wash towel if he is able to wash the genitalia area.
-if the patient is unconscious or un able complete the bath by the nurse. -Put on a clean gown on the patient & comb patient’s hair while protecting the pillow with a towel. -Cut & clean nails of the fingers & toes. -Prepare occupied bed & re move the screen. -Take care of the used equipment & re turn to its proper place, leave everything tidy open the window & door. -Wash hands & report on chart any finding.
Giving tub bath- This type of bath is given to an ambulatory pt. • The nurse should assist the pt. into and out of the tub. Anyone can fall during this procedure. The pt. may become tired or dizzy, and slip causing injury. Some pts require the nurse’s help through out the bath • Special precautions must be taken to avoid having the pt. slip in the shower or tub • The nurse should place a nonskid bath mat in the tub or shower
• Even though pts seem strong and alert they should be checked at least every five minutes • Showers and tub baths do not need to last more than ten minutes • Pt who are taking a shower or bath after prolonged bed rest, need to be watched care fully for dizziness. These pt may also tire easily
Assisting with a shower A pt. must show no signs of weakness before a shower is permitted. The doctor will indicate when the pt. is ready for this activity however; the nurse should also use judgment to decide whether a pt is able to shower. The pt’s condition may vary throughout the day. A pt. may have medical permission, how ever, signs of weakness, dizziness, or fatigue may require postponement of the shower, and safety precautions explained at the beginning of the unit should be reviewed. Observing safety rules in the shower helps prevent injuries.
Purpose – To arrange the pt. during admission – To refresh and relaxed the admitted pt. precautions and contraindications • Have water at correct temperature • Avoid chilling the pt. • Do not leave pt alone in bathroom • Always keep bathroom door unlocked • Check pt. frequently for signs of exhaustion • Do not allow the pt. to remain in the shower longer than ten minutes
Equipment • Soap with soap dish • Wash cloth • Bath towel and face towel • Gown or pajama • Slipper • Chair • Bath blanket if it is needed • Bath mat – to avoided slipping of pt. • Bath powder or lotion • Bath thermometer
Procedure • Explain procedure to the pt. • Assemble equipment and take to the bathroom, Close windows • Help pt to undress, Help pt to bath himself or her self assisting as necessary • Assist pt. out of tub or shower vary and put a gown on the pt, Clean the tub or shower and leave room in order • Return pt. to room and put to bed • Do not allow the pt. to remain in the shower longer than ten minutes
Giving back car • Back care is often called aback rub or a massage of the back. Purpose- - To refresh patient & relieve fatigue. • To improve circulation to this area, thus aiding in the prevention of pressure sores. • Gives a good opportunity to turn the patient • To observe the condition of the patient.
precaution/observations to be made during back care • All bed pts receive back care in the morning and in the after noon and Evening: • The duration of a massage ranges from 5-20 minutes • Remember the location of bony prominence to avoid direct pressure over this areas • If the pt’s skin is dry, use of powder may not be advisable • Nurses should be sure their fingernails are short enough so as not to scratch the pt.
Equipment- • Wash hands assemble equipment • Two basins with warm water • Soap with soap dish • Two wash towel • Two towels • Body powder • Lotion or alcohol • Air ring or cotton ring as needed • Pillow • Screen
Procedure • Greet patient & explain procedure., Screen the bed • Arrange the patients gown so that the back is exposed • Assist the patient into a prone position • Place towel under patient side • Wash the back with soap & water& dry with towel • Apply lotion to your own hands & rub it between the hands until it is warm • Give special attention to bony prominence • Use firm & long strokes up ward & down ward.
• Repeat up ward & down ward stroke several times but use a circular motion with the palm on the down ward. Continue rubbing in this manner for three to five minutes. • Wipe away excess lotion & apply powder to the patients back. • Dress the patient & assist in to comfortable position. • Turn patients on back & apply air ring or cotton ring as necessary. • If there is breakage of the skin sterile dressing should be applied., Clean & store the equipment. • Wash your hand., Report any abnormality finding.
Special points to remember • All bed patients should have back care once a day • All incontinent patients should have their back care each time the linen is changed • Any patient who lies in one position or cannot move freely should have back care at least 2 times a day or more Care of pressure sore (decubitus) • Pressure sore-It a break down of the skin & death of the tissue in certain areas as a result of pressure which interfere with the blood circulation of the area. • Pressure sores-commonly develops on bony prominence area such as hell, elbow, sacral region hips & shoulder
Predisposing causes of bed sores • Chronic illness • Obesity • Poor circulation • In frequent change of position • In continence • Prolonged pressure on the area Sings of bed sore • Redness, Blister • Breakage of the skin & Necrosis (death of tissue
Prevention of bed sore • change patients position frequently or every two hours • keep bed free from wrinkle & crumbs • keep bed dry • use air ring, cotton rings & air mattress to relive pressure • keep patients skin clean & dry • give back care frequently, giving special attention to reddened area •
Giving mouth care for helpless patient Proper care of the mouth & teeth is always necessary but it be comes particularly important when a person is sick. Purpose • To clean the teeth gum • To stimulate appetite • To avoid bad smell • To prevent tooth decay • To prevent infection from spreading to the throat & ears
• Equipment and using solution • Glass of fresh water • Mouth washing solution like- • -Hydrogen per oxide • - Juice-two tea spoons to cup of water • - Water-1/2 tea spoons of salt in glass of water. • Kidney dish, Tongue depressor, Tooth brush or a applicators, Towels, Lubricants, to lubricate the lips, Cotton applicators, Gauze & cotton
Procedure • Wash hands & collect equipment • Explain the procedure to the patient • Have all equipment ready on the bed side table or trolley • Place towel under patients chin across his chest • Turn patients head to the side & arrange basin at corner mouth
• Dip applicator or tooth brush in mouth wash solution, & carefully & gently go over the inside of the mouth, the tongue & tooth by discarding or changing the swab. • Do repeat the procedure until the mouth become clean • Allow the patient to rinse the mouth wash solution after use • Allow him to rinse his mouth with clean water • Apply lubricant on the lips of the patient •
• Give the patient a tissue paper to clean the mouth & chin • Remove the towel • Rinse the tooth brush with water • Take care of equipment • Wash hands after procedure • Chart time & any finding Patients who need special care of the mouth • Patient with gum bleeding • Children, A patient with fever, Unconscious patients • Post operative patients, Any patients they can not care for than selves.
Making patient bed General Principles of bed making – Put covers orderly – After handing a patient, linen and other equipments washing hands to the hands and uniform. – While handling a soiled linen should for a way from uniform – Never put patient’s bed covers on another patient’s bed. – Shaking a soiled linen in the word and forbidden, because various types of micro organisms can spread to other site.
– When stripping and making a bed, time and energy by stripping and making up one side as completely as possible before working on the other side. – To avoid unnecessary trips to the linen supply area, gather all needed linen before starting to strip bed. – The palm of the hand should face down while tucking bed linen under the mattress, to protect the nail.
Stripping of a bed Definition: removing the bed linen from a bed which has been previously made – up. Purpose -To air the bed and bedding and prepare the bed for remaking -To prepare the bed for different patients, who different problems. Equipment • Made up close bed & bed side chair
Procedure:- • Place chair conveniently at the foot of the bed • Place the pillow on seat of chair • Loosen the bedding all around ,starting from the right ( do not tear sheets on springs ) • Fold bedspread twice ,bring top to bottom ,pickup from the center • Fold the blanket and top sheet ,in similar manner • Place solid bedding on the chair ,and placed that which is to be used again ,over back of chair • Fold the draw sheet in two and place on the chair • Remove and fold the bottom sheet in same manner • Turn mattress from top to bottom or from side to side
Precautions:- • No bedding ,either clean or solid ,should over be put on the floor • Do not let your uniform touch the bedding
Order of bed making – Mattress cover – Bottom sheet – Rubber sheet – Cotton (cloth ) draw sheet – Top sheet – Blanket – Pillow case – Bed spread
1. Making Open bed Definition:- Open bed is one which is made for an ambulatory patient are made in the same way but the top covers of an open bed are folded back to make it easier for a client to gain it Purpose:--To provide comfort and cleanliness for a patient Required equipments • Two large sheets, Rubber draw sheet • Blanket ,Pillow cases • Bed spread
Procedure • wash hands and collect necessary materials • Place and materials to be used on the chair .Turn mattress and arrange evenly on the bed • Place bottom sheet with correct side up, center of sheet on center of bed and then at the head of the bed • Tuck sheet under matters at the head of bed and miter the corner • Remain on one side of bed until you have completed making the bed on that side • Tuck on the sides & foot of bed, mitering the corners
• Tuck sheets smoothly under the matters, there should be no wrinkles • Place rubbers draw at the center of the bed & tuck smoothly & tightly • Place cotton draw sheet on top of rubber draw sheet & tuck. The rubber draw sheet should be covered completely. • Place to sheet with wrong side up, center fold of sheet on center of bed wide hem at hex of box • Tuck sheet of foot of bed meting the corner • Place blanket with center of blanket on center of bed tuck at the foot of beds and miter the corner • Folds top sheet over blanket • Place bed spread with right sides up and tuck it
• Miter the corners at the foot of the bed • Go to other side of bed and tuck in bottom sheet, draw sheet, mitering corners and smoothing out all wrinkles, put pillow case on pillow and place under the matters • See that bed is neat and smooth • Leave bed in place and furniture in order • Wash hands
tuck the sheet under the mattress
2. Making closed bed Definition:-Is a type of bed which is prepared for newly coming pt Purpose • To provide a clean comfortable bed a new pt • To keep bed for the new pt • To give the bed a good appearance Required equipments: Pillow (with plastic cover, if necessary), Pillow case, Blanket cover or bed sheets or bed cover, Blankets, Two large sheets, Rubber draw sheet,(mackintosh) one Draw sheet, one Mattress cover, if necessary
Procedure • Wash hands & arrange the necessary material in the order in which it is to be used on the strait chair, in a convenient position near the foot of the bed • Turn mattress from top to bottom or from side to the facing up & arrange evenly on the bed • Place the bottom sheet with right side of the facing up & wide hem at top • Turn the sheet well under head of the mattress making mitered corner & tuck in a long the side & foot of bed making mitered corner • Remain on one side of bed until you completed making the bed on the side • Place rubber draw sheet across the approximate center of the bed & tuck tightly
• Place cotton draw sheet on top of rubber draw sheet & tuck • The rubber draw sheet should be covered completely • Place top sheet with wrong side up , center fold of sheet on center of bed • Tuck sheet at foot of bed, mitering the corner • Place blanket with center of blanket on center of bed, tuck at the foot of the , & miter the corner • Fold top sheet over blanket • Place bed spread with right side up & tuck it • Mitering corners at the foot of the bed
• Go the other side of bed & tuck in bottom sheet, draw sheet; mitering corners & smoothing out all wrinkles, put pillow case on pillow & place on bed • See that bed neat & smooth • Leave bed on place & furniture in order
3. Making an occupied bed Definition:-Is a bed prepared for a week pt that is unable to get out of bed Purpose • To make a smooth & comfortable bed with the least distribution of pt in it. • To provide comfort cleanliness & to facilitate position of the pt • Which is used by bed ridden pt
Required equipments • Two large sheets, Draw sheet, Pillow case • Pyjama or gown, as needed, Hamper & Glove • Precautions in handling the patient • If pressure areas need to be treated, do it before removing the draw sheet. • Obtain extra assistance in two nurses can not manage the patient alone to keep the pt, from falling down. • Remove any crumbs from the bottom end of the sheet, and tuck it in securely. • Never turn has a helpless patient, away from you as this may cause had him/her too fallen out bed.
Procedure…… Fan-fold the bottom linens close to the client toward the center of the bed.
Procedure • If bath is not given this time, the back of the helpless pt should be washed & back care given • Arrange linen on the chair in the manner in which it is going to be used • Explain the procedure to the pt • Screen pt, if necessary • Make sure ,the windows and doors are closed • Lower head of the bed if in Fowlers position • Loosen top bedding • Remove bed spread and blanket ,fold and place over the chair • Lift patient’s head and remove all pillows except one • Loosen the bottom bedding
• Move pillow to one side .Turn patient on side away from you • Never turn a helpless or unconscious patient away from you as this may cause him to fall out of bed • Have patient flax knees ,or assist patient to do so .With one hand over patient to wards you, get another nurse to help if necessary • Roll or fanfold the draw sheet against the patient’s back • Roll the rubber sheet and fold it back loosely over patient • Roll bottom sheet as far under patients back as possible • Sometime the top sheet with right side up , center of sheet on center of bed wide hem under the mattress at head of bed and making mitered corner
• Place rubber draw sheet in the center of the bed and tuck smoothly and tightly • Place draw sheet on top of rubber sheet and tuck rubber sheet should be covered completely • Turn patient on his side to wards you ,on to the clean sheet • Now go to the other side of the bed if alone ,pull out soiled linen which has been folded under the patient • Place solid linen on the chair .Never throw it on the floor • Pull and tighten bottom sheet and tuck in at top making a square corner. Then tuck in smoothly a long the side and foot of bed making mitered corner • Pull and tighten draw sheet and tuck in well • Place clean top sheet on the patient with large hem at the head with long side of the hem up over the dirty top sheet and ask the patient to hold the •
4. Making on anesthetic bed Definition:-A bed especially prepared to receive apt, after surgery and major recovery from anesthesia. Purpose • To protect the pt , from becoming chilled. • To protect the mattress and bedding from bleeding, vomiting drainage or discharge. • To arrange bedding so that a pt .can be moved it from a stretcher
Required equipments • Linen and other materials for closed bed, add woolen blanket and large sheet • Suction machine • Iv stand • Blood pressure apparatus • Vital sign sheet for pulse and temperature, B/P report watch • Hot water bottles with cover
Procedure • Make the foundation of the bed as usual with large sheet Continue with reminder of bed us usual but do not miter bottom corners of top bedding • Fun folds upper bedding to one side, opposite the stretcher. • In cold season place hot bottle in middle of the bed and cover with fan fold top bedding • Place emesis basin on bed side table • Place I.V stands on bed side table NOTE :-Never leave a hot water battle in the bed after a patient placed in bed ,un less specifically ordered by the doctor.
5. Making Cardiac bed It is a bed prepared for a patient who has heart ds. Purpose:-To believe Dyspnea • To provide comfort • To prevent complication Required equipments • Ordinary bed equipment • Cardiac table • Extra pillows – two for back • Back – rest (if not fowler’s bed) • Foot – rest board • Air – ring
Precaution on the degree of angle of bed and taking vital sign • A patient should be in an upright sitting position (45 up to 60 degree) to ease difficulty in breathing. Although, an upright sitting position is preferable, some times a patient may develop carcinogenic shock-so, by following vital sign change to shock position and as needed
Procedure • Make an ordinary bed with foot – rest at the foot of the bed • Place back – rest at patients back, making if comfortable with pillows .Adjust accordingly to the need of the patient. • Place cardiac table in front of the patient with pillow ,it so that he may lean for ward to rest his head and arms only • Leave your patient comfortable in bed. • Discard soiled linen in the proper place.
6. Making an amputation bed It is amputation bed and Amputation. - Special type of bed which is prepared for amputation patent. -Amputation is – the removal of a limb .part of a limb, or any other portion of the body. Purpose:- to allow the nurse to do repeated procedures To allow the nurse to make frequent observation i.e. after amputation of the leg with out disturbing the patient.
Equipments • Ordinary bed equipment • A set of top bedding • Blanket and bed covers • Bath blankets • Pillow and plastic covers • Sand bags if amputation bed is too made.
Procedure Make the foundation of the bed as usual • Spread both blankets next to the patient’s body. • Make bottom half of the bed Fold sheet cross wise art the center of the bed at bottom tuck and make corner .To make upper half of the bed. • Fold a sheet in half wise right hem side up. Allow 15cm at top to fold back over the bedding .The two halves should over lap about 7.25cm • Place blanket keep 22.5cm from the top of the mattress & fold the top sheet down over it • Do like wise with the bed spread • Remove the bath blanket placed next to the pt fold it & put it in its proper place
7. Making fracture bed It is a bed which is prepared for orthopedic pt common (spine, pelvis, leg) Purpose • To provide comfort for pt • To support affected part of a body • To facilitate healing pros • To prevent fracture complication Equipment – same as for a simple occupied bed, • Fracture broad • Fracture bed • Sand bag with cover • Bed cradle
Precaution - If the injured area is bleeding place a small plastic sheet and a folded draw sheet under it, as these are easier to change than the bed sheets. -Should position a patient, depending on type and site of fracture. - If the patient is dirty or blood-stained, the additional requirements for an emergency admission- bed are also needed.
Procedure • Place the fracture broad directly over the bed springs or under the mattress • Place a thin mattress or pad over the fracture broad. Remove inner spring mattress • Procedure to make this bed is same as for an ordinary occupied bed. • The small rubber and draw sheet are easier to change than the whole bed. This applies especially to an arm or a leg, which is bleeding or has discharge. • Fold back the bed cloths at foot of the bed for leg fracture cover the uninjured site with a small blanket place the cradle over the linen to adjust easy observation
Giving perennial care Perineum- The tissue between the anus & external genitalia. Purposes • cleans & avoid bad smell • To relive pain & inflammation • As preoperative procedure • As post operative procedure( e.g., episiotomy)
Indication • All maternity pts. After delivery or C/S for one week or as long as necessary • All abortion cases • Post operatives and all vaginal operation cases • Any bed pts. With vaginal bleeding or purulent discharge • After using a bed pan
For female • Remove dressing or pad used • Inspect the perinea area for inflammation, excoriation, swelling or any discharge Female perineum • Is made up of the vulva (external genitalia) including the monspubis, prepuce, clitoris, urethral and vaginal or if ices, and labia major and minora • The skin of the vaginal odor due to the cells and normal vaginal florae • The clitoris consists and erectile tissues and many
Precautions and contradiction • To avoid carrying infection up to genital area from anal site, should wipe • from up to down & using each swab once only is important . • Wear a glove while giving care to protect your self & patient Equipment • Sterile forceps or glove, Sterile cotton balls (swabs or gauze), Sterile pads, Anti septic solution such as zephiran chloride 1: 1000 Warm water, Rubber sheet & cover,Bed pan, Screen, Kidney basin
Procedure • Wash hands • Prepare trolley with the above equipment • Explain the procedure & take the equipment to the patients room & Screen bed & close the door & windows. Help patients to use bed pan • Remove the soiled pad, place in bowel or kidney basin • Fan fold top covers to the chest of the patient • Flex patient knees & cover with top sheet • Clean perineum with cotton swab dipped in solution using down ward strokes by using gloves or forceps • Use only one cotton swab for each stroke • Discard used cotton swabs • Repeat cleaning by pouring the anti septic solution over the genitalia
• Avoid hurting the patient with the forceps • Be care full with episiotomy stitches • Dry perineum & genitalia using cotton swabs • Remove bed pan • Turn patient one side & dry anal area • Put perennial pad in place • Straighten the bed & leave the patient comfortable • Clean equipment & return it to its proper • Chart time & any observation • wash hands
Body mechanics and mobility Introduction to mechanics Body mechanics -Is the coordinated effort, and safe use of the body to produce motion and maintain balance during activities. • A person maintains balance as long as the line of gravity passes through the center of the body and the base of support. • Line of gravity, base of support and center of gravity are important components of body balance, an important element of body mechanics are :-
* Line of gravity: is an imaginary vertical line drown through an objects. • Center of gravity: - is the point at which all of the mass of an object is centered * Base of support: - is the foundation on which an object rests
Purpose:- Proper body mechanics is achieved through coordinated movement, maintaining body balance and body alignment. • promotes body musculoskeletal functioning • reduces the energy required to move and maintain balance • Reduces fatigue and decreases the risk of injury • Facilitates safe and efficient use of appropriate groups of muscles N.B. Standing position posture is unstable because of • Narrow base of support • High center of gravity • Consistently shifting line of gravity
Positioning a patient - Place a pt, in comfortable position, according to procedure Purpose – Used for examination of rectum or vaginal, during diagnosis – For treatment , e.x- for bedridden pt. who has bed sore
Types of positioning There are different positions used for different proposes • Supine – The pt lies flat on the back with the head supported by pillows • Prone position – The patient is turned or lies face down; there is no pillow under the head, but there is a small pillow to support the abdomen • Fowler’s position – The pt is almost in a sitting position to facilitate easy breathing and to drain fluid from the abdominal cavity • Semi fowler’s position – The pt sitting and half lying with several pillows placed behind the pt.
• Shock position – Used when a pt has gone in to shock. The foot of the bed must be higher than the head of the bed • Lithotomy position – The pt lies on his or her back with the legs flexed and spread apart. It is used in vaginal and rectal examinations and catheterization, and delivery • Left lateral position – The pt lies on his or her left side, with the lower leg extended and the upper leg flexed. This position is used during an enema • Knee-chest position – (egnupectoral position) the pt rest on the chest and knees. The knees are slightly separated with the thighs perpendicular or at aright angle with bed. The face turned to one side and may rest on the forearms.
• Trendelenburg position – The pt lies flat on the back with Hips and knees elevated the portion of his legs below the knee rests on an inclined plane slanting down ward, shoulder supports is used to prevent the pt. from slipping • Dorsal Elevated position – This position is the same as the dorsal recumbent position except that extra pillows are placed under the head and shoulders to further relax the abdominal muscles
• Semi Recumbent :Position in w/c pt’s head and shoulders are raised by placing pillows under the head shoulders of the pt, • Sim’s position (3/4th prone position) – Dorsal Recumbent : Pt. lies on back, knee flexed and separated • Erect position- one having occipit and heals in line with nose, and great toes in the same line.
Helping a patient with crutch walk Definition:- • Crutches are a form of medical device that are generally used by individuals who can't walk properly or have extreme difficulty and pain while walking. • Crutches are artificial supports and assists patients who need aid in walking because of disease, injury, or a birth defect.
Purpose: • reducing the weight load on one of the legs of the person, • helping in broadening the support base that helps in maintaining a stable and upright position. • Crutches are of great use to people who have foot or leg pain, have weak muscles or an unstable gait, helping them in walking without difficulty.
• To assist client who cannot bear any weight on one leg. • Prevent injury to client who has difficulty in ambulation. Types of Crutches Many forms of crutches are used worldwide. Some of the most common types include 1. Axillary or Underarm Crutches 2. Forearm Crutches
Axillary or Underarm Crutches • Axillary crutches are generally made up of wood or aluminum. • they can be easily adjusted according to the height of the person using them. • These crutches are generally used by people who suffer from temporary disabilities or injuries. • Axillary crutches generally have padding just beneath the armpits, helping the individual to hold them easily and tightly without difficulty.
Forearm Crutches • Forearm crutches are the most common form of crutches used by individuals suffering from permanent disabilities. • designed in a way that the person using them can slip his arm into the cuff and thus hold and grip tightly.
Walking with Crutches - There are four kinds of walking with crutches:- • Four-Point Crutch Gait: • Three-Point Crutch Gait: • Two-Point Crutch Gait • Swing-Through Crutch Gait
1. Four-Point Crutch Gait: • Indication: Weakness in both legs or poor coordination. • Pattern Sequence: Left crutch, right foot, right crutch, left foot. Then repeat. • Advantages: Provides excellent stability as there are always three points in contact with the ground • Disadvantages: Slow walking speed
Four-Point Gait. A. Moving Right Crutch Forward and Left Foot Forward; and B. Moving Left Crutch Forward and Right Foot Forward, Even with Right Crutch
2. Three-Point Crutch Gait: • Indication: Inability to bear weight on one leg. (fractures, pain, amputations) • Pattern Sequence: First move both crutches and the weaker lower limb forward. Then bear all your weight down through the crutches, and move the stronger or unaffected lower limb forward. Repeat. • Advantages: Eliminates all weight bearing on the affected leg. • Disadvantages: Good balance is required.
3. Two-Point Crutch Gait: • Indication: Weakness in both legs or poor coordination. • Pattern Sequence: Left crutch and right foot together, then the right crutch and left foot together. Repeat. • Advantages: Faster than the four point date. • Disadvantages: Can be difficult to learn the pattern.
4. Swing-Through Crutch Gait: • Indications: Inability to fully bear weight on both legs. (fractures, pain, amputations) • Pattern Sequence: Advance both crutches forward then, while bearing all weight down through both crutches, swing both legs forward at the same time past the crutches. • Advantage: Fastest gait pattern of all six. • Disadvantage: Energy consuming and requires good upper extremity strength.
Crutch Walking: Swing-Through Gait
Equipment -Gait belt - Tape measure - Crutches -Sturdy footwear, properly fitted
Procedure 1. Inform the client you will be teaching crutch ambulation. Rationale: Reduces anxiety. Helps increase comprehension and cooperation, promotes client independence. 2. Assess the client for strength, mobility, visual acuity, perceptual difficulties and balance. Note: nurse and therapist often collaborate on this assessment. Rationale: Helps determine the clients capabilities and amount of assistance required. 3. Adjust crutches to fit the client. With the client supine, measure from the heel to the axilla. With the client standing, set the crutch position at a 4-5 inches lateral to the client and 4-6 inches in front of the client. The crutch pad should fit 1.5 – inches below the axilla (3 finger width). The hand grip should be adjusted to allow for the client to have elbows bent at 30 degree flexion.
Rationale: Provide broad base of support for the client. Space between the crutch pad and axilla prevents pressure on radial nerves. The elbow flexion allows for space between the crutch pad and axilla. 4. Lower the height of the bed. Rationale: Allows the client to sit with feet on the floor for stability. 5. Assess for vertigo. Rationale: Allows for stabilization of blood pressure, thus preventing orthostatic hypotension. 6. Instruct the client to position crutches lateral to and forward to feet. Demonstrate correct positioning. Rationale: Increases client comprehension and cooperation.
7. Apply the gait belt around the client’s waist if needed. Rationale: Provides support, promotes client safety. 8. Assist the client to a standing position with crutches. Rationale: Standing for a few minutes will assist in preventing orthostatic hypotension. Four-Point Gait 9. a. Position crutches to the side and in front of each foot. b. Move the right crutch forward 4 to 6 inches. c. Move the left foot forward, even with the left crutch. d. Move the left crutch forward 4 to 6 inches. e. Move the right foot forward, even with the left crutch. f. Repeat the four-point gait. Rationale: The four point gait provides greater stability. Weight bearing is on three points at all times. The client must be able to bear weight with both legs.
Three-Point Gait 10. a. Advance both crutches and the weaker leg forward together. b. Move the stronger leg forward, even with crutches. c. Repeat three-point gait. Rationale: The three point gait provides a strong base of support. This gait can be used if the client has a weak or non-weight- bearing leg. Two-Point Gait 11. a. Move left crutch and right leg forward 4 – 6 inches. b. Move right crutch and left leg forward 4 – 6 inches. c. Repeat two-point gait. Rationale: The two pint gait provides a strong base of support. The client must be able to bear on both legs. This gait is faster than four-point gait..
12. Set realistic goals. Rationale: Crutch walking takes up to 10 times the energy required for unassisted ambulation. 13. Consult with a physical therapist. Rationale: The physical therapist is the expert on the health care team for crutch-walking techniques. 14. Wash hands. Rationale: Reduces the transmission of microorganisms.
Patient Transfer Lifting a patient in bed Patient lifting and moving - moving and lifting of a patient is an integral part of nursing care in which relation to moving & lifting patient in health care setting and has been for a high risk of back injury to nurses, when the body alignment of the nurse is improper way.
• Principle of patient lifting – Always try to find a lifting partner – Choose suitable lifting method that partner agrees with. – Explain to the patient why lifting is necessary and how he/she can assist. – Wait for signal from the leading lifter so the lifters can move together. – When lifting is completed, make sure patient is comfortable – To minimize the risk of back injury, lift by bending the knees and using the tight muscles. – Remove all obstacles form the sit.
Purpose • To assist patient who is unable to move him self. • To prevent fatigue and injury • To maintain good body alignment • To stimulate circulation Precautions – Lifting a patient up in bed (help less patient Equipment According to procedure being performed
Procedure • Explain procedure to the patient • Remove all pillows, air rings etc. • lower the head of the bed and fold back • bedding from the side that it will not interfere with lifting • flex the patient’s knees • lifter “A” slips one arm under the patients head and shoulder and one arm under patient ‘s back • lifter “B” slips one arm below lifter “A” and one arm under things • lifter “A” gives directions to lift and both lift at the same time • the patient may slip his arms around the lifters shoulder
Assisting a patient up in Bed • Explain procedure to the patient • Remove all pillows, air rings, etc • Have patient flex his knees • Patient puts one hand on one of the lifter’s shoulders • Lifter puts one arm under patients shoulder & one under tights • Have patient lift himself & push with his heels • As you lift the patient to word the head of the bed, swing own Wright on to your for ward foot.
Moving a patient from bed to stretcher and from stretcher to bed Purpose • To send a patient to operation room • To send a patient to other room, like as; x-ray, ct-scan and so on. If a patient is unable to wake by him/her self • To change bed covers
Steps for moving apt, from bed to stretcher • Have bed ready to receive patient. • Bring stretcher to bed, placing head of stretcher at foot of bed a right angle to the bed • Three lifters come to the same side of the stretcher on the inner angle • Roll blanket to words the patient so it isn’t in the way. • The first lifter places hands and arms under patient‘s head & shoulders • The second lifter places one arm under the back and the other hand under the buttocks • The third lifter places one arm under the part of the leg & the other under the lower legs.
• Indication – Bed ridden patient – Debilitated patient – Fractured patient, if he/she is unable to move Precaution • Avoid sudden twists when lifting. • Always keep your back straight when lifting, with the chin slightly tucked in. • Keep your body fit and strong by regular exercise, E.G by brisk, running, not ball, swimming etc.
• Moving patient from bed to chair and from chair to bed Purpose – To get a helpless patient out of bed & into a chair with as little exertion as possible, and make him comfortable. • Equipment • Chair (preferably with arms for support) • Blankets or two pillows • Patient’s robe and slippers
• Steps for moving from bed to chair A. Assists the patient, to sit on the side of the bed, and dress the patient appropriately. B. Assist the patient to stand on the floor, then to walk to the chair, to sit down and be comfortable C. Assist the patient, to sit down and leave him comfortable. D. Assist the patient, to rise from the chair, to stand it straight, to return to the bed and to be comfortable.
Indication • When a patient‘s linen is soiled & need s changing. • A patient is interested to sit on chair. Precaution • If the patient is heavy or helpless, powdering the fore arms makes it easier to insert them under him, particularly when the skin is moist. • Be as close as possible to the patient before lifting, and remain as close as possible to him throughout the entire lift, because the closer the load is to the body, the less strain the load is to the body, less strain is on the lifters back. • When the lifting is complete make sure that the patient is comfortable.
Procedure • Explain what you are going to do to patient – Place chair on convents side of bed with the blank of the chair parallel to the foot of the bed. If wheel chair is used, seen than the foot rest in up and that the wheels and locked. – Place blanket in seat of chair, top edge even with back of chair. – If pillows are used place one standing against back of chair and on pillow on seat of chair. – Check patient is pulse – Bring patient to edge of bed – Fold bedding to foot of bed and flex patients knees
– With right arm under patient’s head and shoulders and with left arm under tights, lift patient up and at the same time swing him around into a sitting position with feet hanging over edge of the bed. – Slip on robe – Steady him for a few seconds – Put on slippers or shoes – Sanding directly in front of him with one hand in each axilla slip the patient to his feet and at same time turn him gently and place him in the chair. – Make bed •
– Watch patient constantly and note patient’s pulse after he has been in chair for a few minutes. – Never leaver leave the patient in chair without some way to call for help if the needs it.
TEACHING THE PATIENT COUGHING AND DEEP BREATING EXERCISE • The coughing exercise is one of the best known and most effective forms of chest physiotherapy. • Coughing deeply will help in clearing your lung after surgery. • When you stay in bed for a long time after surgery, you need to keep your lungs active as if you are doing your daily activities.
COUGHING – is a reflexive response to irritation in airways Or Is sudden explosive exhalation. Function of cough: • to help clear offending substance from the air ways. • Serves as a warning signals’ that the airways are being assaulted by possibly harmful stimuli. Causes of cough- cough can be triggered by • anything that enters the air way that does not normally belong there, Eg. Chemical substance or physical substance. • Inflammation of the tissue by disease that results in increase of histamine w/c irritates the air ways and triggers a cough.
DEEP BREATHING- • It is a condition in which there is more than the normal amount of air entering and leaving the lungs Indication for coughing and deep breathing: Pts with infective air way clearance and excessive secretion in the respiratory tracts
• Pts with infective breathing pattern • Respiratory defect, hypoventilation • Pts under water- seal drainage tube
Coughing Technique • Start with sitting on a chair with both feet on the floor, Relax. • Fold your arms across your abdomen and breathe in slowly through your nose. The power of the cough comes from moving air. • To exhale: lean forward, pressing your arms against your abdomen. Slightly open mouth. • Cough two to three times, short and sharp. • The first cough loosens the mucus. The second and third cough moves the mucus up and out.
Oxygen therapy is the administering of oxygen at a concentration greater than found in the environmental atmosphere. Purpose • To provide & maintain a normal supply of O2 for blood & tissue. – Oxygen transport to the tissue depends on:- • factors such as cardiac out put, arterial oxygen amount, adequate concentration of hemoglobin ADMINSTERING OXYGEN THERAPY
• To reduce the effect of anoxaemia( oxygen deficiency) • To maintain health level of tissue oxygenation. – Hypoxemia:- is a decrease in the arterial oxygen tension in the blood – Hypoxia: - is decrease in oxygen supply to the tissue Indication of oxygen therapy • Obstruction in airway passage like forewing body, Bronchial asthma, Pneumonia and pulmonary edema, Cardiac insufficiency • Peripheral circulatory failure
Types of oxygen administration divice 1. CANNULA /NASAL PRONGS 1-4 lts 2. SIMPLE FACE MASKS 6-10 lts 3. NASAL CATHETER 1-6 lts 4. Oxygen Tent 8-10 lts
NURSING RESPOSIBILITIES 1) Administration – the nursing staff is responsible for the subsequent administration this Includes: – Checking the dosage of oxygen rate of flow, the concentration of O2 – Checking the function of humidifying equipment – Monitoring the pt and depth of the pt’s respiration – Every water of the apparatus should be clean to prevent infection 2) Safety – • the safety of pt and others must be ensured when O2 is being used • “No smoking” signs must be posted and rigidly enforce • All electrical plugs, outlets & equipments must be grounded
ADMINISTERING OXYGEN BY NASAL CANNULA , OR MASK • Equipments – O2 Cylinder with it’s stand & accessories( humidifier with sterile distilled water& flow meter) – Nasal cannula, catheter . – Gauze to pad the tubing over the check bone . – Simple O2 mask – No smoking sign – Adhesive tabs, gauze to pad the tubing over the check bone
PROCEDURE • Determine the need for oxygen therapy and the physician order • Assist the client to a semi- flower’s position as possible. It permits easier chest expansion & easier breathing • Explain the procedure to the patient and inform the client & support persons about safety precautions connected with oxygen use. • Set up the oxygen equipment & humidified. • Turn on the oxygen at the prescribed rate & ensure proper function. • Put the cannula over the clients face. • If the cannula will not stay in place tape if at sides of face.
If a mask is to be used • Connect the mask tubing & open the fine adjustment to the required rate of flow • Apply mask to the pt face making sure that it rests comfortable on the pt’s face. • Asses the client regularly. • Asses the vital signs, color breathing pattern & chest movement. • Check the equipment are working regularly. • Make sure that safety precaution are being followed.
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FUNDAMENTAL NURSING -I.ppt

  • 1. UNIT ONE Essential Assessment Components Nursing Art for Health Officer
  • 2. Vital Signs Vital sings are signs that reflect changes in the functions of the body. • The “taking of vital signs” refers to measurement of the client’s body temperature (T), pulse (P) and respiratory (R) rates, and blood pressure (BP). • Vital signs are fundamental to physical assessment (the first step in the physical examination) to establish baseline values of the vital signs. • The sequence for recording vital signs measurement in the nurses’ notes is T-P-R and BP.
  • 3. Cont….. Types of v/s There are five v/s 1. The Blood pressure 2. The temperature 3. The pulse rate 4. The respiratory rate 5. The weight and Height
  • 4. Cont… Times to Assess vital signs • On admission – obtain baseline date • When a client has a change in health status • According to a nursing or medical order • Before and after the administration of certain medications • Before and after surgery or an invasive diagnostic procedures • Before and after any nursing intervention that could affect the v/s
  • 5. FACTORS INFLUENCING VITAL SIGNS • Several factors can cause changes in one or more of the vital signs: age, gender, lifestyle, environment, medications, pain, and other factors such as exercise and anxiety and stress, postural changes.
  • 6. Cont… Purpose • To determine the condition of the patient • To aid in diagnosis • To monitor changes • To give medication • To provide appropriate care • To pronounce death  Equipment The measurement of the client’s vital signs requires the appropriate instruments. All pieces of equipment should be maintained to function accurately.
  • 7. Thermometer- Glass 1. Oral- Slim tip 2. Axillary 3. Rectal- Stubby, pear-shaped tip 4. Electronic Battery-powered display unit with a sensitive probe (blue for oral and red for rectal) covered with a disposable plastic sheath for individual use 5. Disposable -Thin strips of plastic with chemically impregnated dots that (chemical), change color to reflect temperature single-use 6. Tympanic- Battery-powered display unit with disposable speculums and infrared-sensing electronics. (Courtesy, The Gillette Company.)
  • 8.
  • 9. 1. Blood pressure is the force exerted by the heart on the blood to pump it through the arteries & around the body.  In blood pressure there are the systole & the diastole. A. The systole: - is the period when the heart pumps the blood out into the arteries or contraction of ventricle. When if forces the blood in to the aorta. B. The diastole: - is the phase during which heart is filling with blood in preparation for the next pumping action.
  • 10. • Blood pressure can be measured by an instrument called sphygmomanometer • Blood pressure is recorded in mmHg • normal B.P of adult is 100-120 mmHg systolic • normal B.P of adult is 80-90mmHg diastolic
  • 11. Stethoscope  Acoustic- Closed cylinder that prevents dissipation of sound waves and amplifies the sound through a diaphragm. Flat-disc diaphragm transmits high- pitched sounds, and the bell-shaped diaphragm transmits low-pitched sounds.  Sphygmomanometer 1. Mercury Wall or portable unit that contains a mercury-filled glass manometer column, calibrated in millimeters; the mercury rises and falls in response to pressure created when the cuff is inflated.
  • 12. 2. Aneroid manometer Portable unit with a glass-enclosed gauge containing a needle to register millimeter calibration and a metal bellows within the gauge that expands and collapses in response to pressure variations from the inflated cuff.
  • 14. Cont…. Positions of patients to take blood pressure • The blood pressure can be checked with the patient in the lying, sitting, or standing positions. Sites for measuring Blood pressure Upper arm- Using brachial artery Thigh around – Poplital artery Fore-arm – Using radial artery  Leg – using posterior tibia or dorsal pedis
  • 15. Cont…. So:- - The patients arm should be slightly bent and relaxed - Do not applies the cuff too tightly the last beat.
  • 16. • Procedure • Explain the procedure to the patient • If the patient is ambulatory place him in a sitting position. • If a bed patient places him in dorsal if up on recumbent of fowler’s position. • Roll patients sleeve above elbow, or slip sleeve off if convenient. • Have patients extend arm; support if up on the bed or a small pillow or table. • Apply cuff of sphygmomanometer smoothly & not too tightly or too loose. • Be sure there is no pressure on the arm
  • 17. • Sit down if possible, so that your eye is on a level with the scale on the blood pressure apparatus, avoids the scale from the line of vision of the patient. • Palpate the brachial artery & place the stethoscope over pulsating vessel. Do not press too hard. • Close air value screw, pump bulb & inflate cuff until pulse disappears or mercury column should reach about the 150 more or more up to 200. • Open value screw slightly, releasing the air slowly in the cuff. (the mercury column should not fall faster) • Note read the scale until the first beat is heard. This is the systolic B/P. • Continue letting air out very slowly until last dull beat is heard or until the sound disappear this is the diastolic reading.
  • 18. • Repeat the procedure & check the B.P to be sure. • Remove cuff & roll it up • Make the patient comfortable • Chart the blood pressure & any observations • Return the equipment you used to its proper place. • Ear pieces & the diaphragm should be clean with alcohol swab after use • Wash hands
  • 19. Measuring patient pulse rate The pulse is the heart beat conveniently felt at the wrist & at any point Where an artery passes superficially over a bone. Site for taking pulse rate This pulse may be observed readily over the following arteries – Radial- the radial artery is palpated in wrist just below the thumb. – Temporal – the temporal artery is palpated immediately in front of the ear or the end of the eye brow. – Carotid – is palpated at the front of the neck on either side.
  • 20. Cont…. – Brachial- the brachial artery at anterior & inner aspect of the elbow joint. – Femoral- the femoral artery is palpated on either sides of the groin. – Popliteal- the popliteal artery is palpated at the back of the knee • Do not make to great pressure • Do not use thumb to feel pulse • Note rate, regularity, skipped beats & force
  • 21. Types of pulse The pulse may be classified according to; • Rate– means the rate at which heart is beating. • Normal rate is considered to be between 60- 80b/m, average is 72b/m. • Rhythm - is a regularity with which the heart beats. • Normal or regular rhythm; is a regular pattern of beats & intervals. • Volume- strength of the pulse
  • 22. Cont…. Procedure •Explain the procedure to the patient •Place the patient in a comfortable position lying or seated with the arm resting across the chest •Usually you can count the pulse while the day thermometer is in place. •Place two or three fingers over the radial artery •The thumb should not be used over the area, it may cut off the circulation & the pulse cannot be felt. •The pulse is commonly taken over the radial artery, but it can be taken at other arteries. •If the pulse is irregular count it for a full one minute.
  • 23. Cont… • If it is regular count 30 sec. & multiply by 2. • Chart the pulse rate & report any abnormal The normal pulse rate; • Infant age have 120-140 beat/min • children ( 1-5 age) have 100 beat/min • Elderly people (> 60 yrs age) usually have 50- 60beat/min
  • 24. Cont…. Taking patient’s respiratory rate measurement Respiration - defined as the process of inhaling air in to the lungs & exhaling co2 from the lungs . • Respiration is controlled by the respiratory centre in the brain.
  • 25. Cont…. Normal respiration rate • Normally the respiration number about 14- 20b/min at rest time. • Infant 28-40/min – children 20-28/min – adult 16-18/min – Old people 12-14/min Equipment • Watch with second hand & paper & pen or pencil
  • 26. Procedure • respiration are counted while taking the pulse • After counting the pulse leave fingers on the wrist & count the respiration by watching the rise & fall of the chest or abdomen • The patient should not be aware that you are counting his respiration as he might control his breathing • Count respiration for all min • Observe the rate & depth of respiration & report any symptoms • Chart procedure time & observation.
  • 27. Measuring patient’s body Temperature • Body temperature-degree of bodily heat, as measured by clinical thermometer. • Normal temperature is the balance maintained in the body between the heat produced & the heat lost. • Anything which interferes with this balance interferes with the function of the whole body. • The clinical thermometer is an instrument used for measuring the temperature of the bodily heat or cold.
  • 28. Cont… • Measurement of Height and Weight • Measuring height and weight is as important as assessing the client’s vital signs. Routine measurement provides data related to growth and development in infants and children and signals the possible onset of alterations that may indicate illness in all age groups. • Height • Measurement of height is expressed in inches (in.), feet (ft), centimeters (cm), or meters (m). See the accompanying display for conversion equivalents from one system to another.
  • 29. Site for taking body Temperature 1. Oral/mouth 2. Rectum 3. Axilla or Groin 4. Ear Normal temperature A/ by mouth – 98.6 oF or 37 oC B/ by rectum- 99.6 oF or 37.9 oC one degree higher than by mouth C/ by auxiliary – 97.6 oF or 36.4 oC one degree lower than by mouth.
  • 30. • Calculations from oF to oC ,oC or oC to oF • When changing Fahrenheit to centigrade temperature the formula is as follows. Example C = oF – 32o x5/9 = 99oF – 32ox5/9 = 99 – 32 = 67x5/9 = 37.2oC
  • 31. • Example 2 101.4oF – 32x5/9 = 99 – 32 = 67x5/9 = 38.5oC  When changing centigrade to Fahrenheit use the following formula:- F = C x 9/5 Example 1) 100oC x 9/5 + 32 = 180o + 32
  • 32. = 212oF • Example 2 = 37oC x 9/5 + 32oC = 66.6o + 32 = 98.6oF
  • 33. 1- Procedure for oral Temperature • The nurse must wash her hands • Place the thermometer try on the locker between two patients. • Explain the procedure to new patients • Ask patient if he/she has taken any thing by mouth. • If so wait for ten minutes • Remove the thermometer from its tube, rinse in water & wipe from bulb to stem in circular movement. • Read & shake down mercury to below 95oF or 35oC
  • 34. • Instruct the patient to open his mouth, and then place the thermometer under his tongue. Warm he to keep his lips closed, to avoid taking & closing teeth on the thermometer. • It must be left in place for 1-2 minutes to allow registering fully. • Place the second thermometer in the next patient’s mouth in the same way while waiting for the first. • Return to the first patient & count his respiration record temperature, in book or on chart. • Remove thermometer, wipe with swab from stem to bulb, read the thermometer, wash in soap solution, wipe again, clean swab & return to test tube, record temperature in temperature book or on chart.
  • 35. • Wash the hands after all the temperature have been taken. • Change solutions & cotton after taking morning and evening temperature, twice daily, unless a separate thermometer is used for each patient. • Be sure equipment is clean before putting it a way in its proper place. Equipment is locked up after thermometers are counted • Chart accurately, in the right day, right patients chart use a ruler when drawing lines on graphic chart.
  • 36. Procedure • Measurements must be taken each day at the same time and under the same conditions • Daily weights are usually taken each morning after the pt voids and before breakfast • The pt must wear the same amount and type of clothing at each weighing • Allow the pt to stand on the scale • Look at the measurements on the scale carefully • Report the weight or record on the pt’s chart • Make the pt comfortable after the procedure • Wash hands
  • 37. Taking patient height measurement Body height – is a measurement from base to top or head to foot. Patient position when taking height - For a child or adult who is unable to stand place the child/adult lying on his back on a firm surface (by horizontal measuring board). - A tall board is made to stand upright against the wall, and the patient’s removes the shoes, and stands on the floor with his or her back to the measuring board, and stands in up right against the wall (by standing measuring board).
  • 38. Measuring patients body weight Body weight- is the load of a body. • The unit measurement is kg  Essential equipment • Scale • Pencil and pt chart
  • 39. Cont… Weighing a Client on a Standing Scale
  • 40. 1.2 Diagnostic tests procedure Collecting patient’s specimen  Specimen mean a sample of urine, stool, any discharge blood & sputum, which is send to laboratory for investigation. • Specimen is sent to the laboratory on time & all specimens should be fresh collection. • Purpose- If necessary – Collect a specimen for examination – To determine the prognosis of the patient out put. – To know the effect of any treatment
  • 41. General instruction for collecting specimen • give the right specimen bottle • Identify the right patient, time & collect in the right specimen bottle • every specimen must have a label with the patients full name, room no., ward no., & hospital no. & nurses signature with date & time. • Orders or types of tests are written on laboratory request form. • Specimen must be placed on the specified place in the laboratory specimen shelf.
  • 42. • Kinds of specimen – blood – urine – stool – sputum – body fluid
  • 43. Taking urine specimen Urine Is a fluid formed in the kidney and excreted through the urinary organs. It is clear and straw yellow and composed of 95% of water and 5% solids an average out put of urine is 1.5 liters per day. Urine specimen :- A routine urine specimen is collected for a test called a urinalysis. a complete test includes a study of color and degree of cloudiness, PH, specific gravity, tests for glucose and protein (albumin). Addition shows the presence of blood; pus or casts.
  • 44.  Types of urine specimen • Random/routine urine specimen • Mid-stream urine /sterile urine • Timed specimen /24hrs urine specimen Purpose – For routine screening of pt’s status • Equipment Specimen bottle Bed pan or urinal Request form Tissue paper
  • 45. Procedure • instruct the patient about the procedure & tell him not to pass the stool in the same bed pan • pour 100-150ml of urine in specimen bottle • make a label with all necessary information • send in to laboratory with its request form Sterile urine specimen - It is only taken by catheterization.
  • 46. Twenty four hours urine specimen; Purpose • to know the amount of urine passed in 24hr • for diagnosis & to know the effect of the drug  Equipment • Large container • Label for bottle • Request form Procedure • label container with correct information
  • 47. • inform the patient & staff the 24hrs urine is in progress • start in early morning, after that each time patient voids, pour the urine in to the same container & keep it covered • measure the total amount & then take the laboratory properly labelled • Total amount urine should be noted on chart. N.B- Oliguria – decrease formation of urine –Polyuria – increase or formation of excess urine –Anuria – failure to secrete urine
  • 48. Taking blood specimen Blood: - is the only fluid tissue circulating through out the body, carrying Nutrients and oxygen to the tissues and removing wastes and carbon dioxide.  Purpose of taking blood specimen • To detect infectious agent such as bacteria….. • To diagnose non-infectious d/s such as leukemia • To investigate anemia and monitor response of a pt to treatment • To demonstrate abnormal amount of the normal constituents or blood such as glucose and immunoglobulin
  • 49. Types of method of taking blood specimen 1. Capillary puncture 2 .Vein puncture  Sites of taking blood specimen Capillary puncture – Lateral side of ring finger – Ear lobe for children and adults – Planter surface of the big toe or the heel for infantes
  • 50. Vein puncture • Forearm/anticubital fosse • Wrist or ankle • External jugular vein for infant • Femoral vein for infant Precaution • Do not apply the tourniquet too tightly or to long a period b/c this will cause venous stasis leading to a concentration of substances in the blood such s hemoglobin and plasma proteins • Do no collect the blood from an arm in to w/c an intravenous (IV) infusion is being given. • Follow a safe technique and wear protective gloves when collecting and handling blood specimens .
  • 51. Necessary materials • Lancet • Alcohol swab with its container • Gloves • Request form • Slide • Libeling marker
  • 52. Procedure • The puncture site should be warmed to assure good circulation of bd. If it is cold, apply warm water (38-400c) for few mints • The site to be punctured, is first rubbed with 70% alcohol socked swab to move dirty materials • While making a finger puncture apply gentle pressure to the puncture site to hold the skin tightly. • Make a quick, firm, swab (3-4mm) • The 1st drop of blood should be wiped away before specimen is taken • The blood must not be squeezed out since this dilutes it with fluid from the tissue • After the desired specimen has been collected on the slide have the pt hold sterile dry gauze over the wound until bleeding stops.
  • 53.  Obtaining blood specimen by vein puncture • Venous blood is used when more than 100ml blood is require • The method may need anticoagulants (e.g. Trisodiumcitrate ,heparin)  Necessary materials • Sterile syringe and needle, Tourniquet • Test tube bottle, Alcohol swab with container • Gloves, Labeling marker, Request form • Dry cotton
  • 54. Procedure • Place an identifying label on the blood collecting bottle/test tube. • Remove sterile syringe and attain the needle • Cheek to be sure that the syringe works smoothly and that the needle is not plugged • Place the tourniquet around the pt’s arm above the elbow tightly enough w/c make the vein more prominent • Instruct the pt at open and close the fist several times to ↑ increase circulation • By inspection and palpation locate the desired vine • Cleanse the skin over the selected vein must use 70% alcohol swab
  • 55. Shortly • Place the tourniquet on pt arm • Clean the area and make a puncture • Release the needle before unknot the tourniquet • Collect the blood in the appropriate test tube
  • 56. Taking sputum specimens Sputum; - is a mucous substance expelled by clearing the throat or by coughing.  This matter may come from the lungs or bronchi the tubes entering the lungs.  Sputum may consists of a discharge from the nasal or throat area depending on the pt’s disease, sputum may consist of pus, blood, mucus, and micro organisms
  • 57. • The pt, should be instructed to cough deeply in order to bring up material from the bronchi and lungs. Other wise, the specimen consists only of saliva and nose and mouth secretions. • The specimen may be collected at any time the pt is able to produce the sputum. • Sometimes a 24-hr collection of sputum may be ordered. • The amount of sputum, the appearance (consistency and color) and the odor are significant Purpose :- Sputum specimen aids the doctor in diagnosing problems in the respiratory system
  • 58. Precaution - Wear a mask when collecting the sputum to protect your self from droplet infection. - Wash your hands carefully after handling the container. • Amount • Appearance- Containing pus/yellow/ -Gray or black -A rusty color or streaks of red blood -Green-colored • Odor • Equipment • Sputum mug , Request form, Labeling marker
  • 59.  Procedure • Cheek doctor’s order, and explain procedure to the pt. • give specimen bottle to pt • Have pt clean her/his mouth well and encourage pt to cough and expectorate in to specimen bottle, explain that the pt should cough deeply and bring up the sputum from deep in the lungs • Should be collected early in the morning before the pt gets out of bed • Label container and send to the lab with a request form if the pt is suspected of having TB he/she should not cough in front of other pts and should at least cover the mouth when coughing
  • 60. • NB- When pulmonary Tuberculosis is suspected, up to three specimens (morning spot) should be collected to detected AFB (Acid fast bacilli)
  • 61. UNIT TWO Selected Clinical Nursing Therapeutics
  • 62. 2.1 Asepsis • Asepsis is the absence of microorganisms. • Providing nursing care using aseptic technique decreases the risk and spread of nosocomial infections. • Aseptic technique is the infection control practice used to prevent the transmission of pathogens. • Two types of asepsis are medical and surgical.
  • 63. Medical Asepsis • Medical asepsis uses practices to reduce the number, growth, and spread of microorganisms. • Medical asepsis also referred to as “clean technique.” • Objects are generally referred to as “clean” or “dirty” in medical asepsis. • Clean objects are considered to have the presence of some microorganisms that are usually not pathogenic. • Dirty (soiled) objects are considered to have a high number of microorganisms, with some that are potentially pathogenic.
  • 64. • Common medical aseptic measures used for clean or dirty objects are:-  hand washing  gloves changing linens daily  cleaning floors and hospital furniture daily.
  • 65. Surgical Asepsis • Surgical asepsis, or sterile technique, consists of those practices that eliminate all microorganisms and spores from an object or area. • Surgical asepsis refers to :-  hand washing  the donning of surgical attire (caps, masks, and eyewear)  handling of sterile instruments and equipment  establishing and maintaining sterile fields.
  • 66. • Common nursing procedures that require sterile technique are: All invasive procedures, intentional perforation of the skin such as:- injections,  insertion of intravenous needles  catheters or entry into a bodily orifice (tracheobronchial suctioning, insertion of a urinary catheter)
  • 67. 2.2 Hand washing • Hand washing is the rubbing together of all surfaces of the hands using a soap or chemical and water. • Hand washing is a component of all types of isolation precautions and is the most basic and effective infection control measure that prevents and controls the transmission of infectious agents. • The CDC (2000) commends vigorous scrubbing with warm, soapy water for at least 15 seconds to prevent the transfer of germs.
  • 68. • The three essential elements of hand washing are soap or chemical, water, and friction • Hand washing should be performed after arriving at work, before leaving work, between client contacts, after nurseries, usually require about a 2-minute hand wash. Equipment • Soap Paper or cloth towels • Sink Running water
  • 69. Procedure 1. Remove jewelry, Wristwatch may be pushed up above the wrist (midforearm). Push sleeves of uniform or shirt up above the wrist at midforearm level. 2. Assess hands for hangnails, cuts or breaks in the skin, and areas that are heavily soiled. 3. Turn on the water. Adjust the flow and temperature. Temperature of the water should be warm. 4.Wet hands and lower forearms thoroughly by holding under running water. Keep hands and forearms in the down position with elbows straight. Avoid splashing water and touching the sides of the sink.
  • 70. 5. Apply about 5 ml (1 teaspoon) of liquid soap. Lather thoroughly. 6. Thoroughly rub hands together for about 10 to 15 seconds. Interlace fingers and thumbs and move back and forth to wash between digits(Figure A). Rub palms and back of hands with circular motion. Special attention should be provided to areas such as the knuckles and fingernails, which are known to harbor organisms(Figure B).
  • 71. Fig. A . Interlace fingers to wash between the digits Fig B. Provide special attention to washing knuckles and fingernails
  • 72. 7. Rinse with hands in the down position, elbows straight. Rinse in the direction of forearm to wrist to fingers. 8. Blot hands and forearms to dry thoroughly. Dry in the direction of fingers to wrist and forearms. Discard the paper towels in the proper receptacle. 9. Turn off the water faucet with a clean, dry paper towel (see Figure C).
  • 73. Fig. C Turn off faucet with a clean, dry paper towel. NURSING ALERT Handwashing Wash hands before and after every client contact. The most common cause of nosocomial infections is contaminated hands of health care providers.
  • 74. 2.3 Donning Sterile Gloves • There are two methods for applying sterile gloves: open and closed. • The open method is used most frequently when performing procedures that require the sterile technique, such as dressing changes. • The closed method is used when the nurse wears a sterile gown.
  • 75. Donning Surgical Attire • Surgical nurses are required to wear a surgical mask and a clean cloth or paper cap that covers all of the hair. • After the cap is applied, the nurse positions the mask to cover the nose and mouth Protective eyewear (glasses or goggles) is worn during all procedures that pose a threat of splashing body fluids into the eyes.
  • 76. Procedure- Performing Open Gloving and Removal of Soiled Gloves 1. Wash hands 2. Read the manufacturer’s instructions on the package of sterile gloves; proceed as directed in removing the outer wrapper from the package, placing the inner wrapper onto a clean, dry surface. 3. Identify right and left hand; glove dominant hand first.
  • 77. 4. Grasp the 2-inch- (5-cm-) wide cuff with the thumb and first two fingers of the non dominant hand, touching only the inside of the cuff. 5. Gently pull the glove over the dominant hand, making sure the thumb and fingers fit into the proper spaces of the glove (see Figure A). • With the gloved dominant hand, slip your fingers under the cuff of the other glove, gloved thumb abducted, making sure it does not touch any part on your non dominant hand (see Figure B).
  • 78. Fig. A Pull the glove over the dominant hand. Fig B. Slip the fingers under the cuff of the glove for the nondominant hand and abduct the thumb.
  • 79. 7. Gently slip the glove onto your on dominant hand, making sure the fingers slip into the proper spaces. 8. With gloved hands, interlock fingers to fit the gloves onto each finger. If the gloves are soiled, remove by turning inside out as follows: 9.Slip gloved fingers of the dominant hand under the cuff of the opposite hand or grasp the outer part of the glove at the wrist if there is no cuff (Figure C).
  • 80. Fig . C. Insert gloved fingers under the cuff of the other glove. Fig. D Pull the glove down to the fingers and turn inside out.
  • 81. 10. Pull the glove down to the fingers, exposing the thumb (see Figure D). 11. Slip the uncovered thumb into the opposite glove at the wrist, allowing only the glove-covered fingers of the hand to touch the soiled glove. 12.Pull the glove down over the dominant hand almost to the fingertips and slip the glove onto the other hand. 13. With the dominant hand touching only the inside of the other glove, pull the glove over the dominant hand so that only the inside (clean surface) is exposed. 14. Dispose of soiled gloves according to institutional policy and wash hands.
  • 82. 2.4 Medication Administration  A drug is a chemical substance intended for use in the diagnosis, treatment, cure, or prevention of a disease.  When a drug is given to a client, there is an intended specific effect.  An assumption made by nurses before administration of any medication is that the drug will be safe for the client to consume if the dose, frequency, and route are within the therapeutic range for that drug.
  • 83. DRUG NOMENCLATURE • The terms drug, medication, and medicine are often used interchangeably by health care providers and laypersons. • Drugs can be identified by their chemical, generic, official, or trade names. • The chemical name is a precise description of the drug’s composition (chemical formula). • The nonproprietary, or generic, is the name assigned by the manufacturer who first develops the drug.
  • 84. • When the drug is approved, it is given an official name that may be the same as the non proprietary name (Lehne, 1994). • When pharmaceutical companies market the drug, they assign a proprietary name, also called a trade, or brand, name; therefore, one generic drug may have several trade names based on the number of companies marketing the drug. • For example, ibuprofen is a generic name; common trade names for this drug are Advil, Excedrin IB, Motrin
  • 85. DRUG ACTION • Drug action refers to a drug’s ability to combine with a cellular drug receptor. Depending on the location of different cellular receptors affected by a given drug, a drug can have a local effect, systemic effect, or both. • For example, when diphenhydramine hydrochloride (Benadryl) cream is applied to the skin, it elicits only a local effect; however, when this drug is administered in a tablet or injectable form, it causes both systemic and local effects.
  • 86. Preparation and Route • Drugs are available in many forms for administration by a specific route such as ;- • Oral Solids( Tablets, Capsule, Powder and granules, Troches, lozenges and Enteric-coated) • Topical (Ointments) • Inhalants • Solutions (Suspensions, Syrups, Optic (eye) and otic (ear) solutions) • The route refers to how the drug is absorbed: oral, buccal, sublingual, rectal, parenteral (hypodermic routes), topical, and inhalation.
  • 87. 1. Oral Route • Most drugs are administered by the oral route because it is the safest, most convenient, and least expensive method. • When small amounts of drugs are required, the buccal (cheek) or sublingual route is used. • Drugs administered through these routes act quickly because of the oral mucosa’s thin epithelium and large vascular system, which allows the drug to quickly be absorbed by the blood.
  • 88. 2. Parenteral Route  parenteral means introduction of a medication by any route other than the oral- gastrointestinal route. • Sterile technique is always used for any medication injection. • The four routs that nurses commonly use to administer parenteral medications are: IV, IM, SC and ID
  • 89. • Intradermal (ID) is an injection into the dermis. • Subcutaneous (SC or SQ) is an injection into the subcutaneous tissue. • Intramuscular (IM) is an injection into the muscle. • Intravenous (IV) is an injection into a vein. 3. Topical Route • Most topical drugs are given to deliver a drug at, or immediately beneath, the point of application. Although a large number of topical drugs are applied to the skin, other topical drugs include eye, nose and throat, ear, rectal, and vaginal preparations.
  • 90. 4. Inhalants • Inhalants such as oxygen and most general anesthetics deliver gaseous or volatile substances that are almost immediately absorbed into the systemic circulation. • The inhalants are delivered into the alveoli of the lungs, which promote fast absorption.
  • 91. FACTORS INFLUENCING DRUG ACTION • Individual client characteristics such as  genetic factors age  height and weight physical and mental conditions can influence the action of drugs on the body.
  • 92. Guidelines for Medication Administration • To protect the client from medication errors, nurses have traditionally used as a guideline the “five rights” of drug administration. 1. Right drug 2. Right dose 3. Right client 4. Right route 5. Right time
  • 93. 1. Administering an Oral Medication(procedure) Equipment • Medication administration record (MAR) Medication cup, Medication cart or tray Medication properly labeled, Glass of water or juice Straw 1. Assess the client for potential problems (e.g., absence of a gag reflex). 2. Check the MAR against the health care praxis practitioner’swritten orders.
  • 94. 3. Check for drug allergies. 4. Wash your hands. 5. Prepare the medications for one client at a time:. Check for drug allergies. Wash your hands • Prepare the medications for one client at a time: Prepare liquids by placing the label side of the medicine bottle against the palm of your hand and pouring the liquid at eye level (Figure). • Liquids should be measured at fluid level at the surface or the meniscus not the edges. • Recheck medications prepared with MAR.
  • 95. • Check MAR to make sure all medications to be administered have been prepared.Place on the tray or medication cart. 6. Check client’s armband before administering the medications. 7. Identify the drug for the client and its therapeutic purpose. 8. Perform any assessment required before the administration (such as apical pulse rate befor administration of digoxin.) 9. Assist client to a sitting position.
  • 96. 10. Offer liquids before and during ingestion; encourage the patient to drink 5–6 oz of water. • If the client is unable to hold the medication cup, assist the client by using the medication cup to introduce the pills to the person’s mouth one at a time. • If a medication falls on the floor, discard the pill and start over.
  • 97. 11. Remain with the client until all medications have been swallowed. 12. Wash your hands. 13. Record the administered medications on the MAR. 14. Observe the client for side effects or adverse reactions.
  • 98. Fig. A. Check the client’s mouth to ensure that medications have been swallowed.
  • 99. 2. Administer Parenteral Drugs Equipment • Nurses use special equipment such as syringes(hub, barrel, or outside part and plunger ), needles, ampules, and vials when administering parenteral medications. • Angle of Injection The angle of insertion depends on the type of injection.
  • 100. Figure A. Angles of Insertion for Parenteral Injections.
  • 101. Intradermal Injection • Intradermal (ID) or intracutaneous injections are typically used to diagnose tuberculosis, identify allergens, and administer local anesthetics. • The drug’s dosage for an ID injection is usually contained in a small quantity of solution (0.01 to 0.1 ml).
  • 102. Figure B. Intradermal Injection Sites: A. Inner Aspect of the Forearm; B. Upper Chest; C. Upper Back
  • 103. Equipment • Medication administration record (MAR), Medication,Sterile tuberculin syringe and short bevel, 25 to Alcohol swab and sterile 2 × 2 gauze pad, 27 gauge, 3/8- to 1/2-inch needle, Disposable gloves Procedure 1. Check with the client and the chart for any known allergies. 2. Wash hands, and Follow the five rights. 4. Prepare the medication from an ampule or vial; refer to Procedure 29-2 or 29-3 as appropriate. Take the medication to the client’s room and place on a clean surface.
  • 104. 5. Check the client’s identification armband. 6. Explain the procedure to the client. 7. Place the client in a comfortable position; provide for privacy. 8. Wash hands and don nonsterile gloves. 9. Select and clean the site. • Assess the client’s skin for bruises, redness, or broken tissue. • Select an appropriate site using appropriate anatomic landmarks
  • 105. • Cleanse the site with an alcohol wipe using a firm circular motion; cleanse from inside to outside; allow alcohol to dry. 10. Prepare the syringe for injection. • Remove the needle guard. • Express any air bubbles from the syringe. • Check the amount of solution in the syringe. 11. Inject the medication. Hold the syringe in dominant hand. • With nondominant hand, grasp the client’s • dorsal forearm and gently pull the skin taut • on ventral forearm(Figure C).
  • 106. Figure C. Spread the skin taut for an intradermal injection.
  • 107. • Place the needle close to the skin, bevel side up. Insert the needle at a 10° to 15° angle until resistance is felt, and advance the needle approximately 3 mm below the skin surface; the needle’s tip should be visible under the skin. • Administer the medication slowly; observe the development of a bleb (large flaccid vesicle that resembles a mosquito bite). If none appears, withdraw the needle slightly. • Withdraw the needle.
  • 108. • Pat area gently with a dry 2 × 2 sterile gauze pad. • Do not massage the area after removing the needle. 12. Discard the needle and syringe in a sharps container. 13. Remove gloves, dispose of in appropriate receptacle, and wash hands. 14. Observe for signs of an allergic reaction. 15. Draw a circle around the perimeter of the bleb with a ball point pen. 16. Document medication and site of injection on the MAR.
  • 109. Subcutaneous Injection • Subcutaneous (SC or SQ) injections are commonly used in the administration of medications. • SC injections place the medication into the subcutaneous tissue, between the dermis and the muscle. • Clients who administer frequent subcutaneous injections should rotate sites regularly. • The amount of medication given varies but should not exceed 1.0 ml;
  • 110. Figure D. Subcutaneous Injection Sites: A. Abdomen; B. Lateral and Anterior Aspects of Upper Arm and Thigh; C. Scapular Area on Back; D. Upper Ventrodorsal Gluteal Area.
  • 111. Equipment • Medication administration record (MAR) 2 alcohol swabs, Sterile syringe and 5/8-inch needle Medication as prescribed, Disposable gloves 1. Check with client and the chart for any known Allergies, Wash your hands. 3. Follow the five rights. 4. Prepare the medication from an ampule or vial; refer to Procedure 29-2 or 29-3 as appropriate. Take medication to the client’s room and place on a clean surface.
  • 112. 5. Check the client’s identification armband. 6. Explain the procedure to the client. 7. Place the client in a comfortable position; provide for privacy. 8. Don nonsterile gloves. 9. Select and clean the site. • Assess the client’s skin for bruises, redness hard tissue, or broken skin. • Cleanse the site with an alcohol swab; cleanse from inside outward. 10. Prepare for the injection.
  • 113. • Remove the needle guard and express any air bubbles from the syringe; check the dosage in the syringe. • With dominant hand, hold the syringe like a dart between your thumb and forefingers. • Pinch the subcutaneous tissue between the thumb and forefinger with the nondominant hand. If the client has substantial subcutaneous tissue, spread the tissue taut. 11. Administer the injection. • Insert the needle quickly at a 45° or 90° angle
  • 114. • Release the subcutaneous tissue and grasp the barrel of the syringe with nondominant hand. • With dominant hand, aspirate by pulling back on the plunger gently, except when administering an anticoagulant injection. • If blood appears, remove needle and discard in a sharps container. • Inject medication slowly if there is no blood present. • Remove the needle quickly and lightly massage area with alcohol swab; do not massage the injection site after the administration of an anticoagulant.
  • 115. • Do not recap the needle; discard the needle in a sharps container. 12. Position client for comfort. 13. Remove gloves and wash hands. 14. Record on the MAR the route, site, and time of injection. 15. Observe the client for any side or adverse effects and assess the effectiveness of the medication at the appropriate time.
  • 116. Intramuscular Injection • Intramuscular (IM) injections are used to promote rapid drug absorption. COMMON INTRAMUSCULAR INJECTION SITES AND MUSCLES Site Muscle Dorsogluteal Gluteus maximus Ventrogluteal Gluteus medius Anterolateral aspect of thigh Vastus lateralis Upper arm Deltoid
  • 117. Equipment • Medication administration report (MAR) Medication as prescribed Sterile 3-ml syringe and long bevel, 20 to 22 gauge, Alcohol swab 1- to 2-inch needle (average-sized, adult client Nonsterile gloves receiving a drug in an aqueous solution), Sterile 2 × 2 gauze pad
  • 118. Procedure 1. Check with client and the chart for any known allergies, Wash hands. 2. Follow the five rights. 3. Prepare the medication from an ampule or vial; refer to Procedure 29-2 or 29-3 as appropriate. • Add 0.1 to 0.2 ml of air to the syringe. • Take medication to the client’s room and place on a clean surface. 4. Check the client’s identification armband. 5. Explain the procedure to the client; provide for privacy
  • 119. 6. Place the client in an appropriate position to expose the site. • Deltoid: sitting position. • Ventrogluteal: • Side-lying: flex the knee, pivot the leg forward from the hip about 20° so it can rest on the bed. • Supine: flex the knee on the injection side. • Prone: point toes inward toward each other to internally rotate the femur. 7. Don nonsterile gloves.
  • 120. 8. Select and clean the site. • Assess the client’s skin for redness, scarring, breaks in the skin, and palpate for lumps or nodules. • Select site using the anatomic landmarks. • Cleanse the area with an alcohol swab, cleanse from inside outward using friction; wait 30 seconds to allow to dry. 9. Prepare for the injection. • Remove the needle cap by pulling it straight off, and expel any air bubbles from the syringe.
  • 121. • Pull the skin down or to one side (Z-track technique) with nondominant hand. 10. Administer the injection. • Deltoid: quickly insert the needle with a dartlike motion at a 90° angle (Figure D). • Ventrogluteal: quickly insert the needle using a dartlike motion and steady pressure at a 90° angle to the iliac crest in the middle of the V (Figure D). • Aspirate by pulling back on the plunger, and observe for blood. • If blood appears, remove the needle and discard.
  • 122. • If blood does not appear, inject the medication slowly, about 10 sec/ml. • Wait 10 seconds after the medication has been injected, then smoothly withdraw the needle at the same angle of insertion. • Apply gentle pressure at the site with a dry, sterile 2 × 2 gauze; do not massage the injection site. Swab using gentle pressure. • Discard the needle and syringe in a sharps container; do not recap the needle.
  • 123. 11. Position client for comfort; encourage client receiving ventrogluteal injections to perform leg exercises (flexion and extension). 12. Remove gloves, wash hands. 13. Record on the MAR the dosage, route, site, and time. 14. Inspect the injection site within 2 to 4 hours and evaluate the client’s response to the medication.
  • 124. Figure D. Administering Intramuscular Injection into the Deltoid Muscle E. Grasp and pull the muscle laterally before injecting medication
  • 125. Intravenous Injections • The intravenous (IV) route is used when a rapid drug effect is desired or when the medication is irritating to tissue. Equipment • Medication administration record (MAR) Secondary administration set Prepared and labeled medication 50-ml solution Needle-less locking cannula • bag from pharmacy • Alcohol swab
  • 126. Procedure 1. Gather prepared equipment (medication labeled with the client’s name, and time tape for fluids to infuse per hour). 2. Wash hands. 3. Check the client’s armband. 4. Explain the procedure to the client. 5. Assess the puncture site. • Observe for redness and puffiness. • Palpate for tenderness. 6. Check patency of infusion site.
  • 127. • Observe fluid infusing. • Remove IV container from the pole and lower the container below the level of infusion site. • Observe for backflow of blood into the hub of the venous access device. • Replace container on IV pole. 7. Secure medication bag prepared and labeled by pharmacy and check health care practitioner’s prescription and the MAR. 8. Check the client’s chart for allergies, and check the drug compatibility chart. 9. Hang the secondary bag on IV pole.
  • 128. 10. Add the administration set to the secondary bag and prime the tubing. 11. Affix a needle-less locking cannula to the end of tubing (Figure F). 12. Cleanse needle-less Y–site injection port of primary IV tubing closest to infusion site with an alcohol swab; allow to dry. 13. Insert needle-less locking cannula of secondary bag set into Y–site injection port of primary set and secure in place with tape (Figure 29-29B). 14. Affix the extension hook to the primary bag on the IV pole so that the primary bag hangs below the level of the secondary bag.
  • 129. 15. Open clamp of secondary tubing and adjust drip rate to desired infusion rate. • Slowly close the regular clamp while observing the drip chamber until the fluid is dripping at a slow, steady pace (Figure 29-29C). • Count the drops for a 15-second interval and multiply by 4 (e.g., if the drop factor of
  • 130. Figure E. Administering Medications by IV Piggyback. Connect a needle-free locking cannula to a secondary infusion line. Figure F. Monitor the infusion rate.
  • 131. Types of Syringe Types of Syringes. A. Hypodermic B. Standard U-100 Insulin. C. 1-ml Tuberculin D. Disposable Plastic
  • 132. Length of syringe Various Lengths and Gauges of Needles. Gauge from left to right: 18, 20, 22, 25.
  • 133. 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. Total fluid volume × drop factor = drops/min Total time (minutes)
  • 134. • For example, if 1000 ml is to infuse over 8 hours with a tubing drop factor of 10 drops per milliliter: 1000 ml × 10 drops/ml =10,000 drops = 20.8 or 21 8(60) min 480 min  21 drops/min
  • 135. 3. Administer Topical Medications • Topical medications may be administered to the skin, eyes, ears, nose, throat, rectum, and vagina. • The medication generally provides a local effect but can also cause systemic effects. • Drugs directly applied to the skin to produce a local effect include lotions, pastes, ointments, • creams, powders, and aerosol sprays. The rate • and degree of the drug’s absorption are determined by the vascularity of the area.
  • 137. 1. Self care and hygiene Giving bed bath • A bed bath is a cleaning sponge bath given to a patient in bed patients. Types of bed bath • There is two type of bed bath Complete bed bath and partial bath:- – Complete bed bath -Partial bath
  • 138. 1. Complete bed bath: - Taking a bath of whole body. 2. Partial bath: - The face, arms, hands and back are washed; a complete daily bath is not advisable for all pts. Elderly pts have a decrease in production of perspiration and natural oils w/c keeps the skin moist as a result, these pts. Need not wash as frequently. • Purpose – To cleanse the body – To prevent multiplication of bacteria on the skin – To stimulate circulation – To improve general muscle tone
  • 139. – Give a good opportunity to observe his condition & establish friendly communication with him. . – Teach the patients the essentials of health – To keep the skin surface dry, thus helping to prevent bed sores. Precaution and contra indication • Change the water frequently whenever it is dirty/cold • Do not go to opposite side of bed during bath, as all work can be done from one side
  • 140. • Put up screen to protect the pt’s privacy • Close the door and the window to prevent draft • Report to ward supervisor any undesirable symptoms, such as rash, swelling, pressure sores or discoloration. Equipment • Two wash clothes, Two bath towels, Two linen cloths, One draw sheet & rubber sheet if necessary, Two basins & jug with water, Soap with soap dish, Pyjamas as night clothes, Comb, Back care tray, Mouth care tray & Scissors for nail care
  • 141. • Screen, Bed pan or urinal, Toilet paper and Waste receiver Procedure for complete bed bath -Wash hands& collect the equipment -Greet the patient & explain the procedure -Bring the necessary articles to the bed side. -Close the door & window -Screen the unit -Offer bed pan or urinal empty & clean before preceding with bath, wash hands. -Loosen top bed covers at sides & foot
  • 142. -Remove bed spread & blanket & place them on a chair. Leaving the top sheet to cover the patient & remove gown or pyjama. -Prepare the water & check the temperature of the water the back of your hand, water at temp. of 105- 115*F(41-46*C) -Place towel under the chin, wash face, eyes, ears& neck. -Ask the patient if he likes to have his face washed with soap or with out soap. -First wash eyes from inner to outer corners, then the for head, down the face to the neck, then rinse& dry well.
  • 143. -Place the towel under the arm further away from the nurse. -Place your hand under the arm to give support. -Soap the wash towel, wash & rinse the arm & hand, repeat the other arm. -Cover the chest with both towel & turn blanket down to abdomen, put the towel under the patient, wash, rinse& dry well. -Re cover the chest -Re covers the abdomen, protect the matters wash rinse& dry the abdomen. -Observe the patient & communicate during the bath.
  • 144. -Uncover far leg & drape with bath blanket arranging bath towel under the foot. Flex knee, wash leg, rinse& dry well. -Repeat the same with near leg. -Change water now & whenever it is dirty or becomes cold -Turn patient on side, with back to wards you. Wash back & dry well. Rub the back with oil. Observe condition of skin, especially over pressure points. -Put towel under the hip & give him the wash towel if he is able to wash the genitalia area.
  • 145. -if the patient is unconscious or un able complete the bath by the nurse. -Put on a clean gown on the patient & comb patient’s hair while protecting the pillow with a towel. -Cut & clean nails of the fingers & toes. -Prepare occupied bed & re move the screen. -Take care of the used equipment & re turn to its proper place, leave everything tidy open the window & door. -Wash hands & report on chart any finding.
  • 146. Giving tub bath- This type of bath is given to an ambulatory pt. • The nurse should assist the pt. into and out of the tub. Anyone can fall during this procedure. The pt. may become tired or dizzy, and slip causing injury. Some pts require the nurse’s help through out the bath • Special precautions must be taken to avoid having the pt. slip in the shower or tub • The nurse should place a nonskid bath mat in the tub or shower
  • 147. • Even though pts seem strong and alert they should be checked at least every five minutes • Showers and tub baths do not need to last more than ten minutes • Pt who are taking a shower or bath after prolonged bed rest, need to be watched care fully for dizziness. These pt may also tire easily
  • 148. Assisting with a shower A pt. must show no signs of weakness before a shower is permitted. The doctor will indicate when the pt. is ready for this activity however; the nurse should also use judgment to decide whether a pt is able to shower. The pt’s condition may vary throughout the day. A pt. may have medical permission, how ever, signs of weakness, dizziness, or fatigue may require postponement of the shower, and safety precautions explained at the beginning of the unit should be reviewed. Observing safety rules in the shower helps prevent injuries.
  • 149. Purpose – To arrange the pt. during admission – To refresh and relaxed the admitted pt. precautions and contraindications • Have water at correct temperature • Avoid chilling the pt. • Do not leave pt alone in bathroom • Always keep bathroom door unlocked • Check pt. frequently for signs of exhaustion • Do not allow the pt. to remain in the shower longer than ten minutes
  • 150. Equipment • Soap with soap dish • Wash cloth • Bath towel and face towel • Gown or pajama • Slipper • Chair • Bath blanket if it is needed • Bath mat – to avoided slipping of pt. • Bath powder or lotion • Bath thermometer
  • 151. Procedure • Explain procedure to the pt. • Assemble equipment and take to the bathroom, Close windows • Help pt to undress, Help pt to bath himself or her self assisting as necessary • Assist pt. out of tub or shower vary and put a gown on the pt, Clean the tub or shower and leave room in order • Return pt. to room and put to bed • Do not allow the pt. to remain in the shower longer than ten minutes
  • 152. Giving back car • Back care is often called aback rub or a massage of the back. Purpose- - To refresh patient & relieve fatigue. • To improve circulation to this area, thus aiding in the prevention of pressure sores. • Gives a good opportunity to turn the patient • To observe the condition of the patient.
  • 153. precaution/observations to be made during back care • All bed pts receive back care in the morning and in the after noon and Evening: • The duration of a massage ranges from 5-20 minutes • Remember the location of bony prominence to avoid direct pressure over this areas • If the pt’s skin is dry, use of powder may not be advisable • Nurses should be sure their fingernails are short enough so as not to scratch the pt.
  • 154. Equipment- • Wash hands assemble equipment • Two basins with warm water • Soap with soap dish • Two wash towel • Two towels • Body powder • Lotion or alcohol • Air ring or cotton ring as needed • Pillow • Screen
  • 155. Procedure • Greet patient & explain procedure., Screen the bed • Arrange the patients gown so that the back is exposed • Assist the patient into a prone position • Place towel under patient side • Wash the back with soap & water& dry with towel • Apply lotion to your own hands & rub it between the hands until it is warm • Give special attention to bony prominence • Use firm & long strokes up ward & down ward.
  • 156. • Repeat up ward & down ward stroke several times but use a circular motion with the palm on the down ward. Continue rubbing in this manner for three to five minutes. • Wipe away excess lotion & apply powder to the patients back. • Dress the patient & assist in to comfortable position. • Turn patients on back & apply air ring or cotton ring as necessary. • If there is breakage of the skin sterile dressing should be applied., Clean & store the equipment. • Wash your hand., Report any abnormality finding.
  • 157. Special points to remember • All bed patients should have back care once a day • All incontinent patients should have their back care each time the linen is changed • Any patient who lies in one position or cannot move freely should have back care at least 2 times a day or more Care of pressure sore (decubitus) • Pressure sore-It a break down of the skin & death of the tissue in certain areas as a result of pressure which interfere with the blood circulation of the area. • Pressure sores-commonly develops on bony prominence area such as hell, elbow, sacral region hips & shoulder
  • 158. Predisposing causes of bed sores • Chronic illness • Obesity • Poor circulation • In frequent change of position • In continence • Prolonged pressure on the area Sings of bed sore • Redness, Blister • Breakage of the skin & Necrosis (death of tissue
  • 159. Prevention of bed sore • change patients position frequently or every two hours • keep bed free from wrinkle & crumbs • keep bed dry • use air ring, cotton rings & air mattress to relive pressure • keep patients skin clean & dry • give back care frequently, giving special attention to reddened area •
  • 160. Giving mouth care for helpless patient Proper care of the mouth & teeth is always necessary but it be comes particularly important when a person is sick. Purpose • To clean the teeth gum • To stimulate appetite • To avoid bad smell • To prevent tooth decay • To prevent infection from spreading to the throat & ears
  • 161. • Equipment and using solution • Glass of fresh water • Mouth washing solution like- • -Hydrogen per oxide • - Juice-two tea spoons to cup of water • - Water-1/2 tea spoons of salt in glass of water. • Kidney dish, Tongue depressor, Tooth brush or a applicators, Towels, Lubricants, to lubricate the lips, Cotton applicators, Gauze & cotton
  • 162. Procedure • Wash hands & collect equipment • Explain the procedure to the patient • Have all equipment ready on the bed side table or trolley • Place towel under patients chin across his chest • Turn patients head to the side & arrange basin at corner mouth
  • 163. • Dip applicator or tooth brush in mouth wash solution, & carefully & gently go over the inside of the mouth, the tongue & tooth by discarding or changing the swab. • Do repeat the procedure until the mouth become clean • Allow the patient to rinse the mouth wash solution after use • Allow him to rinse his mouth with clean water • Apply lubricant on the lips of the patient •
  • 164. • Give the patient a tissue paper to clean the mouth & chin • Remove the towel • Rinse the tooth brush with water • Take care of equipment • Wash hands after procedure • Chart time & any finding Patients who need special care of the mouth • Patient with gum bleeding • Children, A patient with fever, Unconscious patients • Post operative patients, Any patients they can not care for than selves.
  • 165. Making patient bed General Principles of bed making – Put covers orderly – After handing a patient, linen and other equipments washing hands to the hands and uniform. – While handling a soiled linen should for a way from uniform – Never put patient’s bed covers on another patient’s bed. – Shaking a soiled linen in the word and forbidden, because various types of micro organisms can spread to other site.
  • 166. – When stripping and making a bed, time and energy by stripping and making up one side as completely as possible before working on the other side. – To avoid unnecessary trips to the linen supply area, gather all needed linen before starting to strip bed. – The palm of the hand should face down while tucking bed linen under the mattress, to protect the nail.
  • 167. Stripping of a bed Definition: removing the bed linen from a bed which has been previously made – up. Purpose -To air the bed and bedding and prepare the bed for remaking -To prepare the bed for different patients, who different problems. Equipment • Made up close bed & bed side chair
  • 168. Procedure:- • Place chair conveniently at the foot of the bed • Place the pillow on seat of chair • Loosen the bedding all around ,starting from the right ( do not tear sheets on springs ) • Fold bedspread twice ,bring top to bottom ,pickup from the center • Fold the blanket and top sheet ,in similar manner • Place solid bedding on the chair ,and placed that which is to be used again ,over back of chair • Fold the draw sheet in two and place on the chair • Remove and fold the bottom sheet in same manner • Turn mattress from top to bottom or from side to side
  • 169. Precautions:- • No bedding ,either clean or solid ,should over be put on the floor • Do not let your uniform touch the bedding
  • 170. Order of bed making – Mattress cover – Bottom sheet – Rubber sheet – Cotton (cloth ) draw sheet – Top sheet – Blanket – Pillow case – Bed spread
  • 171. 1. Making Open bed Definition:- Open bed is one which is made for an ambulatory patient are made in the same way but the top covers of an open bed are folded back to make it easier for a client to gain it Purpose:--To provide comfort and cleanliness for a patient Required equipments • Two large sheets, Rubber draw sheet • Blanket ,Pillow cases • Bed spread
  • 172. Procedure • wash hands and collect necessary materials • Place and materials to be used on the chair .Turn mattress and arrange evenly on the bed • Place bottom sheet with correct side up, center of sheet on center of bed and then at the head of the bed • Tuck sheet under matters at the head of bed and miter the corner • Remain on one side of bed until you have completed making the bed on that side • Tuck on the sides & foot of bed, mitering the corners
  • 173. • Tuck sheets smoothly under the matters, there should be no wrinkles • Place rubbers draw at the center of the bed & tuck smoothly & tightly • Place cotton draw sheet on top of rubber draw sheet & tuck. The rubber draw sheet should be covered completely. • Place to sheet with wrong side up, center fold of sheet on center of bed wide hem at hex of box • Tuck sheet of foot of bed meting the corner • Place blanket with center of blanket on center of bed tuck at the foot of beds and miter the corner • Folds top sheet over blanket • Place bed spread with right sides up and tuck it
  • 174. • Miter the corners at the foot of the bed • Go to other side of bed and tuck in bottom sheet, draw sheet, mitering corners and smoothing out all wrinkles, put pillow case on pillow and place under the matters • See that bed is neat and smooth • Leave bed in place and furniture in order • Wash hands
  • 175. tuck the sheet under the mattress
  • 176. 2. Making closed bed Definition:-Is a type of bed which is prepared for newly coming pt Purpose • To provide a clean comfortable bed a new pt • To keep bed for the new pt • To give the bed a good appearance Required equipments: Pillow (with plastic cover, if necessary), Pillow case, Blanket cover or bed sheets or bed cover, Blankets, Two large sheets, Rubber draw sheet,(mackintosh) one Draw sheet, one Mattress cover, if necessary
  • 177. Procedure • Wash hands & arrange the necessary material in the order in which it is to be used on the strait chair, in a convenient position near the foot of the bed • Turn mattress from top to bottom or from side to the facing up & arrange evenly on the bed • Place the bottom sheet with right side of the facing up & wide hem at top • Turn the sheet well under head of the mattress making mitered corner & tuck in a long the side & foot of bed making mitered corner • Remain on one side of bed until you completed making the bed on the side • Place rubber draw sheet across the approximate center of the bed & tuck tightly
  • 178. • Place cotton draw sheet on top of rubber draw sheet & tuck • The rubber draw sheet should be covered completely • Place top sheet with wrong side up , center fold of sheet on center of bed • Tuck sheet at foot of bed, mitering the corner • Place blanket with center of blanket on center of bed, tuck at the foot of the , & miter the corner • Fold top sheet over blanket • Place bed spread with right side up & tuck it • Mitering corners at the foot of the bed
  • 179. • Go the other side of bed & tuck in bottom sheet, draw sheet; mitering corners & smoothing out all wrinkles, put pillow case on pillow & place on bed • See that bed neat & smooth • Leave bed on place & furniture in order
  • 180. 3. Making an occupied bed Definition:-Is a bed prepared for a week pt that is unable to get out of bed Purpose • To make a smooth & comfortable bed with the least distribution of pt in it. • To provide comfort cleanliness & to facilitate position of the pt • Which is used by bed ridden pt
  • 181. Required equipments • Two large sheets, Draw sheet, Pillow case • Pyjama or gown, as needed, Hamper & Glove • Precautions in handling the patient • If pressure areas need to be treated, do it before removing the draw sheet. • Obtain extra assistance in two nurses can not manage the patient alone to keep the pt, from falling down. • Remove any crumbs from the bottom end of the sheet, and tuck it in securely. • Never turn has a helpless patient, away from you as this may cause had him/her too fallen out bed.
  • 182. Procedure…… Fan-fold the bottom linens close to the client toward the center of the bed.
  • 183.
  • 184. Procedure • If bath is not given this time, the back of the helpless pt should be washed & back care given • Arrange linen on the chair in the manner in which it is going to be used • Explain the procedure to the pt • Screen pt, if necessary • Make sure ,the windows and doors are closed • Lower head of the bed if in Fowlers position • Loosen top bedding • Remove bed spread and blanket ,fold and place over the chair • Lift patient’s head and remove all pillows except one • Loosen the bottom bedding
  • 185. • Move pillow to one side .Turn patient on side away from you • Never turn a helpless or unconscious patient away from you as this may cause him to fall out of bed • Have patient flax knees ,or assist patient to do so .With one hand over patient to wards you, get another nurse to help if necessary • Roll or fanfold the draw sheet against the patient’s back • Roll the rubber sheet and fold it back loosely over patient • Roll bottom sheet as far under patients back as possible • Sometime the top sheet with right side up , center of sheet on center of bed wide hem under the mattress at head of bed and making mitered corner
  • 186. • Place rubber draw sheet in the center of the bed and tuck smoothly and tightly • Place draw sheet on top of rubber sheet and tuck rubber sheet should be covered completely • Turn patient on his side to wards you ,on to the clean sheet • Now go to the other side of the bed if alone ,pull out soiled linen which has been folded under the patient • Place solid linen on the chair .Never throw it on the floor • Pull and tighten bottom sheet and tuck in at top making a square corner. Then tuck in smoothly a long the side and foot of bed making mitered corner • Pull and tighten draw sheet and tuck in well • Place clean top sheet on the patient with large hem at the head with long side of the hem up over the dirty top sheet and ask the patient to hold the •
  • 187. 4. Making on anesthetic bed Definition:-A bed especially prepared to receive apt, after surgery and major recovery from anesthesia. Purpose • To protect the pt , from becoming chilled. • To protect the mattress and bedding from bleeding, vomiting drainage or discharge. • To arrange bedding so that a pt .can be moved it from a stretcher
  • 188. Required equipments • Linen and other materials for closed bed, add woolen blanket and large sheet • Suction machine • Iv stand • Blood pressure apparatus • Vital sign sheet for pulse and temperature, B/P report watch • Hot water bottles with cover
  • 189. Procedure • Make the foundation of the bed as usual with large sheet Continue with reminder of bed us usual but do not miter bottom corners of top bedding • Fun folds upper bedding to one side, opposite the stretcher. • In cold season place hot bottle in middle of the bed and cover with fan fold top bedding • Place emesis basin on bed side table • Place I.V stands on bed side table NOTE :-Never leave a hot water battle in the bed after a patient placed in bed ,un less specifically ordered by the doctor.
  • 190. 5. Making Cardiac bed It is a bed prepared for a patient who has heart ds. Purpose:-To believe Dyspnea • To provide comfort • To prevent complication Required equipments • Ordinary bed equipment • Cardiac table • Extra pillows – two for back • Back – rest (if not fowler’s bed) • Foot – rest board • Air – ring
  • 191. Precaution on the degree of angle of bed and taking vital sign • A patient should be in an upright sitting position (45 up to 60 degree) to ease difficulty in breathing. Although, an upright sitting position is preferable, some times a patient may develop carcinogenic shock-so, by following vital sign change to shock position and as needed
  • 192. Procedure • Make an ordinary bed with foot – rest at the foot of the bed • Place back – rest at patients back, making if comfortable with pillows .Adjust accordingly to the need of the patient. • Place cardiac table in front of the patient with pillow ,it so that he may lean for ward to rest his head and arms only • Leave your patient comfortable in bed. • Discard soiled linen in the proper place.
  • 193. 6. Making an amputation bed It is amputation bed and Amputation. - Special type of bed which is prepared for amputation patent. -Amputation is – the removal of a limb .part of a limb, or any other portion of the body. Purpose:- to allow the nurse to do repeated procedures To allow the nurse to make frequent observation i.e. after amputation of the leg with out disturbing the patient.
  • 194. Equipments • Ordinary bed equipment • A set of top bedding • Blanket and bed covers • Bath blankets • Pillow and plastic covers • Sand bags if amputation bed is too made.
  • 195. Procedure Make the foundation of the bed as usual • Spread both blankets next to the patient’s body. • Make bottom half of the bed Fold sheet cross wise art the center of the bed at bottom tuck and make corner .To make upper half of the bed. • Fold a sheet in half wise right hem side up. Allow 15cm at top to fold back over the bedding .The two halves should over lap about 7.25cm • Place blanket keep 22.5cm from the top of the mattress & fold the top sheet down over it • Do like wise with the bed spread • Remove the bath blanket placed next to the pt fold it & put it in its proper place
  • 196. 7. Making fracture bed It is a bed which is prepared for orthopedic pt common (spine, pelvis, leg) Purpose • To provide comfort for pt • To support affected part of a body • To facilitate healing pros • To prevent fracture complication Equipment – same as for a simple occupied bed, • Fracture broad • Fracture bed • Sand bag with cover • Bed cradle
  • 197. Precaution - If the injured area is bleeding place a small plastic sheet and a folded draw sheet under it, as these are easier to change than the bed sheets. -Should position a patient, depending on type and site of fracture. - If the patient is dirty or blood-stained, the additional requirements for an emergency admission- bed are also needed.
  • 198. Procedure • Place the fracture broad directly over the bed springs or under the mattress • Place a thin mattress or pad over the fracture broad. Remove inner spring mattress • Procedure to make this bed is same as for an ordinary occupied bed. • The small rubber and draw sheet are easier to change than the whole bed. This applies especially to an arm or a leg, which is bleeding or has discharge. • Fold back the bed cloths at foot of the bed for leg fracture cover the uninjured site with a small blanket place the cradle over the linen to adjust easy observation
  • 199. Giving perennial care Perineum- The tissue between the anus & external genitalia. Purposes • cleans & avoid bad smell • To relive pain & inflammation • As preoperative procedure • As post operative procedure( e.g., episiotomy)
  • 200. Indication • All maternity pts. After delivery or C/S for one week or as long as necessary • All abortion cases • Post operatives and all vaginal operation cases • Any bed pts. With vaginal bleeding or purulent discharge • After using a bed pan
  • 201. For female • Remove dressing or pad used • Inspect the perinea area for inflammation, excoriation, swelling or any discharge Female perineum • Is made up of the vulva (external genitalia) including the monspubis, prepuce, clitoris, urethral and vaginal or if ices, and labia major and minora • The skin of the vaginal odor due to the cells and normal vaginal florae • The clitoris consists and erectile tissues and many
  • 202. Precautions and contradiction • To avoid carrying infection up to genital area from anal site, should wipe • from up to down & using each swab once only is important . • Wear a glove while giving care to protect your self & patient Equipment • Sterile forceps or glove, Sterile cotton balls (swabs or gauze), Sterile pads, Anti septic solution such as zephiran chloride 1: 1000 Warm water, Rubber sheet & cover,Bed pan, Screen, Kidney basin
  • 203. Procedure • Wash hands • Prepare trolley with the above equipment • Explain the procedure & take the equipment to the patients room & Screen bed & close the door & windows. Help patients to use bed pan • Remove the soiled pad, place in bowel or kidney basin • Fan fold top covers to the chest of the patient • Flex patient knees & cover with top sheet • Clean perineum with cotton swab dipped in solution using down ward strokes by using gloves or forceps • Use only one cotton swab for each stroke • Discard used cotton swabs • Repeat cleaning by pouring the anti septic solution over the genitalia
  • 204. • Avoid hurting the patient with the forceps • Be care full with episiotomy stitches • Dry perineum & genitalia using cotton swabs • Remove bed pan • Turn patient one side & dry anal area • Put perennial pad in place • Straighten the bed & leave the patient comfortable • Clean equipment & return it to its proper • Chart time & any observation • wash hands
  • 205. Body mechanics and mobility Introduction to mechanics Body mechanics -Is the coordinated effort, and safe use of the body to produce motion and maintain balance during activities. • A person maintains balance as long as the line of gravity passes through the center of the body and the base of support. • Line of gravity, base of support and center of gravity are important components of body balance, an important element of body mechanics are :-
  • 206. * Line of gravity: is an imaginary vertical line drown through an objects. • Center of gravity: - is the point at which all of the mass of an object is centered * Base of support: - is the foundation on which an object rests
  • 207. Purpose:- Proper body mechanics is achieved through coordinated movement, maintaining body balance and body alignment. • promotes body musculoskeletal functioning • reduces the energy required to move and maintain balance • Reduces fatigue and decreases the risk of injury • Facilitates safe and efficient use of appropriate groups of muscles N.B. Standing position posture is unstable because of • Narrow base of support • High center of gravity • Consistently shifting line of gravity
  • 208. Positioning a patient - Place a pt, in comfortable position, according to procedure Purpose – Used for examination of rectum or vaginal, during diagnosis – For treatment , e.x- for bedridden pt. who has bed sore
  • 209. Types of positioning There are different positions used for different proposes • Supine – The pt lies flat on the back with the head supported by pillows • Prone position – The patient is turned or lies face down; there is no pillow under the head, but there is a small pillow to support the abdomen • Fowler’s position – The pt is almost in a sitting position to facilitate easy breathing and to drain fluid from the abdominal cavity • Semi fowler’s position – The pt sitting and half lying with several pillows placed behind the pt.
  • 210. • Shock position – Used when a pt has gone in to shock. The foot of the bed must be higher than the head of the bed • Lithotomy position – The pt lies on his or her back with the legs flexed and spread apart. It is used in vaginal and rectal examinations and catheterization, and delivery • Left lateral position – The pt lies on his or her left side, with the lower leg extended and the upper leg flexed. This position is used during an enema • Knee-chest position – (egnupectoral position) the pt rest on the chest and knees. The knees are slightly separated with the thighs perpendicular or at aright angle with bed. The face turned to one side and may rest on the forearms.
  • 211. • Trendelenburg position – The pt lies flat on the back with Hips and knees elevated the portion of his legs below the knee rests on an inclined plane slanting down ward, shoulder supports is used to prevent the pt. from slipping • Dorsal Elevated position – This position is the same as the dorsal recumbent position except that extra pillows are placed under the head and shoulders to further relax the abdominal muscles
  • 212. • Semi Recumbent :Position in w/c pt’s head and shoulders are raised by placing pillows under the head shoulders of the pt, • Sim’s position (3/4th prone position) – Dorsal Recumbent : Pt. lies on back, knee flexed and separated • Erect position- one having occipit and heals in line with nose, and great toes in the same line.
  • 213. Helping a patient with crutch walk Definition:- • Crutches are a form of medical device that are generally used by individuals who can't walk properly or have extreme difficulty and pain while walking. • Crutches are artificial supports and assists patients who need aid in walking because of disease, injury, or a birth defect.
  • 214. Purpose: • reducing the weight load on one of the legs of the person, • helping in broadening the support base that helps in maintaining a stable and upright position. • Crutches are of great use to people who have foot or leg pain, have weak muscles or an unstable gait, helping them in walking without difficulty.
  • 215. • To assist client who cannot bear any weight on one leg. • Prevent injury to client who has difficulty in ambulation. Types of Crutches Many forms of crutches are used worldwide. Some of the most common types include 1. Axillary or Underarm Crutches 2. Forearm Crutches
  • 216. Axillary or Underarm Crutches • Axillary crutches are generally made up of wood or aluminum. • they can be easily adjusted according to the height of the person using them. • These crutches are generally used by people who suffer from temporary disabilities or injuries. • Axillary crutches generally have padding just beneath the armpits, helping the individual to hold them easily and tightly without difficulty.
  • 217. Forearm Crutches • Forearm crutches are the most common form of crutches used by individuals suffering from permanent disabilities. • designed in a way that the person using them can slip his arm into the cuff and thus hold and grip tightly.
  • 218. Walking with Crutches - There are four kinds of walking with crutches:- • Four-Point Crutch Gait: • Three-Point Crutch Gait: • Two-Point Crutch Gait • Swing-Through Crutch Gait
  • 219. 1. Four-Point Crutch Gait: • Indication: Weakness in both legs or poor coordination. • Pattern Sequence: Left crutch, right foot, right crutch, left foot. Then repeat. • Advantages: Provides excellent stability as there are always three points in contact with the ground • Disadvantages: Slow walking speed
  • 220. Four-Point Gait. A. Moving Right Crutch Forward and Left Foot Forward; and B. Moving Left Crutch Forward and Right Foot Forward, Even with Right Crutch
  • 221. 2. Three-Point Crutch Gait: • Indication: Inability to bear weight on one leg. (fractures, pain, amputations) • Pattern Sequence: First move both crutches and the weaker lower limb forward. Then bear all your weight down through the crutches, and move the stronger or unaffected lower limb forward. Repeat. • Advantages: Eliminates all weight bearing on the affected leg. • Disadvantages: Good balance is required.
  • 222. 3. Two-Point Crutch Gait: • Indication: Weakness in both legs or poor coordination. • Pattern Sequence: Left crutch and right foot together, then the right crutch and left foot together. Repeat. • Advantages: Faster than the four point date. • Disadvantages: Can be difficult to learn the pattern.
  • 223. 4. Swing-Through Crutch Gait: • Indications: Inability to fully bear weight on both legs. (fractures, pain, amputations) • Pattern Sequence: Advance both crutches forward then, while bearing all weight down through both crutches, swing both legs forward at the same time past the crutches. • Advantage: Fastest gait pattern of all six. • Disadvantage: Energy consuming and requires good upper extremity strength.
  • 226. Procedure 1. Inform the client you will be teaching crutch ambulation. Rationale: Reduces anxiety. Helps increase comprehension and cooperation, promotes client independence. 2. Assess the client for strength, mobility, visual acuity, perceptual difficulties and balance. Note: nurse and therapist often collaborate on this assessment. Rationale: Helps determine the clients capabilities and amount of assistance required. 3. Adjust crutches to fit the client. With the client supine, measure from the heel to the axilla. With the client standing, set the crutch position at a 4-5 inches lateral to the client and 4-6 inches in front of the client. The crutch pad should fit 1.5 – inches below the axilla (3 finger width). The hand grip should be adjusted to allow for the client to have elbows bent at 30 degree flexion.
  • 227. Rationale: Provide broad base of support for the client. Space between the crutch pad and axilla prevents pressure on radial nerves. The elbow flexion allows for space between the crutch pad and axilla. 4. Lower the height of the bed. Rationale: Allows the client to sit with feet on the floor for stability. 5. Assess for vertigo. Rationale: Allows for stabilization of blood pressure, thus preventing orthostatic hypotension. 6. Instruct the client to position crutches lateral to and forward to feet. Demonstrate correct positioning. Rationale: Increases client comprehension and cooperation.
  • 228. 7. Apply the gait belt around the client’s waist if needed. Rationale: Provides support, promotes client safety. 8. Assist the client to a standing position with crutches. Rationale: Standing for a few minutes will assist in preventing orthostatic hypotension. Four-Point Gait 9. a. Position crutches to the side and in front of each foot. b. Move the right crutch forward 4 to 6 inches. c. Move the left foot forward, even with the left crutch. d. Move the left crutch forward 4 to 6 inches. e. Move the right foot forward, even with the left crutch. f. Repeat the four-point gait. Rationale: The four point gait provides greater stability. Weight bearing is on three points at all times. The client must be able to bear weight with both legs.
  • 229. Three-Point Gait 10. a. Advance both crutches and the weaker leg forward together. b. Move the stronger leg forward, even with crutches. c. Repeat three-point gait. Rationale: The three point gait provides a strong base of support. This gait can be used if the client has a weak or non-weight- bearing leg. Two-Point Gait 11. a. Move left crutch and right leg forward 4 – 6 inches. b. Move right crutch and left leg forward 4 – 6 inches. c. Repeat two-point gait. Rationale: The two pint gait provides a strong base of support. The client must be able to bear on both legs. This gait is faster than four-point gait..
  • 230. 12. Set realistic goals. Rationale: Crutch walking takes up to 10 times the energy required for unassisted ambulation. 13. Consult with a physical therapist. Rationale: The physical therapist is the expert on the health care team for crutch-walking techniques. 14. Wash hands. Rationale: Reduces the transmission of microorganisms.
  • 231.
  • 232. Patient Transfer Lifting a patient in bed Patient lifting and moving - moving and lifting of a patient is an integral part of nursing care in which relation to moving & lifting patient in health care setting and has been for a high risk of back injury to nurses, when the body alignment of the nurse is improper way.
  • 233. • Principle of patient lifting – Always try to find a lifting partner – Choose suitable lifting method that partner agrees with. – Explain to the patient why lifting is necessary and how he/she can assist. – Wait for signal from the leading lifter so the lifters can move together. – When lifting is completed, make sure patient is comfortable – To minimize the risk of back injury, lift by bending the knees and using the tight muscles. – Remove all obstacles form the sit.
  • 234. Purpose • To assist patient who is unable to move him self. • To prevent fatigue and injury • To maintain good body alignment • To stimulate circulation Precautions – Lifting a patient up in bed (help less patient Equipment According to procedure being performed
  • 235. Procedure • Explain procedure to the patient • Remove all pillows, air rings etc. • lower the head of the bed and fold back • bedding from the side that it will not interfere with lifting • flex the patient’s knees • lifter “A” slips one arm under the patients head and shoulder and one arm under patient ‘s back • lifter “B” slips one arm below lifter “A” and one arm under things • lifter “A” gives directions to lift and both lift at the same time • the patient may slip his arms around the lifters shoulder
  • 236. Assisting a patient up in Bed • Explain procedure to the patient • Remove all pillows, air rings, etc • Have patient flex his knees • Patient puts one hand on one of the lifter’s shoulders • Lifter puts one arm under patients shoulder & one under tights • Have patient lift himself & push with his heels • As you lift the patient to word the head of the bed, swing own Wright on to your for ward foot.
  • 237. Moving a patient from bed to stretcher and from stretcher to bed Purpose • To send a patient to operation room • To send a patient to other room, like as; x-ray, ct-scan and so on. If a patient is unable to wake by him/her self • To change bed covers
  • 238. Steps for moving apt, from bed to stretcher • Have bed ready to receive patient. • Bring stretcher to bed, placing head of stretcher at foot of bed a right angle to the bed • Three lifters come to the same side of the stretcher on the inner angle • Roll blanket to words the patient so it isn’t in the way. • The first lifter places hands and arms under patient‘s head & shoulders • The second lifter places one arm under the back and the other hand under the buttocks • The third lifter places one arm under the part of the leg & the other under the lower legs.
  • 239. • Indication – Bed ridden patient – Debilitated patient – Fractured patient, if he/she is unable to move Precaution • Avoid sudden twists when lifting. • Always keep your back straight when lifting, with the chin slightly tucked in. • Keep your body fit and strong by regular exercise, E.G by brisk, running, not ball, swimming etc.
  • 240. • Moving patient from bed to chair and from chair to bed Purpose – To get a helpless patient out of bed & into a chair with as little exertion as possible, and make him comfortable. • Equipment • Chair (preferably with arms for support) • Blankets or two pillows • Patient’s robe and slippers
  • 241. • Steps for moving from bed to chair A. Assists the patient, to sit on the side of the bed, and dress the patient appropriately. B. Assist the patient to stand on the floor, then to walk to the chair, to sit down and be comfortable C. Assist the patient, to sit down and leave him comfortable. D. Assist the patient, to rise from the chair, to stand it straight, to return to the bed and to be comfortable.
  • 242. Indication • When a patient‘s linen is soiled & need s changing. • A patient is interested to sit on chair. Precaution • If the patient is heavy or helpless, powdering the fore arms makes it easier to insert them under him, particularly when the skin is moist. • Be as close as possible to the patient before lifting, and remain as close as possible to him throughout the entire lift, because the closer the load is to the body, the less strain the load is to the body, less strain is on the lifters back. • When the lifting is complete make sure that the patient is comfortable.
  • 243. Procedure • Explain what you are going to do to patient – Place chair on convents side of bed with the blank of the chair parallel to the foot of the bed. If wheel chair is used, seen than the foot rest in up and that the wheels and locked. – Place blanket in seat of chair, top edge even with back of chair. – If pillows are used place one standing against back of chair and on pillow on seat of chair. – Check patient is pulse – Bring patient to edge of bed – Fold bedding to foot of bed and flex patients knees
  • 244. – With right arm under patient’s head and shoulders and with left arm under tights, lift patient up and at the same time swing him around into a sitting position with feet hanging over edge of the bed. – Slip on robe – Steady him for a few seconds – Put on slippers or shoes – Sanding directly in front of him with one hand in each axilla slip the patient to his feet and at same time turn him gently and place him in the chair. – Make bed •
  • 245. – Watch patient constantly and note patient’s pulse after he has been in chair for a few minutes. – Never leaver leave the patient in chair without some way to call for help if the needs it.
  • 246. TEACHING THE PATIENT COUGHING AND DEEP BREATING EXERCISE • The coughing exercise is one of the best known and most effective forms of chest physiotherapy. • Coughing deeply will help in clearing your lung after surgery. • When you stay in bed for a long time after surgery, you need to keep your lungs active as if you are doing your daily activities.
  • 247. COUGHING – is a reflexive response to irritation in airways Or Is sudden explosive exhalation. Function of cough: • to help clear offending substance from the air ways. • Serves as a warning signals’ that the airways are being assaulted by possibly harmful stimuli. Causes of cough- cough can be triggered by • anything that enters the air way that does not normally belong there, Eg. Chemical substance or physical substance. • Inflammation of the tissue by disease that results in increase of histamine w/c irritates the air ways and triggers a cough.
  • 248. DEEP BREATHING- • It is a condition in which there is more than the normal amount of air entering and leaving the lungs Indication for coughing and deep breathing: Pts with infective air way clearance and excessive secretion in the respiratory tracts
  • 249. • Pts with infective breathing pattern • Respiratory defect, hypoventilation • Pts under water- seal drainage tube
  • 250. Coughing Technique • Start with sitting on a chair with both feet on the floor, Relax. • Fold your arms across your abdomen and breathe in slowly through your nose. The power of the cough comes from moving air. • To exhale: lean forward, pressing your arms against your abdomen. Slightly open mouth. • Cough two to three times, short and sharp. • The first cough loosens the mucus. The second and third cough moves the mucus up and out.
  • 251. Oxygen therapy is the administering of oxygen at a concentration greater than found in the environmental atmosphere. Purpose • To provide & maintain a normal supply of O2 for blood & tissue. – Oxygen transport to the tissue depends on:- • factors such as cardiac out put, arterial oxygen amount, adequate concentration of hemoglobin ADMINSTERING OXYGEN THERAPY
  • 252. • To reduce the effect of anoxaemia( oxygen deficiency) • To maintain health level of tissue oxygenation. – Hypoxemia:- is a decrease in the arterial oxygen tension in the blood – Hypoxia: - is decrease in oxygen supply to the tissue Indication of oxygen therapy • Obstruction in airway passage like forewing body, Bronchial asthma, Pneumonia and pulmonary edema, Cardiac insufficiency • Peripheral circulatory failure
  • 253. Types of oxygen administration divice 1. CANNULA /NASAL PRONGS 1-4 lts 2. SIMPLE FACE MASKS 6-10 lts 3. NASAL CATHETER 1-6 lts 4. Oxygen Tent 8-10 lts
  • 254. NURSING RESPOSIBILITIES 1) Administration – the nursing staff is responsible for the subsequent administration this Includes: – Checking the dosage of oxygen rate of flow, the concentration of O2 – Checking the function of humidifying equipment – Monitoring the pt and depth of the pt’s respiration – Every water of the apparatus should be clean to prevent infection 2) Safety – • the safety of pt and others must be ensured when O2 is being used • “No smoking” signs must be posted and rigidly enforce • All electrical plugs, outlets & equipments must be grounded
  • 255. ADMINISTERING OXYGEN BY NASAL CANNULA , OR MASK • Equipments – O2 Cylinder with it’s stand & accessories( humidifier with sterile distilled water& flow meter) – Nasal cannula, catheter . – Gauze to pad the tubing over the check bone . – Simple O2 mask – No smoking sign – Adhesive tabs, gauze to pad the tubing over the check bone
  • 256. PROCEDURE • Determine the need for oxygen therapy and the physician order • Assist the client to a semi- flower’s position as possible. It permits easier chest expansion & easier breathing • Explain the procedure to the patient and inform the client & support persons about safety precautions connected with oxygen use. • Set up the oxygen equipment & humidified. • Turn on the oxygen at the prescribed rate & ensure proper function. • Put the cannula over the clients face. • If the cannula will not stay in place tape if at sides of face.
  • 257. If a mask is to be used • Connect the mask tubing & open the fine adjustment to the required rate of flow • Apply mask to the pt face making sure that it rests comfortable on the pt’s face. • Asses the client regularly. • Asses the vital signs, color breathing pattern & chest movement. • Check the equipment are working regularly. • Make sure that safety precaution are being followed.