Cannulation(1)

University of GondarUniversity of Gondar
College of Medicine and HealthCollege of Medicine and Health
SciencesSciences
School of MedicineSchool of Medicine
Department of MedicalDepartment of Medical
AnesthesiologyAnesthesiology
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Tadesse B. Introduction to Basic/Nursing
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Course nameCourse name
• Introduction to Nursing/ Basic/ Preclinical ArtIntroduction to Nursing/ Basic/ Preclinical Art
Module 9:
• Basic Clinical Skills Module
Course Number -Course Number - Nurs2091
ECTSECTS -- 3, 2chr, 08 days3, 2chr, 08 days
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Course Description:
• This course is designed to:
• Perform different clinical procedures before attachment:Perform different clinical procedures before attachment:
• Identification of signs and symptomssigns and symptoms
• Record, maintain and share medical records.
• Take, record and use vital signsvital signs
• Administration of medicationsAdministration of medications by different route
• Perioperative patient preparation and carepreparation and care.
• Insertion of NGT, catheterization, cannulationNGT, catheterization, cannulation (IV)
• Giving wound carewound care (simple)
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Facilitator
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Tadesse Belayneh (RN, Bsc, MPH),
Department of Anesthesia, UoG, 2016/17
Contact- e-mail- tadbel20@gmail.com
Cell phone- 0918-77-74-96
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Course Objective
At the end of this course students are
expected to :-
• Observe and record clinical manifestation
• Take and record vital signs
• Administer medications by different routes
• Perform different clinical procedures (IV
cannulation, wound care, NGT, Catheterization…)
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Teaching methods
• Interactive Lectures
• Video/picture
• Demonstration
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Evaluation methods
• Continues assessment – 50%
– Reading assignment
– Tests and quiz, Mid exam - 40%
– Class participation
– Presentation?? 10%
• Final exam – 50%
• Class attendance – 100%
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Tentative schedule
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Week/Day Topic covered 22, 5 exam Remark
Week/Day 1 Observation and recording of S/S , charting -2hrs Test 1
Test 1 before class 10% - 1hrs
Week/Day 2, 3 Vital signs -2hrs Demo - 2hrs
Week/Day 4, 5 Medication admi, safety – 2hrs Demo -2hrs Test 2
Test 2 before class 10% - 1hrs
Week/Day 4,5 Perioperative preparation and care – 2hrs
Week/Day 6 IV cannulation and catheterization -2hrs Demo-4hrs
Week/Day 6 Wound care, dressing , NGT - 2hrs Demo- 2hrs Test 3
Week/Day 7 Test 3 before class 20% -1hrs
Week/Day 8-13 Study day
Week/Day 14 Final exam 50%
Time – lecture – 12hrs, Demo-12hrs Quiz-3hrs, Final-
2hrs, Study leave- 20hrs

Assessment, Observation andAssessment, Observation and
Recording of Signs and SymptomsRecording of Signs and Symptoms
in patients medical recordsin patients medical records
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Session Objectives
At the end of this session students are able to:
• Define and list importance of assessment
• List data important to assess patient to reach outcome
• Identify difference b/n signs and symptoms
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Assessment - (Anesthetist)
• Assessment is a tool used to collect and
document critical data regarding a patient’s
health, psychological and social status.
• This assessment remains accessible to the
entire health care teamhealth care team during the course of
a patient’s stay in order to assist the team
– in determining proper patient careproper patient care and
treatment.treatment.
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Assessment…
During assessment, the anesthetist gathers data
via both Subjective and Objective methods.
What Subjective and Objective data are?
Subjective dataSubjective data are what the patient/client
actually states (e.g. "I'm tired"). These are his/herhis/her
feelingsfeelings and perceptions.
 Objective dataObjective data are concrete, observable
information such as: vital signs, laboratory studies,
changes in physical appearance.
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Assessment…
• Medically these subjective and objective data are
called - Signs and Symptoms.Signs and Symptoms.
• What is the difference b/n S/S?
• Signs:Signs:
– are objective data which could be seen by healthhealth
professionals.professionals.
• Symptoms:Symptoms:
– are subjectivesubjective complaints described by patients.
NB: SS=Subjective data are Stated. OO =
Objective data are Observed.
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Maintaining Patient MedicalMaintaining Patient Medical
RecordsRecords
in anesthesia/anesthesiain anesthesia/anesthesia
sheetsheet
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• Explain the purpose of compiling patient medical records.
• Describe the contents of patient record forms.
• Describe how to create and maintain a patient record.
• Discuss the need for neatness, timeliness, accuracy, and
professional tone in patient records.
• Explain how to correct a medical record.
• Explain how to update a medical record.
• Identify when and how a medical record may be released.
Learning Outcomes
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The Medical Record
The medical record (MR) is the centralcentral
documentationdocumentation of the patient’s visit to a health
care facility.
A well-managed MR system is critical to providing
efficient and high qualityefficient and high quality patient care.
The primary purpose of the MR is to act as anan
immediate record availableimmediate record available at all times,
documenting the patient’s presenting symptoms
and the subsequent care and treatmentsubsequent care and treatment.
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The Medical Record…
• The medical record is an analysis of a patient’s health status.
• It contains a medical history, current findings, considerations, test
results, and treatment information related to conditions or
diseases that ail the patient.
• Notes in the medical record are usually entered by the physicianphysician
and other members of the health care teamand other members of the health care team.
• There are two major types of medical records:
– Paper recordsPaper records are medical records that are stored in file
folders.
– Paperless recordsPaperless records are computerized records or records
stored in digital format and are often referred to as electronic
medical records (EMRs) or electronic health records (EHRs).
– Another type of medical record, the personal health recordpersonal health record
(PHR),(PHR), is a copy of the patient’s own medical record that may
be in paper or digital format.
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The Medical Record…
• The term 'Medical record''Medical record' is used both for the
physical folderphysical folder for each individual patient and for
the body of informationbody of information which comprises the total
of each patient's health history.
• Medical records are intensely personalintensely personal documents
and there are many ethical and legal issuesethical and legal issues
surrounding them such as the degree of third-party
access and appropriate storage and disposalappropriate storage and disposal.
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The medical record…
• The maintenance of the medical record is often assigned
to administrative staff membersadministrative staff members; however, clinical staff
members also have responsibilities in records
maintenance.
• The clinical team is usually responsible for
• Ensuring that all outstanding lab and x-ray results are enteredentered
into the record.into the record.
• They are also responsible for updatingupdating patient history and
other data on a regular basis.
• Have additional responsibilities such as removing dataremoving data from
the chart, copyingcopying the data, sending isending it to other health
facilities, and returning any removedreturning any removed data to its original
location.
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Important Uses of the Medical Record
To provide the provider with precise health dataprecise health data to assist in
formulating an accurate diagnosisdiagnosis, plan an appropriate
treatmenttreatment, and track a patient’s progresspatient’s progress.
Assists the provider in formulating disease prevention measuresdisease prevention measures
and overall health maintenance goals for the patient.health maintenance goals for the patient.
Moreover,
◦ To provide a means of communication:To provide a means of communication: health-team
◦ To be used for financial purposesfinancial purposes: BILLING,BILLING, administration.administration.
◦
◦ To be used as an educational and researcheducational and research tool: Pt, student
◦ To serve as a legal document: legal doc admissible in court
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Medical records formats
• There are two different documentation formats that are
used for medical records,
• The source-oriented medical recordsource-oriented medical record and
• The problem-oriented medical recordproblem-oriented medical record.
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Source-Oriented Medical Record (SOMR)
• It is the more traditional formattraditional format used for recording data in
the medical record.
• Charts in which the SOMR format is used are divided into
specific sections including:
– History and Physical, Progress Notes (notes that track the patient’s
progress), Nursing/Medical Assisting Notes, Laboratory, and
Diagnostic Testing.
• The “source” or individual providing the data enters the
information within the appropriate section of the chart.appropriate section of the chart.
• All reports and notes are kept in reverse chronologicalreverse chronological
order, meaning the most recent note is on top.
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Problem-Oriented Medical RecordsProblem-Oriented Medical Records
• A method of recording data about the health status of a patient in
a problem-solving system.
• The POMR preserves the data in an easily accessible way that
encourages ongoing assessmentongoing assessment and revision of the health care
plan by all members of the health care team.
• The particular format of the system used varies from setting to
setting, but the components of the method are similar.
• The POMR is developed using four categorizations or stagesfour categorizations or stages:
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Problem-Oriented Medical Records…Problem-Oriented Medical Records…
1. Develop a database:1. Develop a database:
• A data baseA data base is collected before beginning the process
of identifying the patient's problems.
• The database should include patient historypatient history, physical
findings, and baseline readingsbaseline readings for diagnostic and
laboratory testing.
• It is recommended that the data base be as complete ascomplete as
possiblepossible, limited only by potential hazard, pain or
discomfort to the patient, or excessive assumed expense
of the diagnostic procedure.
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Problem-Oriented Medical Records…Problem-Oriented Medical Records…
2. Assemble a detailed problem list:2. Assemble a detailed problem list:
• Each problem as identified represents a conclusion or aconclusion or a
decisiondecision resulting from examination, investigation, and analysis
of the data base.
• A problem is definedproblem is defined as anything that causes concern to the
patient or to the caregiver, including physical abnormalities,
psychological disturbance, and socioeconomic problems.
• Each time the patient is seen for a particular problem, the
progress note will reference the number listed on the problem list.
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Problem-Oriented Medical Records..Problem-Oriented Medical Records..
3. Formulate a plan of action for each problem:3. Formulate a plan of action for each problem:
• The plan for each problem may be found as a separate listing
within the chart or may be included in the problem list. This
section should include plans for testing, treatment, and education.
4. Provide ongoing progress notesProvide ongoing progress notes for each problem on the
problem list.
• Problems may be added, and intervention or plans for
intervention may be changed; thus the status of each problem is
available for the information of all members of the various
professions involved in caring for the patient.
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SOAP NotesSOAP Notes
• The POMR system uses the subjective, objective, assessment, plan
(SOAP) note format for each progress noteeach progress note.
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ubjective data
bjective data
ssessment
lan
Information
the patient
tells you
What the anesthetist observes
during the examination
The impression of the patient’s problem that
leads to diagnosis
The management plan to correct the illness or problem/
anesthesia
SOAP Documentation
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• There are a number of advantages of using the POMR
including:
• It makes explorationexploration of the chart much moremore
efficientefficient.
• It decreases ambiguitydecreases ambiguity of prior problems and
treatment goals.
• It encourages uniformity amongstuniformity amongst those using the
chart.
• It simplifies record keepingsimplifies record keeping.
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Documenting in the Medical Record
Elements of Good documentation
Complete, accurate, and well-documented records
are evidence of appropriate care.appropriate care.
Incomplete, inaccurate, altered, or illegible records
may imply poor standardspoor standards.
Everyone who documents in the patient record has
a responsibility to the patient.
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Documenting in the Medical Record…
Unaltered/Unaltered/ExactnessExactness
– Do not use a word you are not sure of
CompletenessCompleteness
– No omission, avoid unnecessary words or
statement
Accuracy /spellingAccuracy /spelling
– Make certain that your documentation is consistentconsistent with
the detail and clarityclarity that would be provided by other
peers in different parts of the country.
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Professional attitude and toneProfessional attitude and tone
– Record patient comments in his or her own words
– Do not record your personal or subjective comments,
judgments, opinions, or speculations
– Never include slang, biased statements, or irrelevant
opinions.
You may call attention to problems or observations by
attaching a note to the chart, but do not make such
comments part of medical record.
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TimelinessTimeliness
– Record all findings as soon as they are
available.
– For late entries, record both original
date and current date
– Retrieve file quickly in event of an
emergency
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Neatness and legibilityNeatness and legibility
–Use a good-quality pen
–Blue ink is preferred (differentiates original
from copy)
–Highlight critical items such as allergies
–Handwriting must be legible
–Make corrections properly
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Forms attached with chart
• Which formats are attached with patient
medical records?
• Sociodemographic
• Medical history sheet
• Order sheets, medication sheet,
• Anesthetic sheet, death summary,
• Progress, operation note,
• Laboratory and radiologic requests and findings,
• Nursing standards,
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Correcting and Updating Patient Records
Medical records are created in “due
course” – at occurrence
◦ Meaning information is to be entered at theat the
time of occurrencetime of occurrence
◦ Information corrected or added after patient’safter patient’s
visitvisit is regarded as “convenient”
Use care with corrections
◦ It is more difficult to explain a chart that has
been altered after something was documented.
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Correcting Patient Records..
When mistakes happen,
correct them immediately
◦ Draw a line through the original
information
It must remain legible
◦ Insert correct information above
or below original line or in
margin
◦ Document why correction was
made.
◦ Date, time, and initial signature
◦ Have a witness, if possible
m/d/yyyy 00:00pm
misspelled JHC
/chj
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Ownership, Retention, and Disposal of medical records
• In general, medical records are the property of the practicepractice
or treating physicianor treating physician or hospitalhospital.
• The practice or physician owns the physical part of the
record, but the patient is the ownerpatient is the owner of the informationinformation
stored within the chartstored within the chart.
• Patients are entitled access to their medicalentitled access to their medical records
and may request copies of it.request copies of it.
• If a patient requests a copy, the patient must sign apatient must sign a
release.release.
• Only copies—and not the originals—ofOnly copies—and not the originals—of the record
should be sent to the patient.
• Exceptions:Exceptions: cases of contagious disease or court
order.
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Release of Records (cont.)
• Procedures for releasing records
– Obtain a signed and newly datedsigned and newly dated release form
authorizing the transfer of information, and placeplace
it in the patient’s record.it in the patient’s record.
– Make photocopiesphotocopies of original materials
• Copy and send only documents covered in the release
authorization
– Call to confirm receiptconfirm receipt of materials
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In Summary
• Anesthetists with other health team must properly
prepare and maintain patient records.
• There are several methods for documentation, but
regardless of method, records must be complete,
legible, current, accurate, and professional.
• Properly maintain, correct, update, and release
patient medical records.
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Vital SignsVital Signs
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Objectives
• Recognize normal and abnormal values of temperature,
pulse, respirations, and blood pressure.
• Recognize common terminology and abbreviations used in
documenting and discussing vital signs.
• Identify the sites for assessing the pulse, temperature and
blood pressure.
• Successfully complete vital signs procedures and
document.
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Vital Signs
• Provides information and are important indicatorsimportant indicators about
changes in normalchanges in normal body function and the body’s responsebody’s response
to physical, environmental, treatment and psychological
stressors.
• Because of the importance of these measurements they
are referred to as Vital Signs.
• These signs are observed, measured, and monitored to
assess an individual's level of physical functioning.
• Temperature, pulse, respiration, blood pressure (B/P), pain,pain,
output and input & oxygen saturationoutput and input & oxygen saturation are the most
frequent measurements taken by HCP.
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Vital Signs…
• VS may reveal sudden changessudden changes in a client’s condition and
baselinebaseline VS are important to identify changes in the
patient’s condition.
• VS are part of a routine physical assessment and are not
assessed in isolation.in isolation.
• Normal vital signs change with age, sex, weight, exercise
tolerance, and condition.
• Prior to measuring vital signs, the patient should have had
the opportunity to sit for approximately fivesit for approximately five minutes.
• Before diving in, take a minute or so to look atlook at the patient
in their entirety/totalin their entirety/total.
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Times to Assess Vital Signs
• On admissionOn admission – to obtain baseline date
• When a client has a change in health statuschange in health status or reports
symptoms such as chest pain or fainting.
• According to medical order -According to medical order - during anesthesia every 5
minutes, postoperative Q15min, Q2hr
• Before and after the administrationBefore and after the administration of certain medications
that could effect HR, T0, RR or BP. E.g. SA, digoxine,
• Perioperative- Before and after surgeryPerioperative- Before and after surgery or an invasive
diagnostic proceduresdiagnostic procedures
• Before and after any interventionBefore and after any intervention that could affect the v/s.
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Pulse RatePulse Rate
Objectives:
At the end of this session students are expected to:
• Identify factors that affect
• Identify sites for taking pulse
• Demonstrate methods of taking pulse
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What is pulse rate?
• It is a wave of blood created by contraction of the leftcontraction of the left ventricle
of the heart. i.e. the pulse reflects the heart beatheart beat or is the same
as the rate of ventricular contractionsrate of ventricular contractions of the heart – in a
healthy person.
• In some types of cardiovascular diseases heart beat and pulse
rate differs.
• E.G. Client's heart produces very weak or small pulses that are
not detectable in a peripheral pulse far from the heart.
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Factors Affecting Pulse Rates
• Age: age increases the PR gradually decreases.
– New born to 1 month – 130 BPM 80-180 (range).
– Adult 72/80 BPM (beat per minute) 60 – 100 BPM
• Sex: after puberty the average males PR is slightly lower than female
• Exercise: PR increase with exercise
• Fever: increases PR in response to the lowered B/P that results from
peripheral vasodilatation – increased metabolic rate.
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Factors Affecting Pulse Rates
• Medications: digitalis decreases PR, Epinephrine – increases PR
• Heat: increase PR as a compensatory mechanism
• Stress: increases the sympathetic nerve stimulation – increases the rate
and force of heart beat
• Position changes: when a patient assumes a sitting or standingsitting or standing position
blood usually pools in dependent vessels of the venous system. Pooling
results in a transient decrease in the venous blood return to heart and
subsequent decrease in BP increases heart ratedecrease in BP increases heart rate.
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Characteristics of the Pulse
Usually characterized by the following :
• RateRate
• Rhythm – regularityRhythm – regularity
• Volume/strengthVolume/strength
• Bilateral Presence/sitesBilateral Presence/sites – pulses should be found within
the same areas on both sides of the body and have the
same rate, rhythm, and volume – except ----------???
But some times – included
• Elasticity of the arterial wallElasticity of the arterial wall
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Characteristics …
Pulse Rate
• Assessed as beats per minutebeats per minute, or BPM.
• Counted for 15, 20, 30, or 60 seconds and multiply by
4,3,2,1 respectively.
Findings -Findings -
• Eucardia - Normal 60-100 b/min (72/80/min)
• Bradycardia – a pulse rate slower than normal, < 60/min
• Tachycardia – a pulse rate faster than normal, excessively
fast heart rate (>100/min)
• Pulse deficitPulse deficit – the difference between the radial pulse and
the apical pulse – indicates a decreasedecrease in peripheral
perfusion from some heart conditions i. e. Atrial
fibrillation.
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Characteristics …
Pulse Rhythm
• The patternpattern and intervalinterval between the beats, randomrandom,
irregularirregular beats – dysrhythmias
• A client with an irregular heartbeat (arrhythmia or
dysrhythmia) must be measured a full minutefull minute to
determine the average rate.
• When documenting pulse rhythm, record as regular orregular or
irregular.irregular.
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RhythmRhythm
RegularRegular
IrregularIrregular
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Characteristics …
Pulse Volume: the force of bloodforce of blood with each beat.
• A normal pulse can be feltfelt with moderate pressuremoderate pressure of the
fingers and can be obliteratedobliterated with greater pressure.
• Pulse volume, or strengthvolume, or strength of the pulse, can be measured
with the following scale:
• 0 – absent, unable to detect.
• 1 – thready or weak, difficult to palpate, and easily
obliterated by light pressure from fingertips.
• 2 – strong or normal, easily found and obliterated by
strong pressure from fingertips.
• 3 – bounding or full, difficult to obliterate with fingertips.
• A thready or weak pulse may indicate decreased
circulation. A bounding pulse may indicate high blood
pressure.
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Pulse Sites
• Temporal: is superior and lateral to the eye
• Carotid: at the side of the neck below tube of the ear
(where the carotid artery runs between the trachea and the
sternoclidiomastoid muscle)
• Apical: at the apex of the heart: routinely used for infant
and children < 3 yrs. In adults – Left mid clavicular line
under the 4th, 5th, 6th intercostals space.
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Pulse Sites
• Brachial: at the inner aspect of the biceps muscle of the arm or
medially in the antecubital space (elbow crease)
• Radial/Ulnar: on the thumb side of the inner aspect of the wrist
– readily available and routinely used
• Femoral: along the inguinal ligament. Used for infants and
children
• Popiliteal: behind the knee. By flexing the knee slightly
• Posterior Tibial: on the medial surface of the ankle
• Pedal (Dorslais Pedis): palpated by feeling the dorsum (upper
surface) of the foot between the big and 2nd toes
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Procedure of taking PR
PeripheralPeripheral
• Place 22ndnd
, 3, 3rdrd
& 4& 4thth
fingersfingers lightly on skin where an artery passes over
an underlying bone.
• Do not use your thumbnot use your thumb (feel pulsations of your own radial artery).
• For regular - count 15, 20, 30 seconds X 4,3,2, for irregular – count
for 1minute.
ApicalApical
• Beat of the heart at it’s apexit’s apex or PMI (point of maximum impulse)
• Place at 55thth
intercostal spaceintercostal space, midclavicular linemidclavicular line, just below Lt nipple
– listen for a full minute.
• Stethoscope - DiaphragmDiaphragm – high pitched sounds, bowel, lung & heart
sounds – tight seal , BellBell – low pitchedlow pitched sounds, heart & vascular sounds,
apply bell lightly.
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ObjectivesObjectives
At conclusion of this session students are
expected to:
• Measure respiration rate
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Respiratory Rate/RRRespiratory Rate/RR

Respiration rate
RespirationRespiration
• Is the act of breathingact of breathing (includes intake of O2 and removal of CO2) –
external
• The respiration rate is the number of breaths a person takes perper
minuteminute.
• Factors affectingFactors affecting
– Respiration rates may affected with fever, illnessillness,
medications, exercises …
– When checking respiration, also note whether a person has
any difficulty breathingdifficulty breathing.
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Procedures to take RR
• The client should be at rest in comfortable condition
• Explain the procedure to patients
• Expose the patients chest adequately.
• Observe /watching the movement of the chest or
abdomen and count for full minute.
• Better while taking PR.
• Characterized the RR by Rate, rhythm, depthRate, rhythm, depth and special
of respiration/character. 14b/m, regular, normal14b/m, regular, normal
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Characteristics of RR
RateRate Number of breathing cycles/minute (inhale/exhale-1cycle-1cycle)
Adult normal - 12-20 breaths/min
EupneaEupnea – normal rate & depth breathing, Apnea -Apnea - absence of breathing
Tachypnea -Tachypnea - abnormal increase, Bradypnea - aBradypnea - abnormal decrease
DepthDepth Amount of air inhaled/exhaled - TV- 500ml
•NormalNormal (deep & even movements of chest)
•ShallowShallow (rise & fall of chest is minimal)
•Shortness of breath-Shortness of breath- SOB (shallow & rapid)
RhythmRhythm Regularity of inhalation/exhalation
Normal (very little variation in length of pauses b/w I&E – 2seconds2seconds
CharacterCharacter Digressions/deviation from normal effortless breathingnormal effortless breathing
DyspneaDyspnea – difficult or labored breathing
Cheyne-StokesCheyne-Stokes – alternating periods of apnea and hyperventilation,
gradual increase & decrease in rate & depth of resp. with period of
apnea at the end of each cycle.
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Objectives
• Define blood pressure
• Identify types of blood pressure
• Identify factors that affect blood pressure
• Measure blood pressure
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Blood PressureBlood Pressure

What is Blood pressure?
• Force exertedForce exerted by the blood against vessel wallsvessel walls.
• There are two types of blood pressure.
– Systolic pressure: is force exerted against the arterial wall as lt. ventricle
contracts & pumps blood into the aorta – maximummaximum pressure exerted on
vessel wall.
– Diastolic blood pressure: is the pressure when the ventricles are at rest
or arterial pressure during ventricular relaxation, when the heart is
filling, minimumminimum pressure in arteries.
– Pulse pressure: is the difference between the systolic and diastolic
pressure , usually 30-60mmhg.
• Measured in mmHg – millimeters of mercury, Normal SBP,110-140 , DBP-
60-90. Hypertensive - >160, >90, Hypotensive <90
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Factors affecting
• Cardiovascular disorders ; Arteriosclerosis " Obesity “
=>Increase
• Neurological conditions
• Kidney and urological disorders
• Pre eclampsia in pregnant women.
• Psychological factors such as stress, anger, or fear
• Various medications
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Sites for Measuring Blood Pressure
• Upper armUpper arm using brachial artery (commonest)
• ThighThigh around Popiliteal artery
• Fore -armFore -arm using radial artery
• LegLeg using posterior tibial or dorsal Pedis
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Methods of Measuring Blood Pressure
• Blood pressure can be assessed directly or indirectly
• Direct (invasive monitoring)
– Measurement involves the insertion of catheterinsertion of catheter in to the brachial,
radial, or femoral artery - Intra arterial catheter
– With use of correct placement, it is highly accuratehighly accurate.
• Indirect (non invasive methods)
– The auscultatoryThe auscultatory
• The auscultatory method is the commonestcommonest method used in health
activities.
– The palpatoryThe palpatory
• This method feel the pressure – usually SBP, identifies five phases
in series of sounds called Korotkoff's sound.
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• Stethoscope, Blood pressure cuff of the
appropriate size(Sphygmomanometer)
• Types of SphygmomanometersSphygmomanometers
• Mercury – has a calibrated glass tube
containing mercury.
• Aneroid – has a calibrated dial with a
needle that points to numbers on the
face of the dial.
• Electronic – uses a digital display and
usually includes the pulse rate.
Equipments
Mercury
Aneroid
Electronic05/12/19
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Preparation for measurement
• Instruct patients to avoid coffee, smoking or any other
unprescribed drug with sympathomimetic activity on the day of
the measurement.
• Because a full bladder affects the blood pressure it should have
been emptied.
• Painful procedures and exercise should not have occurred
within one hour.
• Patient should have been sitting quietly for about 5 minutes.
• BP take in quiet room and comfortable temperature, must
record room temperature and time of day.

Position of the Patient
• Sitting position
• Arm and back are
supported.
• Feet should be
resting firmly on the
floor
• Feet not dangling.

Position of the arm
• The measurements should be made on the right arm
whenever possible.
• Patient arm should be resting on the desk and raised (by
using a pillow)
• Raise patient arm so that the brachial artery is roughly at
the same height as the heart.
• If the arm is held too high, the reading will be artifactually
lowered, and vice versa.
• Palm is facing up. The arm should remain somewhat bent
and completely relaxed
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Cuff Position
• Patient's arm slightly flexed at
elbow
• Push the sleeve up, wrap the
cuff around the bare arm
• Cuff applied directly over skin
(Clothes artificially raises blood
pressure )
• Position lower cuff border 2.5
cm above antecubital
• Center inflatable bladder over
brachial artery.

Cuff Position…
• The manometer scale
should be at eye level, and
the column vertical.
• The patient should not be
able to see the column of
the manometer
• Cuff too wide – false low
reading
• Cuff too narrow – false
high reading
• Cuff too loose – false high
reading

Measure the BP
• Feel for a pulse from the
artery coursing through
the inside of the elbow
(antecubital fossa).
• With your left hand
place the stethoscope
head directly over the
artery you found.
• Press in firmly but not so
hard that you block the
artery.

BP measurement…
• Use your right hand to
pump the squeeze bulb
several times and
• Inflate the cuff until you
can no longer feel the
pulse to level above
suspected SBP - additional
20 mmHg
• Deflate cuff slowly at a
rate of 2-3 mmHg per
second until you can again
detect a radial pulse

BP measurement…
• Listen for auditory
vibrations from artery.
• Systolic blood pressure is
the pressure at which
you can first hear the
pulse.
• Diastolic blood pressure
is the last pressure at
which you can still hear
the pulse.

Measure the BP…
• Avoid moving your hands or the head of the stethoscope while
you are taking readings as this may produce noise that can
obscure the Sounds of Koratkoff.
• BP must take in both arms.
• The two arm readings should be within 10-15 mm Hg,
differences greater then this imply differential blood flow.
• If you wish to repeat the BP measurement you should allow the
cuff to completely deflate, permit any venous congestion in the
arm to resolve and then repeat a minute or so later.
• If the BP is surprisingly high or low, repeat the measurement
towards the end of your exam. (Repeated blood pressure
measurement can be uncomfortable

Objectives:Objectives:
• Identify factors that affect body temperature
• List and discuss the sites used to take a temperature.
• Demonstrate techniques of body temperature measurement
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Temperature

78
Temperature
• Balance between heat production and heat loss is body
temperature
• Heat production
– muscles
– glands
– oxidation of food
• Heat loss
– respiration
– perspiration
– excretion
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Temperature…
• Oral - 97.6° - 99.6° F (Fahrenheit) or 36.5°
-37.5° C (Celsius)
• Rectal - 98.6° - 100.6° F or 37.0° - 38.1° C
• Axillary - 96.6° - 98.6° F or 36.0° - 37.0° C
• Pyrexia: a body temperature above the normal
ranges 38 0
c – 410
c (100.4 – 105.8 o
F )
• Hyper pyrexia: a very high fever, such as 420
C
> 42 0
c leads to death.
• Hypothermia: – body temperature between 34
0
c – 35 0
c, < 34 0
c => death
05/12/19 Tadesse B. Introduction to Basic/Nursing Art

Factors Affecting Body Temperature
Age
• Children’s temperature continue to be more labile than
those of adults until puberty.
• Elderly people, particularly those > 75 are at risk of
hypothermia.
Diurnal variations (circadian rhythms)
• Body temperature varies through out the day
• The point of highest body temperature is usually reached
between 8:00p.m. and midnight and lowest point is
reached during sleep between 4:00 and 6:00 a.m.
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Factors …
Exercise
 Hard or strenuous exercise can increase body temperature
to as high as 38.3 – 40 c – measured rectally
Hormones
 In women progesterone secretion at the time of ovulation
raises body temperature by about 0.3 – 0.6oc above basal
temperature.
Stress
 Stress increases the production of epinephrine and nor
epinephrine – which increases metabolic activity and heat
production.
Environment
• Extremes in temperature can affect a person’s
temperature regulatory systems.
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Measuring Body Temperature
• There are Two Kinds of Body Temperature
1. Core Temperature
• Is the Temperature of the deep tissues of the body,
such as the cranium, thorax, abdominal cavity, and
pelvic cavity.
• Remains relatively constant
2. Surface Temperature:
• The temperature of the skin, the subcutaneous tissue.
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Thermometers – 3 types
• Instrument used to measure body temperature
• Types
– Non/Glass mercury – mercury expands or contracts in
response to heat. (just recently non mercury)
• Oral Rectal
– Electronic – heat sensitive probe, (reads in seconds) there is a
probe for oral/axillary use (red) & a probe for rectal use (blue).
There are disposable plastic cover for each use. Relies on
battery power – return to charging unit after use.
– Infrared Tympanic (Ear) – sensor probe shaped like an otoscope
in external opening of ear canal. Ear canal must be sealed &
probe sensor aimed at tympanic membrane.
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84
Sites to take a Temperature
• Condition of resident determines which is the best site for
measuring body temperature
• Oral – most common
• Rectal – registers one degree Fahrenheit higher than oral
• Axillary – least accurate; registers one degree Fahrenheit
lower than oral
• Tympanic – probe inserted into the ear canal
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Oral Temperature
• Most accessible and convenient
• The thermometer tip is placed beside the frenulum below
the tongue.
• Is 0.65 (1 F) more than the Axillary
• The recommended time is 2-3 minutes
• If a client has been taking cold or hot food or fluids or
smoking wait 30 minutes
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Oral - Contraindication
• Child below 7 yrs
• If the patient is delirious/febrile,
mentally ill, Unconscious
• Uncooperative or in severe pain
• Surgery of the mouth
• Nasal obstruction
• If patient has nasal or gastric tubs in
place
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Axillary Temperature
• Safest and most noninvasive
• The bulb of thermometer is
placed in the client’s axillary
hollow
• Leave it in place for 5-10
minutes
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Tympanic temperature
• By ear a special
thermometer can
quickly measure
the temperature
of the ear drum,
which reflects the
body's core
temperature.

Rectal Temperature
• Is 0.65 (1 F) more than the oral
• Readings are considered to be more accurate, most reliable
Contraindication
– Rectal or perineal surgery;
– Fecal impaction – the depth of the thermometer insertion may be
insufficient;
– Rectal infection;
– Neonates –can cause rectal perforation and ulceration;
• Position the person laterally;
• Apply lubricant 2.5 cm above the bulb;
• Insert the thermometer 1.5 – 4 cm into the anus. For an
infant 2.5cm, for a child 3.7 cm – for an adults 4 cm
• Measured for 2-3 minutes
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Medication administration and safetyMedication administration and safety
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Objectives:
• At the end of this session, students will be
able to
• Identify the six rights during drug
administration
• Identify routes of drug administration
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Medications
• Substance administered for the diagnosis, treatment, or
relief of a symptom or for the prevention of diseases.
• Used interchangeably with the word drug.
• Drug also has the connotation of an illegally obtained
substance
PrescriptionPrescription
• Written directions for the preparation and administration
of a drug
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COMMOM ABBREVIATIONS USED IN
MEDICATION ORDERS/frequency
• MANE
• MIDI
• NOCTE
• BD
• TDS
• QID
• STAT
• PRN
• morning
• midday
• Night
• twice a day
• three times a day
• four times a day
• give immediately
• when required
when necessary
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MEDICATION ORDERS/frequency
• ac
• pc
• q.h.or 1/24
• q2h or 2/24
• q4h or 4/24
• before meals
• after meals
• every hour
• every two hours
• every four hours
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MEDICATION ORDERS/route
• BUC
• O/P.O
• S/L
• ID
• IM
• IMI
• SC
• inside cheek
• oral/per oral
• sublingal
(under the tongue)
• intradermal
• intramuscular
• intramuscular
injection
• subcutaneous
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MEDICATION ORDERS/route
• SCI
• IVI
• IVT
• NEB
• PR
• TOP
• VAG
• subcutaneous
injection
• intravenous injection
• intravenous therapy
• nebuliser
• per rectum
• topical/skin
• vaginal
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The Patients Right
• Because of the risks involved in drug
administration patients have the right to:
– be informed of the name, purpose, action & potential
side effects of drugs
– refuse a medication regardless of the consequences
– receive labelled medications safely in accordance with
the five (6) rights
– be adequately informed of the experimental nature of
any drug and sign a written consent
– not receive unnecessary medications
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Six Rights of Drug/medication
Administration – previously
• Right person
• Right drug
• Right dose
• Right time
• Right route
• Right documentation
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Ten “Rights” of Accurate Medication
Administration – additional present
– Right medication (Drug)
– Right dose
– Right time
– Right route
– Right client
– Right documentation
– Right client education
– Right to refuse
– Right assessment
– Right evaluation
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Right Patient
– check the patient name & hospital number
against the chart & I.D. band.
– ask the patient to state his/her name, & their
date of birth (D.O.B)
– Verify patient ID by comparing medical record,
provider's record, and medical bracelet
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Right Drug
• Identify the drug from the order. Clarify if in
doubt.
• Check the drug three times:
- before removing it from the trolley or shelf
- when the drug is removed from the container
- before the container is returned to storage
• Check the expiry date of the drug
• Compare provider's orders, medication sheet, and
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Right Dose
• Check the dose, read the container label, calculate
the dose & check with a peer if necessary
• Use proper measuring devices for liquids, do not
crush tablets or open capsules unless directed to
by the pharmacist. (do not crush enteric coated
tablets).
• If a drug is required in another form you may get it
from the pharmacy.
• Ensure amount of medication ordered by provider.
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Right Route
• Make sure the order is clear & only give the
medications by the route designated.
• Know the abbreviations for the different
routes.
• Administer medication via the route
specified in the provider's order e.g. PO, IM,
IV, etc.
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Right Time
• Check the time interval ordered & give the
medication at the prescribed time.
• Drugs should be given within 20 minutes of
the prescribed time.
• Administer medications at the prescribed time
as per provider's orders.
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Right Record
• Right Record all information concerning the patient
and medication including:
– Indication for drug administration,
– Dosage, route delivered,
– Patient response to the medication - positive and
negative
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Session Objectives
• Define medication safety
• Provide guidance for health care providers to
implement safe medication practices based on
international standards.
• Describe the public health significance of
unsafe medication
• Explain the frame work for medication
reconciliation, medication management and
Look-alike sound alike medication.

Medication Safety
• Medication safety is a broader term that
includes errorserrors which are not side effectsnot side effects of
drugs, i.e. wrong drug, wrong route, and wrong
dose.
• Medication reconciliation is a process designed
to prevent medication errorsprevent medication errors at patient
transition points.

Medication Safety .…
• Errors are common when medications are
procured, prescribed, dispensed, administered,
and monitored.
• Errors most frequentlymost frequently occur during the
prescribing and administering actions.
• Medication errors harm an estimated 1.5 million
people and kill several thousand each year in US.
• The consequence of these errors in resource
poor countries like Ethiopia is huge and
unbearable.

How can prescribing go wrong?
• Inadequate knowledge about drug indications and
contraindications
• Not considering individual patient factors such as allergies,
pregnancy, co-morbidities, other medications
• Wrong patient, wrong dose, wrong time, wrong drug,
wrong route
• Inadequate communication (written, verbal)
• Documentation - illegible, incomplete, ambiguous
• Mathematical error when calculating dosage
• Incorrect data entry when using computerized prescribing
e.g. duplication, omission, wrong number
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How can drug administration
go wrong?
• Wrong patient
• Wrong route
• Wrong time
• Wrong dose
• Wrong drug
• Omission, failure to administer
• Inadequate documentation
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How can monitoring go wrong?
• Lack of monitoring for side-effects
• Drug not ceased if not working or course complete
• Drug ceased before course completed
• Drug levels not measured, or not followed up on
• Communication failures
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Causes of medication errors
•The existence of confusingexistence of confusing drug names
• Nonproprietary names and proprietary (brand or
trademarked) names.
• Many drug names look or sound likelook or sound like other drug names.
•Some medicines, although marketed under the same or
similar-sounding brand names may contain different activeactive
ingredientsingredients in different countries.

•the same drug marketed by more than one company
may have more than one brand name
•illegible handwriting,
• incomplete knowledge of drug names,
• newly available products,
• similar packaging or labeling,

•similar clinical use,
•similar strengths,
• dosage forms,
•frequency of administration, and
•the failure of manufacturers and regulatory
authorities

Which patients are most at risk of
medication error?
• Patients on multiple medications
• Patients with another condition, e.g. renal
impairment, pregnancy
• Patients who cannot communicate well
• Patients who have more than one doctor
• Patients who do not take an active role in
their own medication use
• Children and babies (dose calculations
required)
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In what situations are staff most likely to
contribute to a medication error?
• Inexperience
• Rushing
• Doing two things at once
• Interruptions
• Fatigue, boredom, being on “automatic pilot” leading to
failure to check and double-check
• Lack of checking and double checking habits
• Poor teamwork and/or communication between
colleagues
• Reluctance to use memory aids
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Medication Reconciliation
•It is a process designed to prevent medication
errors at patient transition points.
oAdmission: Comparing the list against the
admission, transfer, and/or discharge
orders
o Transfer: Communicating the list to the next
provider
oDischarge: Providing the list to the patient
at the time of discharge

Medication Reconciliation …
o Create the most complete and accurate list possible
or “Best Possible Medication History” (BPMH)
o Effectively engaging the patient and family in
medication reconciliation.
o Educate patients about safe medication use
and provide access to reliable, relevant, and
understandable information about their
medications.

Medication Management
Ensure that health-care organizations have clear
policies and procedures in place that require:
• Patient’s medication list should be displayed in a
consistent and visible location
• The use of the home medication list as a
reference when ordering medications at the time
of treatment in a clinic or emergency unit or
upon admission to an inpatient service.
• The provision of the current medication list to the
receiving caregiver(s) at each care

Medication Management…
• Incorporate training on procedures for
reconciling medications into the
1.Educational curricula,
2.Orientation, and
3.Continuing professional development for
health-care professionals.

Administration routesAdministration routes
Buccal Medication AdministrationBuccal Medication Administration
• Place the medication between the patient’s cheek and gum.
Sublingual Medication AdministrationSublingual Medication Administration
Place the pill or direct spray between the underside of the tongue and the
floor of the oral cavity.
Eye Drop Administration:Eye Drop Administration: Use a medication dropper to place the prescribed
dosage on the conjunctival sac.
Parenteral Medication AdministrationParenteral Medication Administration
• IM, IV, SQ,
Pulmonary Drug Administration-Pulmonary Drug Administration- Medications are administered into the
pulmonary system via inhalation or injection.
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Parenteral RoutesParenteral Routes
• Intradermal injection
• Subcutaneous injection
• Intramuscular injection: Deltoid, Dorsal gluteal
– common , Vastus lateralis, Rectus femoris
• Intravenous access
• Intraosseous infusion
DemoDemo
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Session Objectives
• Define injection safety
• Describe the magnitude of unsafe injection
• Identify risks factors leading to unsafe injection
• Recognize the risks and impacts associated with
unsafe injection practices
• Identify the role of prescribers and providers in
injection safety
• Mention injection devices and their safety
features
• Demonstrate best practices of safe injection

Safe Injection Practice …
• A safe injection is one that is given using
appropriate equipment by skilled health provider,
does not harm the receipt, does not expose the
provider to any avoidable risk and does not result in
any waste that is dangerous to the community.
• Unsafe injection: A practice is one that could harm
the recipient, and/ or the provider and / or may
result in waste that is dangerous to the community.

Safe Injection Practice .…
Terms used
• Safety device: A non-needle sharp or needle device used for withdrawing
body fluids, accessing a vein or artery, or administering medications.
• Safety (Sharps) box: A puncture/liquid-proof container designed to hold
used sharps safely during collection, disposal and destruction.
• Auto-disable (A-D) syringe: syringe with a fixed needle, which is
automatically disabled after a single use.
• Safety syringe: Modified, disposable plastic syringe designed so that the
healthcare worker can disablecan disable it and protected and cannot be re-usedcannot be re-used.
• Sharps injury: An injury caused by puncture of the skin by a sharp
object/instrument including an injection needle.
• Needles-stick injury: Puncture of the skin caused by an injection needle.

Safe Injection Practice
• Background
– 16 billion injections are given each year in
developing and transitional countries.
– 90-95% of injections are therapeutic; 5-10% is
given for immunization. Anesthetics ??Anesthetics ??
– 70% of these injections are unnecessary: oral
medications could have been prescribed.

Safe Injection Practice …
• According to 2009 injection safety survey;
– 4 % of injection providers reported of re-use of syringesre-use of syringes
and needlesand needles within 6 months prior to the survey
– 6 % of the injection providers reported to had needles-tickneedles-tick
injuryinjury – within 6 months prior to the survey.
– 47% of the patients’ preferred to take injectionspreferred to take injections
– 25% of the injection provider believed that oralprovider believed that oral
medications are less effectivemedications are less effective than injections for the
treatment of fever caused by minor illness.

Reasons for providing unsafe injections:
• Inadequate dissemination and use of standard
treatment guidelines/adherenceadherence of preventive
measures.
• Moreover,
• Lack of knowledge on the dangers of injectionsdangers of injections,
• Perception that injections are more effectivemore effective than oral
medications,
• Perception that injections give more rapid reliefgive more rapid relief,
• Perception that injections are more potentinjections are more potent,
• Financial incentiveFinancial incentive for prescribing injections
• Perceived belief that patients prefer injectionspatients prefer injections

Risk and Impact of unsafe Injection
• Transmission of blood born infectionsblood born infections
• There are about 40 blood borne pathogens that could be
transmitted via injection - HBV, HCV, HIV/AIDS common
• Injection abscessesInjection abscesses
• ParalysiParalysis- following the damage of a nerve as a
result of injection of a drug into a nerve and trauma.
• Drug/allergicDrug/allergic reactions:

Risks & impact of unsafe injection practices…
• Health Impacts:
o Transmission of blood born infections
o Injection abscesses
o Paralysis and trauma.
o Drug/allergic reactions
• Death
• Litigation
• Economic impact
• Psycho-Social

Role of prescribers
• Eliminating unnecessary injections represents
the highest priority to injection safety.
• Therefore injections should only be used in:
• Life threatening conditions
• Mal-absorption syndromes or
• Inability to swallow

Role of prescribers …
Prescribers and service providers should also:
•Encourage pts to accept oral medicationsaccept oral medications when possible.
•Injections should be given only when necessaryonly when necessary.
•Explain the risks associatedrisks associated with injections
•Explore why patients preferwhy patients prefer injections

Best practice in administering injectionBest practice in administering injection
• Elimination of Unnecessary Injection
• Select safe medicines
• Use of sterile equipment
• Avoid contamination
• Reconstitute drugs or vaccines safely
• Dispose of injection wastes and sharps
properly
• Public health education

Best practice in administering injection …Best practice in administering injection …
Right things to do
• Washed his hands before
the injection
• Gave the right drug
• Used the right equipment
• Gave the right dose
• Through right route
• Used the right sharps
disposal equipment
Wrong things
• Did not confirm the patient
identity
• Did not listen to his patient
• Did not screen the patient
for drug history to rule out
previous reactions
• Did not talk to nor counsel
his patient

Summary
• Injection safety is an integral component of IP &
control
• Injection safety is an element of Standard
Precautions
• Injection safety is key element of patient &
healthcare workers safety
• Injection safety is supported by infection
prevention & control policies & procedures such as
hand hygiene, housekeeping, waste management.

Perioperative (Pre, intra and
Post operative) care
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At the end of this lecture, the student must be able to:
1.Differentiate the phases of perioperative care.
2.Define the types and categories of surgery.
3.Identify the preoperative assessments.
4.Develop a preoperative teaching plan.
5.Describe the preoperative preparation.
6.Discuss assessments needed in immediate and later
postoperative period.
7.Identify the postoperative complications.
Session Objectives:
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What is meant by perioperative
care?
• Perioperative care is a term used to
describe the HCP functions in the total
surgical experience of the patient, pre
operative, intra operative, and post
operative
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Phases of perioperative care
Preoperative: begins with the decision to perform
surgery and continues until the client has reached the
operating area.
Intraoperative: includes the entire
duration of the surgical procedure, until
transfer of the client to the recovery area.
Postoperative: begins with admission to the recovery area and
continues until the client receives a follow up evaluation at wards, home, or
is discharged to a rehabilitation unit.
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Other definition
Preoperative Phase:
– The period of time from when decision for surgical
intervention is made to when the patient is transferred
to the operating room table.
• Intaroperative Phase:
– Period of time from when the patient is transferred to
the operating room table to when he or she is admitted
to the postanesthesia care unit.
• Postoperative Phase:
– Period of time that begins with the admission of the
patient to the postanesthesia care unit and ends after
follow-up evaluation in the clinical setting or home.
• Perioperative Period:
– Period of the time that constitute the surgical
experience, include the preoperative, intraoperative,
postoperative phases.
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:
Preoperative Assessment
I. Review preoperative laboratory and
diagnostic studies
II. Review the client’s health history and
preparation for surgery
III. Assess physical needs
IV. Assess psychological needs
V. Assess cultural needs
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I. Review preoperative laboratory and diagnostic
studies:
• Complete blood count.
• Blood type and cross match.
• Serum electrolytes.
• Urinalysis.
• Chest X-rays.
• Electrocardiogram.
• Other tests related to procedure or client’s medical
condition, such as: prothrombin time, partial
thromboplastin time, blood urea nitrogen, creatinine, and
other radiographic studies.
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II. Review the client’s health history and preparation
for surgery:
• History of present illness and reason for surgery
• Past medical history
• Medical conditions (acute and chronic)
• Previous hospitalization and surgeries
• History of any past problem with anesthesia
• Allergies
• Present medications
• Substance use: alcohol, tobacco, street drugs
• Review of system
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III. Assess physical needs:
• Ability to communicate
• Vital signs
• Level of consciousness – Confusion, Drowsiness,
Unresponsiveness
• Weight and height
• Skin integrity
• Ability to move/ ambulate
• Level of exercise
• Prostheses
• Circulatory status
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IV. Assess psychological needs:
• Emotional state
• Level of understanding of surgical procedure,
preoperative and postoperative instruction
• Coping strategies
• Support system
• Roles and responsibilities
V. Assess cultural needs:
• Language-need for interpreter
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Surgical and anesthetic consent
• Before surgery, the client must sign a surgical consent form
or operative permit.
• Clients must sign a consent form for any procedure that
requires anesthesia and has risks of complications.
• If an adult client is confused, unconscious, a family member
or guardian must sign the consent form.
• If the client is younger than 18 years of age, a parent or
legal guardian must sign the consent form.
• In an emergency, the surgeon may have to operate without
consent, health care personnel, however, makes every
effort to obtain consent by telephone, or fax.
• Clients must sign the consent form before receiving any
preoperative sedatives.
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Preoperative Teaching
 Teaching clients about their surgical procedure and
expectations before and after surgery is best done during
the preoperative period.
 Clients are more alert and free of pain at this time.
 Clients and family members can better participate in
recovery if they know what to expect.
 The HCP adapts instructions and expectations to the
client’s ability to understand.
 Information in a preoperative teaching plan varies with the
type of surgery and the length of the hospitalization.
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Preoperative Teaching Plan Includes:
• Preoperative medication- when they are given and their effects.
• Explaining Postoperative pain control.
• Explanation and description of the post anesthesia recovery room
or post surgical area. Teaching cognitive coping strategies.
• Explanation and demonstration deep breathing and coughing
exercises, use of incentive spirometry, how to support the
incision for breathing exercises and moving, position changes,
and feet and leg exercises.
• Encouraging mobility and active body movement. e.g
Turning(change position),foot and leg exercise.
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Plan Includes…
• Discussion of the frequency of assessing vital signs and use
of monitoring equipment.
• Information about intravenous (IV) fluids and other lines
and tubes such as nasogastric tubes.
• Preoperative teaching time also gives the client the chance
to express any anxieties and fears and for the HCP to
provide explanations that will help alleviate those fears.
• When clients are admitted for emergency surgery, time for
explanation is unavailable; explanations will be more
complete during the postoperative period.
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Preoperative Preparation:
Physical Preparation.
Skin preparation
– It is necessary to remove dirt and transient micro
organisms from the area.
– Local procedures should be followed.
• Is this Hair removal necessary preoperatively?
– Controversial area of discussion!!
– Against
• Pre operative shaving increases risk of post
operative wound infection.
– In favour of shaving:-
• Avoidance of hairs trapping in the incision
• A clear field of vision.
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Physical Preparation.
Food and fluids
• It is routine to fast patients for a minimum of four hours, to
empty the stomach and avoid peri-or post operative
vomiting, or regurgitation, which increases the risk of
aspiration. 2hrs Preoperative for water.
Elimination/bowel preparation
 Is Gastrointestinal preparation required for all types of
surgery?
 It is not required for all types of surgery, and should not be
seen as routine.
• Bowel evacuation is carried out :-
1. To prevent defecation during surgery
2. To reduce the risks of accidental damage to the colon
during abdominal surgery.
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• Physical Preparation.
– Care of valuables
– clothing/ grooming
– Prostheses
• Psychosocial Preparation.
– Careful preoperative teaching can reduce fear
and anxiety of the clients.
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Preoperative preparation….
• Patient may be anxious for numerous reasons.
• Fear of the unknown
• Anaesthetic + side effects / not waking up
• Unrelieved pain
• Restricted in bed postoperative.
• Use of bed pan
• Body image /effect on relationship, family
• Dependant relatives.
• Financial problems if sole provider for family.
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In what ways can the HCP alleviate anxiety in the pre op
patient?
• Pre operative education:-
Patient information leaflets, diagrams, posters
Pre op visit from recovery HCPs.
Specialist HCPs- pain control team, surgical
nurse specialist.
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Commonest Diagnosis –Example
• Anxiety related to results of surgery and
postoperative pain.
• Knowledge deficit related to preoperative
procedures and postoperative expectations.
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Postoperative Care:
Immediate postoperative period.
Initial Assessment
• Airway patency
• Effectiveness of respiration
• Presence of artificial airways
• Mechanical ventilation, or supplemental oxygen
• Circulatory status, vital signs
• Wound condition, including dressings and drains
• Fluid balance, including IV fluids, output from catheters
and drains and ability to void
• Level of consciousness and pain
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Postoperative Care:
Later postoperative period
Ongoing Assessment
• Respiratory function
• General condition
• Vital signs
• Cardiovascular function
• Fluid status
• Pain level
• Bowel and urinary elimination
• Dressings, tubes, drains, and IV lines
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Diagnosis –Example
• Risk for altered respiratory function related to
immobility, effects of anesthesia, analgesics and pain.
• Pain related to surgical incision and manipulation of body
structures.
• Altered Comfort (nausea and vomiting) related to effects
of anesthesia or side effects of narcotics.
• Risk for Infection related to break in skin integrity (surgical
incision, wound drainage devices).
• Activity Intolerance related to decreased mobility and
weakness secondary to anesthesia and surgery.
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Postoperative Complications
• Respiratory complications
Airway obstruction, chest infection
• Cardiovascular complications
shock, haemorrhage, DVT, PE
• Gastrointestinal
vomiting, constipation, paralytic ileus,
retention of urine
• Wound infection
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Responsibilities in Postoperative Phase
Health - team work - nurses, Physician
• Ensures a patent airway
• Helps maintain adequate circulation
• Prevents or assist with the treatment of shock
• Maintains proper position and function of drain
tubes and IV infusion
• Monitor for potential complications
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IV cannulation and
catheterization
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At the end of this session students are able to:
 Identify the principals of IV line insertion using aseptic
technique.
 Identify sites for IV cannulation
 Describe purpose of IV cannulation
• Identify indications, contraindications and
complications
• of IV cannulation.
 Identify equipments used for IV cannulation
• Demonstrate the correct technique of IV line insertion.
OBJECTIVES:
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Definition
• Insertion of cannula to the veins.
• Venepuncture is the most commonly performed
invasive procedure in hospitals.
• ƒ IV cannulation is the second most invasive
procedure for patients in hospital.
• ƒ Today -85% -95% of all hospitalized patients
receive IV’s in one form or another.
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Cannulation
Indications:
• Fluid and electrolyte replacement
• Administration of medicines
• Administration of blood/blood products
• Administration of Total Parenteral Nutrition
• Haemodynamic monitoring
• Blood sampling
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Contraindication
• Sites close to infection
• ƒ Veins of fractured limbs
• ƒ Where there is an AV fistula present
• ƒ Oedema
• ƒƒClotting disorders & on warfarin.
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Cannulation
Advantages
• Immediate effect
• Control over the rate of administration
• Patient cannot tolerate drugs / fluids orally
• Some drugs cannot be absorbed by any other
route
• Pain and irritation is avoided compared to some
substances when given SC/IM
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• Site Choice
• Identify a suitable vein
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Hands
Advantages
• ƒEasy to access
• ƒMore prominent in
obese patients.
NoteNote
• ƒSite most frequently
chosen for IV
cannulation.
• ƒUse non-dominant
hand if possible.
Disadvantages
• ƒSmall veins –small
volumes.
• ƒDifficult to secure
• ƒIncreased risk of
thrombo-phlebitis.
• ƒLimits wrist mobility
• ƒInsertion painful –
large number of
nerve endings.
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Forearm
AdvantagesAdvantages
• ƒHand can be freely
used
• ƒLarger and
straighter veins
-more rapid infusion
• ƒEasier to secure
• Disadvantages
• ƒIf cannula is placed
near the wrist, can
restrict wrist
movement
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ANTECUBITAL FOSSA
AdvantagesAdvantages
• ƒEasy to access
• ƒThe median cubital
is preferred as it
most stable, close to
surface and overlying
skin less sensitive
DisadvantagesDisadvantages
• ƒSite most frequently
chosen to carry out
venepuncture
• ƒFlexion
• ƒMovement Limited
• ƒBrachial artery
• ƒOften not visible
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Cannulation – attribute of ideal vein
• What are the signs of a good vein ?
– Bouncy
– Soft
– Above previous sites
– Refills when depressed
– Visible
– Has a large lumen
– Well supported
– Straight
– Easily palpable
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Cannulation
• What veins should you avoid ?
– Thrombosed / sclerosed / fibrosed
– Inflamed / bruised
– Thin / Fragile
– Mobile
– Near bony prominences
– Areas or sites of infection, oedema or phlebitis
– Have undergone multiple previous punctures
– For venesection avoid the arm with an IV line
running.
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Cannulation
What equipment do you need?
Dressing Tray -
Non Sterile Gloves / Apron
Cleaning Wipes
Gauze swab
 IV cannula (separate slide)IV cannula (separate slide)
 TourniquetTourniquet
Dressing to secure cannula
Alcohol wipes
Saline flush and sterile syringe or fluid to be administered
Sharps bin
Medical record
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Selecting the right cannulaSelecting the right cannula
Two key points to consider:
• What is the cannula going to used for?
• The condition, location and size of the vein
selected?
You should try to select the smallest gauge
possible that will accommodate the
intravenous therapy that is prescribed.
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Exceptions to this rule: -Exceptions to this rule: -
Patients ConditionPatients Condition Cannula SizeCannula Size
All obstetric patientsAll obstetric patients GreyGrey
Active gastrointestinalActive gastrointestinal
(GI bleed)(GI bleed)
BrownBrown oror GreyGrey
At risk of GI bleedAt risk of GI bleed GreyGrey
At risk of epileptic fitAt risk of epileptic fit GreenGreen
At risk of cardiac eventAt risk of cardiac event GreenGreen
At risk of neurological eventAt risk of neurological event GreenGreen
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Cannulation
Preparation:
• Consult with patient
• Give explanation
• Gain consent
• Position the patient appropriately and identify the
non-dominant hand / arm
• Support arm on pillow or in other suitable manner.
• Check for any contra-indications e.g. infection,
damaged tissue, AV fistula etc.
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Cannulation
Encourage venous filling by:
• Correctly applying a tourniquet (A tourniquet should be
applied to the patient’s upper arm. The tourniquet
should be applied at a pressure which is high enough to
impede venous distension but not to restrict arterial
flow)
• Ask patients to opening & closing their fist
• Lower the level of the arm below the heart
• Light tapping / rubbing of the veins
• Warm compresses over the selected vein
• Relax the patient / consider the environment
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Cannulation
Procedure
• Wash hands prepare equipment
• Remove the cannula from the packaging and
check all parts are operational
• Loosen the white cap and gently replace it
• Apply tourniquet
• Identify vein
• Clean the site over the vein with alcohol wipe,
allow to dry
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Cannulation
• Remove tourniquet if not able to proceed
• Put on non-sterile gloves
• Re-apply the tourniquet, 7-10 cm above site
• Remove the protective sleeve from the needle
taking care not to touch it at any time
• Hold the cannula in your dominant hand, stretch
the skin over the vein to anchor the vein with
your non-dominant hand (Do not re palpate the
vein)
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Cannulation
• Lower the cannula slightly to ensure it
enters the lumen and does not puncture
exterior wall of the vessel
• Gently advance the cannula over the
needle whilst withdrawing the guide,
noting secondary flashback along the
cannula
• Release the tourniquet
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Cannulation
• Apply gentle pressure over the vein
(beyond the cannula tip) remove the white
cap from the needle
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Cannulation
• Remove the needle from the cannula and
dispose of it into a sharps container
• Attach the white lock cap
• Secure the cannula with an appropriate
dressing
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Cannulation
• Flush the cannula with 2-5 mls 0.9%
Sodium Chloride or attach an IV giving set
and fluid
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Cannulation
Finally
Document the procedure including
 Date & time
 Site and size of cannula
 Any problems encountered
 Review date (cannula should be in situ no longer than 72 hours
without appropriate risk assessment.)
 Note: some hospitals have pre-printed forms to record cannula
events
Thank the patient
Clean up, dispose of rubbish
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Cannulation
• Possible Complications:
• The intravenous (IV) cannula offers direct
access to a patient's vascular system and
provides a potential route for entry of micro
organisms into that system. These organisms
can cause serious infection if they are
allowed to enter and proliferate in the IV
cannula, insertion site, or IV fluid.
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Cannulation
• IV-Site Infection: Does not produce much
(if any) pus or inflammation at the IV site.
This is the most common cannula-related
infection, may be the most difficult to
identify
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Cannulation
• Cellulites: Warm, red and often tender
skin surrounding the site of cannula
insertion; pus is rarely detectable.
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Cannulation
• Infiltration or tissuing occurs when the
infusion (fluid) leaks into the surrounding
tissue. It is important to detect early as
tissue necrosis could occur – re-site
cannula immediately
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Cannulation
• Thrombolism / thrombophlebitis occur
when a small clot becomes detached from the
sheath of the cannula or the vessel wall –
prevention is the greatest form of defence. Flush
cannula regularly and consider re-siting the
cannula if in prolonged use.
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Cannulation
• Extravasation is the accidental administration
of IV drugs into the surrounding tissue, because
the needle has punctured the vein and the
infusion goes directly into the arm tissue. The
leakage of high osmolarity solutions or
chemotherapy agents can result in significant
tissue destruction, and significant complications
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Cannulation
• Bruising commonly results from failed IV
placement - particularly in the elderly and
those on anticoagulant therapy.
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Cannulation
• Air embolism occurs when air enters the
infusion line, although this is very rare it is
best if we consider the preventive measures
• – Make sure all lines are well primed prior
to use and connections are secure
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Cannulation
• Haematoma occurs when blood leaks out of the
infusion site. The common cause of this is using
cannula that are not tapered at the distal end. It
will also occur if on insertion the cannula has
penetrated through the other side of the vessel
wall – apply pressure to the site for approximately
4 minutes and elevate the limb
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Cannulation
• Phlebitis is common in IV therapy and can
be cause in many ways. It is inflammation
of a vein (redness and pain at the infusion
site) – prevention can be using aseptic
insertion techniques, choosing the smallest
gauge cannula possible for the prescribed
treatment, secure the cannula properly to
prevent movement and carry out regular
checks of the infusion site.
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URINARY CATHETERIZAION:
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Objectives:
• Describe urethral catheterization
• Identify types of Urethral catheters
• Describe indications of urethral catheterization
• Identify equipments used for urethral catheterization
• Demonstrate techniques of urethral catheterization
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Urinary Catheterization
• Urethral catheterization is a routine medical
procedure that facilitates direct drainage of the
urinary bladder.
• It may be used for diagnostic purposes (to help
determine the etiology of various genitourinary
conditions) or therapeutically (to relieve urinary
retention, instill medication, or provide irrigation).
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 Urinary catheterization is done when a
person is unable to urinate using a toilet,
bedpan, urinal, bedside commode, or
when accurate urinary output is required
 A urinary catheter is a tube that is inserted
into the bladder through the urethra to
allow the urine in the bladder to drain out
Urinary Catheterization…
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 A urinary catheter is used in many different situations:
– A urinary catheter may be inserted to drain the bladder
before or during a surgical procedure, during recovery
from a serious illness or injury, or to collect urine for
testing
– A urinary catheter may be used for a person who is
incontinent of urine, if the person has wounds or
pressure ulcers that would be made worse by contact
with urine
– A urinary catheter is necessary when a person is unable
to urinate because of an obstruction in the urethra
Situations When a Urinary Catheter is Used
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Urinary Catheterization…
• Catheters may be inserted as an in-and-out
procedure for immediate drainage,
• Left in with a self-retaining device for short-term
drainage (as during surgery), or
• Left indwelling for long-term drainage for patients
with chronic urinary retention.
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Types of catheters
 A condom catheter, consists of a soft plastic or rubber
sheath, tubing, and a collection bag for the urine. The
sheath is placed over the penis and the collection bag is
attached to the leg. Collects urine when there is no need
for catheter insertion.
 A straight catheter, is used when the catheter is to be
inserted and removed immediately.
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Types of catheters
 A suprapubic catheter is a type of indwelling catheter.
The suprapubic catheter is inserted into the bladder
through a surgical incision made in the abdominal wall,
right above the pubic bone.
 An indwelling catheter, also known as Foley catheter, is
left inside the bladder to provide continuous urine
drainage.
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Indications
Diagnostic indications include the following:
• Collection of uncontaminated urine specimen
• Monitoring of urine output
• Imaging of the urinary tract
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Therapeutic indications include the following:
• Acute urinary retention(eg, blood clots)
• Chronic obstruction
• Initiation of continuous bladder irrigation
• Hygienic care of bed ridden patients
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Equipment for Catheter Insertion
 Equipment: (check packages and expiry dates)
– Catheter tray (with drapes, fenestrated drape, cotton balls, forceps)
– Catheter (14-16 Fr (for women) 12 Fr for young girls
(16-18 Fr (for men)
– Sterile drainage tubing with collection bag
– Correct size syringe (check catheter balloon)
– Sterile water
– Cleansing solution
– Lubricant
– Sterile gloves
– Specimen container
– Tape to anchor tubing
– Gloves
– Bath blanket
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Procedure
• Prepare the client and equipment for perennial
wash
• Position the patient
 Female: dorsal recumbent (supine with knees flexed) or
Sims position (side-lying with upper leg flexed at knee
and hip)
 Male: supine position
• Drape the patient.
• Wash the perennial area with warm water and
soap
• Rinse and dry the area, Prepare the equipment
20805/12/19
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Procedure…
• Create a sterile field
• Cover the client with a sterile drape
 women: fenestrated over perineum
 men: over thighs and fenestrated over penis
• Clean the area with antiseptic solution.
• Lubricate the insertion tip of the catheter (2.5 to 5 cm for
women) and 12.5 to 17.5 cm for men)
• Expose the urinary meatus adequately by retracting the
tissue or the labia minora in an upward direction – female
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Procedures…
 Cleanse meatus:
 Women: with nondominant hand, expose meatus,
maintain position of hand, cleanse with forceps, wipe from
front to back, new cotton ball each swipe, far labial fold,
near, and directly over meatus
 Men: retract foreskin, hold penis below glans, maintain
position of hand, with forceps clean in a circular motion
from meatus down to base of glans, repeat three more
times
• Hold end of catheter loosely coiled in dominant hand,
place end of catheter in tray
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Procedures…
• Insert catheter into the urethral orifice :
• Women: ask client to bear down as if to void,
insert 5 to 7.5 cm or until urine flows, then
advance another 2.5 to 5 cm
• Men: hold penis perpendicular, ask client to bear
down, insert 17 to 22.5 cm or until urine flows,
then advance 2.5 to 5cm to bifurcation
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Procedure con…
 Collect specimen if indicated(about 30 ml)
 Inflate balloon with amount indicated(Foley catheter)
 The balloons are sized by the volume of fluid or air used to inflate
them 5 ml – 30 ml (15 commonly)
 If client complains of pain, aspirate solution and advance
catheter further and inflate
 Gently pull to feel resistance
 Attach catheter to collection bag and attach to bed frame
below bladder
 Allow bladder to empty unless policy restricts (500 to 1000
ml)
 Anchor catheter (thigh if appropriate and coil tubing on
bed and attach to mattress)
• Connect with collecting bag and leave the pt comfortable
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Evaluate
 Palpate bladder
 Assess comfort
 Characteristics and amount of urine
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Document
 Report and record type and size of catheter
 Amount of fluid used to inflate balloon
 Characteristics of urine, amount, reason for
catheter, specimens, client’s response
 E.g. Date 3/26/08 Time - 0915
 14 F Foley catheter inserted without difficulty. 10 ml of sterile
water injected into balloon port. 300 ml clear yellow urine
returned. Pt tolerated procedure with out incident. - Name,
profession
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Catheter-associated Urinary Tract
Infection (CAUTI) - complication
• A urinary tract infection that occurs while a
patient has an indwelling urinary catheter
or within 48 hours of its removal.
• Single most common healthcare-associated
infection (HAI), accounting for 34% of all
HAIs.
• Associated with significant morbidity and
excess healthcare costs.
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Wound care and NGT Insertion
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Objectives:
At the end of this lesson students are expected to:
 Differentiate types of wounds.
 Explain the purpose of wound care.
 List important equipment needed to provide wound care.
 Perform dressing of clean and septic wounds.
 Provide care for the patient with draining wound.
 Demonstrate skill of wound suturing and irrigation.
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What is a Wound?
• Any break in the continuity of body tissue
• A wound is "any injury caused by physical means
that results in disruption of normal continuity of
tissues and structures.
Examples:
• grazes, burns, surgical incisions, stabs, leg ulcers,
decubitus ulcers ( pressure sores)
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Wounds –Classification
• Superficial
• Penetrating
• Perforating
• Laceration
• Puncture
• Abrasion
• Contusion
• Clean
• Contaminated
• Infected
• Colonized
• Pressure Ulcers
Stage I
Stage II
Stage III
Stage IV
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Wound - Healing
• Healthy body has the ability to restore
itself, it depends on the amount of damage
and state of health of the individual.
• Referred to as regeneration (renewal) of
tissue.
• There are (3) phases of regeneration
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Phase I Wound Healing
Inflammatory phaseInflammatory phase /Defensive phase/Defensive phase
• Begins immediately after injury.
• Includes Hemostasis (cessation of bleeding) due to
vasoconstriction and platelet aggregation. Release of
histamine, increasing capillary permeability (plasma
leaking) and vasodilation
• Also phagocytosis ( process when macrophages engulf
microbes and secrete growth factors that promote
angiogenesis) stimulates epithelial buds at injured tissue
resulting in increased circulation
• The four Cardinal S/S – Pain, Redness, Heat, Edema
• Inflammatory Response - SYSTEMIC RESPONSE Elevated
temperature, Elevated WBC ( norms 5000-10000) and
Malaise
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Phase II Wound Healing
Proliferation (Fibroplasia) PhaseProliferation (Fibroplasia) Phase
• Second phase , fibroblasts synthesize collagens which add
strength to the wound.
• Proliferation lasts from day three until the area is healed
and features granulation, contraction, and
epithelialization.
• Thin layer of epithelial cells forms, blood flow is
reinstituted. Tissue forms - known as granulation tissue.
Translucent red color/fragile/bleeds easily.
• Granulation includes neoangiogenesis and increased
collagen formation.05/12/19 222
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Phase III Wound Healing
Maturation (Remodeling) PhaseMaturation (Remodeling) Phase
• Final phase begins about 3 weeks after the injury.
• Collagen originally in haphazard order remodels and
reorganizes into a more orderly structure.
• Maturation is the last phase of healing, and involves scar
remodeling after wound closure and may take years.
• ScarScar (cicatrix) forms - avascular tissue , doesn’t sweat, grow
hair, or tan.
• KeloidKeloid- abnormal amount of collagen laid down,
hypertrophic scar. ( common in dark skin).
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Types of Wound Healing
• Primary Intention: clean, straight line, edges well
approximated with sutures, rapid healing
• Secondary Intention: larger wounds with tissue
loss, edges not approximated, heals from the
inside out, granulation tissue fills in the wound,
longer healing time, larger scars
• Tertiary Intention: delay 3-5 days before injury is
sutured, greater access for pathogens to invade,
greater inflammation, more granulation, larger
scars .
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Factors Influencing Wound Healing
• Good blood supply: ( oxygen, nutrients)
• Good nutrition:
• Rest: skin cells multiply more rapidly
during sleep
• Lack of stress: increased levels of adrenaline and
steriods delay healing
• Lack of infection:
• Age : children heal more rapidly than older people
• Site of wound: face and neck heal more rapidly
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Factors Delaying Wound Healing
General factors
• poor diet
• anaemia
• pulmonary disease
• cardiac insufficiency
• arteriosclerosis
• diabetes mellitus
• smoking
• Jaundice
• malignant disease
• high blood urea
• stress
• lack of sleep
• drug therapy e.g.
steroids and
cytotoxic
• radiotherapy
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Factors Delaying Wound Healing
Local to patient/wound
• Skin edges not lined up
• Dead tissue in wound
• Foreign bodies in wound
• Tension on wound
• Infection
• Irritant material for suturing
• Too tight suturing
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