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Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury

  1. 1. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 1 LECTURES ON BASICS OF PRACTICAL NURSING ………………………FOR BEGINNERS. NURSING DEFINATION, BASIC ROLE OF NURSING BASIC ROLE OF NURSING: Definition: “It is the diagnosis and treatment of human responses to actual or potential health problems” (ANA 1980). It is assisting the individual, sick or well in the performance of those activities contributing to health or its recovery (to peaceful death) that he will perform unaided, if he had the necessary strength, will or knowledge and to do this in such a way as to help him gain independence as rapidly as possible (Virginia Henderson 1960). ROLE OF SISTER and DOCTOR’S PROFESIONAL RELATION SHIP. Great doctor-nurse relationships are critical for quality patient care. Collaboration, clear communication, cooperation, respect, and positive attitudes are the essential ingredients for any relationship. Shared positive attitude and behavior is what will drive a team to be successful. Doctors and nurses need to function at an emotionally intelligent level. Doctor and nurse relationship is very important during work they should work together as a team, the professional nurse should share with the doctor about the treatment for the patient , some doctors still think that nurses only taken order, this vision should be changed. Importance of Nurse in clinical observation. Professional nurse can play a great role in clinical observations and they can guide the consultant for the plan of treatment, to be a good professional than you have to improve your depth in subject and clinical skills. BASIC NURSING PROCEDURES AND SKILLS VITAL SIGNS (Cardinal Signs) Vital signs reflect the body’s physiologic status and provide information critical to evaluating homeostatic balance. The term “vital” is used because the information gathered is the clearest Indicator of overall health status. Vital signs Includes: T(temperature),P (Pulse Rate),R(Respiratory rate) and BP (Blood Pressure) Vital Signs = Temperature, Pulse, Respirations, & Blood Pressure Temperature = Warmth of the body, a balance between heat produced & lost. The Hypothalamus = the thermostat that regulates body temperature.  Blood Pressure(BP) mm/Hg(mercury)  Temperature(temp) degree Fernaheite( ) or ( )  Pulse beats/mt,BPM  Respiration Rate: RPM  Saturation: SpO2 %  Blood Sugar : mg/dl Purposes:  To obtain base line data about the patient condition  To aid in diagnosing patient condition (diagnostic purpose)  For therapeutic purpose so that to intervene accordingly Equipment  Vital sign tray  Stethoscope  Sphygmomanometer  Thermometer (glasses, electronic or tympanic)  Second hand watch.  Red and blue pen  Pencil  Vital sign sheet  Cotton swab in bowel  Disposable gloves if available  Dirty receiver kidney dish Nursing note of vitals Temp= 99 Pulse= 98 BPM R = 22 RPM BP= 110/70 mm Hg. SpO2= 99% RBS= 110 mg/dL
  2. 2. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 2 Times to Assess Vital Signs On admission – to obtain baseline data. When a client has a change in health status or reports symptoms such as chest pain or fainting According to a nursing or medical protocol. Before and after the administration of certain medications that could affect RR or BP (Respiratory and CVS (Cardio Vascular System)). Before and after surgery or an invasive diagnostic procedures. Before and after any nursing intervention that could affect the vital signs. E.g. Ambulation According to hospital or health institution policy. Temperature Body temperature is the measurement of heat inside a person’s body (core temperature); it is the balance between heat produced and heat lost. Normal body temperature using oral (O; or per os, PO) measurement remains as appropriately 37 (Celsius )or 98.6 . 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, this Is the Temperature that we measure with thermometer 2. Surface Temperature:  The temperature of the skin, the subcutaneous tissue and fat. Alterations in Body Temperature Normal body temperature is: 37 or 98.6 (Average) the range is 36-38 or 96.8 – 100  Pyrexia: a body temperature above the normal ranges 38 – 41 100.4 –105.8  Hyper pyrexia: a very high fever, such as 410 C > 42 0c leads to death. A client who has fever is referred as febrile; the one who has not is afebrile.  Hypothermia: – body temperature between 34 0c – 35 0c, < 34 0c is death Temperature Conversations °F = 9/5 °C + 32 °C = 5/9 (°F - 32) Common Types of Fevers  Intermittent fever: the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperature.  Remittent fever: a wide range of temperature fluctuation (more than 2 0c) occurs over the 24 hr period, all of which are above normal Heat production muscles glands oxidation of food Heat loss respiration perspiration excretion
  3. 3. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 3  Relapsing fever: short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature.  Constant fever: the body temperature fluctuates minimally but always remains above normal Factors Affecting Body Temperature 1. 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  Normal body temperature of the newborn if taken orally is 37 0C. 2. Diurnal variations (circadian rhythms)  Body temperature varies throughout the day  The point of highest body temperature is usually reached between 8:00 p.m. and midnight and lowest point is reached during sleep between 4:00 and 6:00 a.m. 3. Exercise  Hard or strenuous exercise can increase body temperature to as high as 38.3 – 40 – measured rectally 4. Hormones  • In women progesterone secretion at the time of ovulation raises body temperature by about 0.3 – 0.6 above basal temperature. 5. Stress  Stimulation of skin can increases the production of epinephrine and nor- epinephrine – which increases metabolic activity and heat production. 6. Environment • Extremes in temperature can affect a person’s Temperature regulatory systems. Measuring Body Temperature/ Sites to Measure Temperature Most common are:  Oral  Rectal  Axillary  Tympanic Thermometer: it is an instrument used to measure body temperature Types of Thermometers 1. Oral thermometer Have long slender tips
  4. 4. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 4 2. Rectal thermometer Short, rounded tips 3. Axillary Long and slender tip 4. Tympanic In other way it is also divided as mercury, digital and electronic types. In developed countries, mercury type thermometers are no more use in hospital setup but in our context still very important. 1. Rectal Temperature recording procedure:  Readings are considered to be more accurate, most reliable, is > 0.650 c (1 0F) higher than the oral temperature. Procedure  Explain the procedure to the patient  Wash hands and assemble necessary equipment and bring to the patient bedside.  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 ORAL THERMAMETER
  5. 5. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 5  Remove the thermometer and read the finding  Clean the thermometer with tissue paper  A rectal thermometer record does not respond to changes in arterial temperature as quickly as an oral thermometer Contraindications  Rectal or perineal surgery;  Fecal impaction – the depth of the thermometer insertion may be insufficient;  Rectal infection;  Neonates –can cause rectal perforation and ulceration; 2. Oral temperature recording procedure  Explain the procedure to the patient  Wash hands and assemble necessary equipment and bring to the patient bedside.  Position the person comfortably and request the patient to open the mouth;  Hold the thermometer firmly with the thumb and fore finger; shake it with strong wrist movements until the mercury line falls to at least 35 Place the bulb of the thermometer well under the client’s tongue. Instruct the client to close the lips (not the teeth) around the bulb. Ensure that the bulb rests well under the tongue, where it will be in contact with blood vessels close to the surface.  Remove the thermometer after 3 to 5 minutes.  Remove the thermometer, wipe it using it once a firm twisting motion  Hold the thermometer at eye level. Read to the nearest tenth Dispose the tissue. Wash the thermometer in lukewarm, soapy water. Dry and replace the thermometer in a container at bedside.  Wash your hands.  Record temperature on paper or flow sheet.  Report an abnormal reading to the appropriate person. Contraindication Child below 7 yrs If the patient is delirious, mentally ill Unconscious Uncooperative or in severe pain Surgery of the mouth Nasal obstruction If patient has nasal or gastric tubs in place 3. Axillary temperature procedure (Armpit thermometer) Wash hands  Make sure that the client’s axilla is dry, If it is moist, pat it dry gently before inserting the thermometer.  After placing the bulb of the thermometer in to the axilla, bring the client’s arm down against the body as tightly as possible, with the forearm resting across chest.  Hold the glass thermometer in place for 8 to 10 minutes. Hold the electronic thermometer in place until the reading registers directly.  Remove and read the thermometer. Dispose of the equipment properly. Wash hands  Record the reading  N.B. The Axillary method is safest and most noninvasive. 4. Tympanic Temperature The tympanic temperature is placed snugly (safely) in to the client’s outer ear canal. It records temperature in 1 to 2 seconds. Many paediatric and intensive care units use this type of thermometer because it records a temperature so rapidly. Procedure
  6. 6. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 6  Wash the hands  Explain the procedure to the client to ensure cooperation and understanding.  Hold the probe in the dominant hand. Use the client’s same ear as your hand (e.g. use the client’s right ear when you use your right hand).  Select the desired mode of temperature. Use the rectal equivalent for children under 3 years of age Wait for “ready” message to display.  With your nondominant hand, grasp the adult’s external ear at the midpoint. Pull the external ear up and back. For a child of 6 years or younger, use your nondominant hand to pull the ear down and back.  Slowly advance the probe in to the client’s ear with a back and forth motion until it seals the ear canal.  Point the probe’s tip in an imaginary line from the client’s sideburns to his or her opposite eyebrow.  As soon as the instrument is in correct position, press the button to activate the thermometer.  Keep the probe in place until the thermometer makes a sound or flashes a light.  Read the temperature and discard the probe cover.  Replace the thermometer and wash your hands.  Record the temperature on the client’s record. Pulse It is a wave of blood created by contraction of the left ventricle of the heart. i.e. the pulse reflects the heart beat or is the same as the rate of ventricular contractions of the heart in a healthy person. In some types of cardiovascular diseases heartbeat and pulse rate differs. Eg. Client's heart produces very weak or small pulses that are not detectable in a peripheral pulse far from the heart. Peripheral Pulse: is a pulse located in the periphery of the body(away from heart) e.g. in the foot, an, or neck, arm Apical Pulse (central pulse): it is located at the apex of the heart The PR is expressed in beats/ minute (BPM) Pulse Deficit- It is a difference that exists between the apical and radial pulse Factors Affecting Pulse Rates  Age: as age increase the PR gradually decreases. New born to 1 month – 130 BPM 80- 180 (range) Adult 80 BPM (beat per minute) – 60 – 100 BPM (beat per minute range)  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  Medications: digitalis preparation 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 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 rate. Pulse Sites Temporal: is superior (above) and lateral to (away from the midline of) the eye
  7. 7. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 7 1. Carotid: at the side of the neck below tube of the ear (where the carotid artery runs between the trachea and the sternoclidiomastoid muscle) 2. Temporal: the pulse is taken at temporal bone area. 3. Apical: at the apex of the heart: routinely used for infant and children < 3 yrs In adults – Left clavicular line under the 4th, 5th, 6th intercostals space Children < 4 yrs of the Lt. mid clavicular line 4. Brachial: at the inner aspect of the biceps muscle of the arm or medially in the antecubital space (elbow crease) 5. Radial: on the thumb side of the inner aspect of the wrist – readily available and routinely used 6. Femoral: along the inguinal ligament. Used or infants and children 7. Popliteal: behind the knee. By flexing the knee slightly 8. Posterior tibial: on the medial surface of the ankle 9. Pedal (Dorslais Pedis): palpated by feeling the dorsum (upper surface) of the foot on an imaginary line drawn from the middle of the ankle to the surface between the big and 2nd toes Method Pulse: is commonly assessed by palpation (feeling) or auscultation (hearing).The middle 3 fingertips are used with moderate pressure for palpation of all pulses except apical; the most distal parts are more sensitive, Assess the pulse for  Rate  Rhythm  Volume  Elasticity of the arterial wall Pulse Rate  Normal pulse 60-100 b/min (80/min)  Tachycardia – excessively fast heart rate (>100/min)  Bradycardia-Less than normal heart rate(< 60/min)
  8. 8. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 8 Normal Results For resting heart rate: Newborns (0-30 days old): 70 - 190 beats per minute Infants (1 - 11 months old): 80-120 beats per minute Children 1 to 10 years: 70 - 130 beats per minute Children over 10 and adults (including seniors): 60 - 100 beats per minute Well-trained athletes: 40 - 60 beats per minute Pulse Rhythm The pattern and interval between the beats, random, irregular beats – dysrythymia Pulse Volume: the force of blood with each beat  A normal pulse can be felt with moderate pressure of the fingers and can be obliterated with greater pressure.  Full or bounding pulse forceful or full blood volume obliterated with difficulty  Weak, feeble or thready readily obliterated with pressure from the finger tips Elasticity of arterial wall  A healthy, normal artery feels, straight, smooth, soft and pliable, easily bent after breaking  Reflects the status of the clients vascular system If the pulse is regular, measure (count) for 30 seconds and multiply by 2, If it is irregular count for 1 full minute Procedure for measuring radial pulse (the most common)  Wash hands  Explain the procedure to the client
  9. 9. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 9  Position the client’s forearm comfortably with the wrist extended and the palm down  Place the tips of your first, second, and third fingers over the client’s radial artery on the inside of the wrist on the thumb side.  Press gently against the client’s radial artery to the point where pulsation can be felt distinctly  Using a watch, count the pulse beats for 30 seconds and multiply by two to get the rate per minute  Count the pulse for full minute if it is abnormal in any way or take an apical pulse  Record the rate (BPM) on paper or the flow sheet. Report any irregular findings to appropriate erson  Wash your hands Respiration Respiration is the act of breathing (includes intake of o2 removal of co2) Ventilation is another word, which refer to the movement of air in and out of the lungs. Hyperventilation: very deep, rapid respiration Hypoventilation: very shallow respiration Two Types of Breathing 1. Costal (thoracic) Involves the external muscles and other accessory muscles (sternoclodio mastoid) Observed by the movement of the chest up ward and down ward. Commonly used for adults 2. Diaphragmatic (abdominal) Involves the contraction and relaxation of the diaphragm, observed by the movement of abdomen. Commonly used for children. Assessment The client should be at rest Assessed by watching the movement of the chest or abdomen. Rate, rhythm, depth and special characteristics of respiration are assessed A. Rate: is described in rate per minute (RPM) Healthy adult RR = 15- 20/ min. is measured for full minute, if regular for 30 seconds. As the age decreases the respiratory rate increases.  Eupnea- normal breathing rate and depth  Bradypnea- slow respiration  Tachypnea - fast breathing  Apnea - temporary cessation of breathing B. Rhythm: is the regularity of expiration and inspiration Normal breathing is automatic & effortless. C. Depth: described as normal, deep or shallow. Deep: a large volume of air inhaled & exhaled, inflates most of the lungs. Shallow: exchange of a small volume of air minimal use of lung tissue. Blood Pressure Blood pressure is the pressure exerted by blood against the wall of blood vessels. It includes arterial, venous and capillary pressures. Arterial BP: it is a measure of a pressure exerted by the blood as it flows through the arteries. Arterial blood pressure (BP) =cardiac output (CO) x total peripheral resistance (TPR). There are two types of blood pressure. 1. Systolic pressure: is the pressure of the blood as a result of contraction of the ventricle (is the pressure of the blood at the height of the blood wave); 2. Diastolic blood pressure: is the pressure when the ventricles are at rest.
  10. 10. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 10 3. Pulse pressure: is the difference between the systolic and diastolic pressure Blood pressure is measured in mm Hg and recorded as fraction. A number of conditions are reflected by changes in blood pressure.  Increase in blood pressure is called hypertension;  Decrease is called hypotension Conditions Affecting Blood Pressure  Fever Increase  Stress”  Arteriosclerosis "  Obesity "  Hemorrhage Decrease  Low hematocrit "  External heat "  Exposure to cold Increase Sites for Measuring Blood Pressure 1. Upper arm using brachial artery (commonest) 2. Thigh around popliteal artery 3. Fore -arm using radial artery 4. Leg using posterior tibial or dorsal pedis Methods of Measuring Blood Pressure Blood pressure can be assessed directly or indirectly 1. Direct (invasive monitoring) measurement involves the insertion of catheter in to the brachial, radial, or femoral artery. The physician inserts the catheter and the nurse monitors the pressure reading. With use of correct placement, it is highly accurate. 2. Indirect (non invasive methods) The auscultatory The palpatory The auscultatory method is the commonest method used in health activities. When taking blood pressure using stethoscope, the nurse identifies five phases in series of sounds called Korotkoff's sound. Phase 1: The pressure level at which the 1st joint clear tapping sound is heard, these sounds gradually become more intense. To ensure that they are not extraneous sounds, the nurse should identify at least two consecutive tapping sounds. Phase 2: The period during deflation when the sound has a swishing quality Phase 3: The period during which the sounds are crisper and more intense Phase 4: The time when the sounds become muffled and have a soft blowing quality Phase 5: The pressure level when the sounds disappear Procedure Assessing Blood pressure Purpose  To obtain base line measure of arterial blood pressure  for subsequent evaluation  To determine the clients homodynamic status  To identify and monitor changes in blood pressure resulting from a disease process and medical therapy. EQUEPMENT
  11. 11. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 11 Sphygmomanometer A sphygmomanometer) or blood pressure meter is a device used to measure blood pressure, comprised by an inflatable cuff to restrict blood flow, and a mercury or mechanical manometer to measure the pressure. It is always used in conjunction with a means to determine at what pressure blood flow is just starting, and at what pressure it is unimpeded. Manual sphygmomanometers are used in conjunction with a stethoscope. The word comes from the Greek sphygmós (pulse), plus the scientific term manometer (pressure meter). The device was invented by Samuel Siegfried Karl Ritter von Basch in 1881. Scipione Riva-Rocci introduced a more easily used version in 1896. In 1901, Harvey Cushing modernized the device and popularized it within the medical community. A sphygmomanometer consists of an inflatable cuff, a measuring unit (the mercury manometer, or aneroid gauge), and inflation bulb and valve, for manual instruments.  Stethoscope  Blood pressure cuff of the appropriate size  Sphygmomanometer Procedure 1. Prepare and position the patient appropriately Make sure that the client has not smoked or ingested caffeine, within 30 minutes prior to measurement. Position the patient in sitting position, unless otherwise specified. The arm should be slightly flexed with the palm of the hand facing up and the fore arm supported at heart level Expose the upper arm
  12. 12. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 12 2. Wrap the deflated cuff evenly around the upper arm.  Apply the center of the bladder directly over the medial aspect of the arm. The bladder inside the cuff must be directly over the artery to be compressed if the reading to be accurate.  For adult, place the lower border of the cuff approximately 2 cm above antecubital space. 3. For initial examination, perform preliminary palipatory determination of systolic pressure  Palpate the brachial artery with the finger tips  Close the valve on the pump by turning the knob clockwise.  Pump up the cuff until you no longer feel the brachial pulse  Note the pressure on sphygmomanometer at which the pulse is no longer felt  Release the pressure completely in the cuff, and wait 1 to 2 minutes before making further measurement 4. Position the stethoscope appropriately  Insert the ear attachments of the stethoscope in your ears so that they tilt slightly foreword.  Place the diaphragm of the stethoscope over the brachial pulse; hold the diaphragm with the thumb and index finger. 5. Auscultate the client's blood pressure Pump up the cuff until the sphygmomanometer registers about 30 mm Hg above the point where the brachial pulse disappeared. Release the valve on the cuff carefully so that the pressure decreases at the rate 2-3 mmHg per second. As the pressure falls, identify the manometer reading at each of the five phases Deflate the cuff rapidly and completely Repeat the above step once or twice as necessary to confirm the accuracy of the reading. 6. Remove the cuff from the client’s arm 7. For initial determination, repeat the procedure on the client's other arm, there should be a difference of no more than 5 to 10 mmHg between the arms. The arm found to have the higher pressure, should be used for subsequent examinations 8. Document and report pertinent assessment data, report any significant change in client's blood pressure to the nurse in charge also report these finding:  Systolic blood pressure (of adult) above 140 mmHg.  Diastolic blood pressure (of an adult) above 90 mmHg.  Systolic blood pressure of (an adult) below 100mmHg. Normal blood pressure less than 120/80mmHg Pre-hypertension 120-139/ 80-89 mmHg High blood pressure (stage 1) 140-159/90-99 mmHg High blood pressure (stage 2) higher than 160/100 mmHg Pulse oximeter A finger mounted pulseoximeter taking measurement through the fingernail. A wrist mounted remote sensor pulseoximeter with Plethysmogram.
  13. 13. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 13 A pulseoximeter (saturometer) is a medical device that indirectly monitors the oxygen saturation of a patient's blood (as opposed to measuring oxygen saturation directly through a blood sample) and changes in blood volume in the skin, producing a photoplethysmograph. It is often attached to a medical monitor so staff can see a patient's oxygenation at all times. Most monitors also display the heart rate. Portable, battery- operated pulseoximeter are also available for home blood-oxygen monitoring. The original oximeter was made by Millikan in the 1940s.[1] The precursor to today's modern pulse oximeter was developed in 1972, by Aoyagi at Nihon Kohden using the ratio of red to infrared light absorption of pulsating components at the measuring site. It was commercialized by Biox in 1981. The device did not see wide adoption in the United States until the late 1980s. ROUTE OF ADMINSTRATION OF DRUGS Defination: The route of administration (ROA) that is chosen may have a profound effect upon the speed and efficiency with which the drug acts CLASSIFICATION SYSTEMIC ROUTES  ENTERAL  ORAL  SUBLINGUAL  RECTAL  PARENTERAL  LOCAL ORAL ROUTE
  15. 15. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 15 Type of Oral Medication  Lozenges (troches) - sweet medicinal tablet containing sugar that dissolve in the mouth so that the medication is applied to the mouth and throat  Tablets - a small disc or flat round piece of dry drug containing one or more drugs made by compressing a powdered form of drug(s)  Capsules - small hollow digestible case usually made of gelatin, filled with a drug to be swallowed by the patient.  Syrups - sugar containing medicine dissolved in water  Tinctures - medicinal substances dissolved in water  Suspensions - liquid medication with undissolved solid particles in it.  Pills and gargle - a small ball of variable size, shape and color some times coated with sugar that contains one or more medicinal substances in solid form taken in mouth.  Effervescence - drugs given of small bubbles of gas.  Gargle - mildly antiseptic solution used to clean the mouth or throat.  Powder - a medicinal preparation consisting of a mixture of two or more drugs in the form of fine particles.
  16. 16. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 16 INTRAMUSULAR ROUTE 1.Very rapid absorption of drugs in aqueous solution 2.Suppository and slow release reparations 3. pain at injection sites for certain drugs IM Injection—Deltoid  Upper arm  Triangular area  Use for vaccinations with small volumes  Muscle is small  Avoid hitting radial nerve  Patient should sit upright or lie flat and relax arm muscles Dorsogluteal Method 1 Divide buttock into imaginary quadrants Administer drug into upper outer quadrant ADVANTAGES
  17. 17. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 17 Dorsogluteal Method 2 Locate posterior superior iliac spine and greater trochanter of femur. Draw imaginary line between the two landmarks. Injection given up and out from this line. IM Injection—Dorsogluteal  Large muscles  Can inject up to 5 mL  Anything >3 mL uncomfortable  Patient lies prone  Toes pointing inward to relax muscles IM Injection—Vastus Lateralis and Rectus Femoris Side by side in thigh Vastus lateralis is preferred injection site for children Rectus Femoris used for self-injection due to its accessibility May inject up to 5 mL in adult Volumes for injection vary with patient age and muscle size IM Injection—Ventrogluteal
  18. 18. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 18 Inhalation 1. Gaseous and volatile agents and aerosols 2. Rapid onset of action due to rapid access to circulation A. large surface area B. thin membranes separate alveoli from circulation C. high blood flow Particles larger than 20 micron and the particles impact in the mouth and throat. Smaller than 0.5 micron and they aren't retained. 6- Inhalation route: Respiratory system. Except for IN, risk hypoxia. Intranasal (snorting) Snuff, cocaine may be partly oral via post-nasal dripping. Fairly fast to brain, local damage to septum. Some of the volatile gases also appear to cross nasal membranes. Smoke (Solids in air suspension, vapors) absorbed across lung alveoli: Nicotine, opium, THC, freebase and crack cocaine, crystal meth. Particles or vapors dissolve in lung fluids, and then diffuse. Longer action than volatile gases. Tissue damage from particles, tars, CO2. Volatile gases: Some an aesthetics (nitrous oxide, ether) [precise control], petroleum distillates. Diffusion and exhalation (alcohol). Lung-based transfer may get drug to brain in as little as five seconds. Intradermal:  10 – 15-degree angle  0.1 mL or less of medication  injection into the Dermis  form a bleb or wheal  common site: forearm, upper back, upper dorsal aspect of the arm, and upper chest  many nerves are in the dermis – painful, burning sensation, stinging  TB and allergy testing most common  27g needle most common  give “slowly” Topical Mucosal membranes (eye drops, antiseptic, sunscreen, callous removal, nasal, etc.) Skin a. Dermal - rubbing in of oil or ointment (local action) b. Transdermal - absorption of drug through skin (systemic action) i. stable blood levels ii. no first pass metabolism Intradermal
  19. 19. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 19 iii. Drug must be potent or patch becomes to large Route for administration -Time of medicine effect starts  intravenous 30-60 seconds  intraosseous 30-60 seconds  endotracheal 2-3 minutes inhalation 2-3 minutes  sublingual 3-5 minutes  intramuscular 10-20 minutes  subcutaneous 15-30 minutes  rectal 5-30 minutes  ingestion(oral) 30-90 minutes  Transdermal (topical) variable (minutes to hours) Very Important Info! No single method of drug administration is ideal for all drugs in all circumstances Parenteral Routes of Medication Administration Routes of Administration and Rates of Absorption  Parenteral Routes  Enteral Routes – drug placed directly in the GI tract:  Sublingual Routes - placed under the tongue  Oral Routes - swallowing (p.o., per os)  Rectal Routes - Absorption through the rectum
  20. 20. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 20 SYRANGES AND NEEDLES Types of Syringes & Needles Giving medications by injection requires the use of the right syringe, the right needle and the right part of the body. Syringes are also used to remove blood from the body during blood donation, for blood samples and to transfuse blood into a patient. About Syringes Syringes are made up of a round cylindrical barrel, a close-fitting plunger and a tip where the hub of a needle is attached. They come in a number of sizes, ranging from .5 ml to 60 ml. A 1- to 3-ml syringe is normally adequate for injections given into tissues under the skin, also called subcutaneous injections, or injections into muscle, also known as intramuscular injections. Larger syringes are used to add medication to intravenous lines and irrigate wounds.
  21. 21. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 21 Classification Syringes are generally classified as Luer-Lok or non-Luer-Lok syringes. This classification is based on the type of syringe tip. Luer-Lok syringes have tips that require needles that can be twisted and locked into place. This design prevents the needle from accidentally slipping off the syringe. Non-Luer-Lok syringes have tips that require needles that can be pressed on to the tip of the syringe without being twisted into place. Insulin Syringe Insulin syringes are small in size, they hold between 0.3 and 1 ml of medication. These needles are not calibrated in milliliters, they are calibrated in units. Most insulin syringes are calibrated up to 100 units. Insulin syringes are designed for self-injection and are used to give subcutaneous injections. Tuberculin Syringe Tuberculin syringes are used for tuberculosis testing. The fluid they contain is injected right into the skin. This syringe is small and is calibrated in milliliters. It has a long, thin barrel with a preattached needle. The tuberculin syringe can hold up to 1 ml of fluid. Even though this syringe is small, it cannot be used to give insulin. About Needles
  22. 22. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 22 Most needles are made of stainless steel. The needle is hollow with a hole in the middle and has three parts: the hub, which fits on to the tip of the syringe; the shaft, which is the long length of the needle; and the bevel, which is the slanted tip of the needle. The bevel creates a narrow slit or hole in a person’s skin through which the fluid in the syringe is injected into a person. This slit closes once the needle is removed from the person's skin so there is no leakage of medication or blood. Long-beveled tips are sharper and narrower, which reduces discomfort when it pierces the skin. Injection Needle Description: Structure: Plastic protector, hub, stainless steel needle cannula Size: 16G--30G in general also available in different sizes. Different color hub for easy recognition of size. This colour code has slight different from company to company it is advisable that look at the number. Types of Needles Needles are differentiated based on their length and diameter. The length of needles range from between 1/2-inch to 3 inches. The diameter of a needle is measured in gauges. A 25-gauge needle has a smaller diameter than a 19-gauge needle. As the needle gauge gets bigger, the needle's diameter gets smaller. Two different needles may have the same length and have different gauge sizes. Needle gauges range from between 7 gauges being the largest to 33 gauge the smallest. Gauge selection is made based on the thickness of a medication to be given. If the medication is thick, a needle with a small gauge and big diameter would be the needle of choice. Intramuscular medications are given with long needles, while subcutaneous medications are given with shorter needles. _____________________________________________________________________________________________________ BEDMAKING AND POSITIONS OF BED Hospital Bed A hospital bed is a special bed that may be needed to care for a person who is ill. You can buy or rent a hospital bed for use at home at medical supply stores. Most hospital beds look like a twin bed made of heavy metal parts. The bed has moveable side rails. Hand cranks or electricity may be used to change positions of the bed. Talk to your caregiver about what kind of bed is the best for you.
  23. 23. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 23 A hospital bed may be needed if you or a family member is ill or recovering from an illness at home. Hospital beds can be manual or electric. Electric beds may be easier for most people to use. Bed positions may be changed on hospital beds. You may raise or lower the head, knees, or foot of the bed. This may help a person in bed breathe easier and be more comfortable. You may also change the entire height of the bed, making it more comfortable for caregivers working with someone in bed. You may be able to change the position of an electric bed by pushing a button, without having to call for help. When choosing a bed, think of your needs, as well as the needs of those caring for you. There are several kinds of hospital beds to choose from. Your caregivers will help you choose the bed that is right for you. Manual hospital bed: With this bed you need to change bed positions by hand using cranks. If you are unable to do this, you will need to ask someone to help you. The cranks are located at the foot or head of the bed. Manual beds may not move to as many positions as an electric bed. Most manual beds can be raised to make it easier for caregivers to help you. The bed may also
  24. 24. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 24 be lowered to make it easier for you to get in and out of bed. A manual bed may be very difficult for a person who has limited hand or arm strength to use. You may need good hand strength to turn the cranks. A person with a back condition or knee problems may also have trouble. A person may need to bend or kneel to use the bed cranks. Electric hospital bed: An electric bed has a motor and a cord to plug into an electrical outlet. There is a control pad hooked to the bed that may look like a television remote control. Each button on the control may have a picture showing how the bed will move when you push the button. Many people like an electric bed because the positions of the bed can be changed easily. These beds may also have a built in scale for weighing a person. There are many kinds of mattresses available for a hospital bed, including mattresses filled with air, gel, or foam. Some special mattresses can reduce pressure on certain body areas, and help prevent pressure sores. You can buy or rent the mattress at the same supply store where you buy or rent the bed. The mattress usually comes with a waterproof cover. You may need other pads or bed attachments. Ask your caregiver for information about renting extra bed equipment if needed. Where the bed should be placed in the home? Place a hospital bed where there is enough room for it when it is in any position. Put the bed in a place where there is room on the sides of the bed to walk around. Be sure others can hear you if you are in bed and call for help. You may want to place the bed near the bathroom. You may want to place it on the main level to avoid having to climb stairs. Place the bed away from windows or doors where they may be cold drafts of air. The best place for a bed may not be a bedroom. Put the bed in a room close to where the family activities are, but still providing privacy. What should I know about safety while using a hospital bed? Keep the wheels of the bed locked at all times. Unlock the wheels only if the bed needs to be moved. Put a bell and a telephone within reach of the bed. These should be available so the person may call for help when needed. Keep the side rails up. If there is danger of the person falling off the bed, keep the rails up at all times. Never light matches, candles or smoke while in or around the bed. Do not let others smoke or light matches or candles near your bed. Follow the specific manufacturer's instructions for using the bed.Put night lights where needed. Night-lights may help prevent falls. If a footstool is needed for the person they get out of bed, make sure it is strong and stable. Put the bed control pad within easy reach of the bed for the person to adjust positions. Learn to use the control panel, and practice the different positions. Test the bed's hand and panel controls to be sure the bed is working correctly. Some hospital bed controls may be locked so that a person in bed cannot change bed positions themselves. If the bed has this "locking" feature, test it to be sure it is working correctly. Check for cracks and damage to the covering of the all bed controls. If covers are damaged, liquids may get into the controls. This may cause them to stop working, and may cause a fire. Have a professional look at all parts of the bed, as well as the floor beneath and around the bed for dust and lint build-up. These areas should be kept clean. Call the bed manufacturer or another professional if there are burning smells or unusual sounds coming from the bed. Do not use the bed if there is a burning smell coming from it. Call if the bed controls are not working correctly to change positions of the bed. What should I know about using electrical outlets and extension cords for the hospital bed? Check the bed's power cord for damage. It may be crushed, pinched, sheared, cut or worn through. Do not place furniture (such as rocking chairs) away from the cord. Avoid placing or rolling the bed over the power cord.
  25. 25. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 25 Do not allow clothing, sheets, blankets, books, or anything else to be in contact with a wall outlet. Do not let these items get stuck between the cord and outlet when the bed is plugged in. This may cause a fire, or damage the cord or the plug. Do not place a rug or carpet over the power cord for the bed, or anything else. Carpets and rugs may cause the cord to heat up too much, and lead to a fire. Do not place the cord in a location where people walk, as this may cause falls and damage the power cord. Do not use an extension cord, or a power strip having more than one plug-in outlet. Any damage to these can cause a fire. If you must use an extension cord or power strip, have a professional check it before using it. It will also need to be checked regularly for as long as you use it. Avoid using outlet boxes that more than one cord may be plugged into. If you must use an outlet box, place it where there is no risk of damage or spilling liquids. Plug the power cord from the bed directly into an outlet on the wall. Have a professional check the outlet to see if it is working correctly. The outlet should also be checked to be sure it is the right type for the cord. The prongs (blades) on the plug should be tight. The cord should fit tightly into the outlet. The plug, outlet and wall plate should not be chipped or cracked. When adjusting the head, foot, or any part of the bed, be sure the bed is able to move freely. It should extend to its full length, and adjust to any position. Be sure bed movement does not affect the bed's power cord, plug, or outlet. Hand control and power cords should not be threaded through moving parts of the bed, or through bed rails. Watch the hand control cables and the power cord as you are adjusting the bed. Normal bed movement should not pinch or damage these cords. What other things may be done so that I am more comfortable? If there is a television near the bed, place it so that it is seen clearly from the bed. Keep a glass and pitcher of water, tissues, hand lotion, and other personal items within easy reach. Place a wastebasket next to the bed. Put a bedside commode (portable toilet) beside the bed if needed. What are the advantages of having side rails on the bed? Providing a place to fasten bed controls that is within easy reach of the person in bed.Provides a place to hold on to when getting into or out of bed. Side rails may allow a person in bed to help with repositioning (turning) themselves. What are the dangers of having side rails on the bed? Injury from a fall if a person climbs over the bed rail and falls. You may have a higher risk of injury than falling from the bed itself. The fall may be more awkward, causing more serious injury. Injury if a part of the body gets caught between the bed rails, or the bed rails and the Beds and Bed Preparation Techniques Definition A hospital bed is the piece of equipment most frequently used by the hospitalized patient. Hospital beds are also found in long-term-care facilities, as well as patients' homes. The ideal hospital bed should be selected for its impact on patients' comfort, safety, medical condition, and ability to change positions. Purpose The purpose of a well-made hospital bed, as well as an appropriately chosen mattress, is to provide a safe, comfortable place for the patient, where repositioning is more easily achieved, and pressure ulcers are prevented. Precautions When selecting a bed, the nurse should consider the patient's mobility, overall medical condition, and risk for pressure ulcer development. Safety factors should also be considered. Unless a patient is accompanied by a health care professional or other caregiver, the bed should always be placed in its lowest position to reduce the risk of injury from a possible fall.
  26. 26. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 26 Another precaution to take, especially for weak or bed-bound patients, or for those with altered mental status, is to elevate the side rails. However, health care professionals should be aware of a safety alert issued by the Food and Drug Administration (FDA) in 1995 concerning the use of hospital beds' side rails. Because of a number of injuries and deaths related to side rail entrapment, the FDA recommends the following actions to prevent potential deaths and injuries related to side rail entrapment: All hospital bed frames, side rails, and mattresses should be inspected regularly to identify potential areas of entrapment.  The alignment of the bed frame, side rail, and mattress should leave no gap that is wide enough to entrap a patient's head or any other part of the body.  Be alert for side rails or mattresses that have been replaced. Not all of these are interchangeable, and may increase the potential for entrapment.  Check side rails for proper installation.  Consider additional safety measures for those patients at high risk for entrapment. Side rail protective barriers may be used to close off open spaces.  Do not use side rails as a substitute for patient protective restraints. Description The usual hospital bed consists of a mattress on a metal frame that can be raised or lowered horizontally. The frame is separated into three sections so the head and foot of the bed can be raised and lowered, in addition to inclining the entire bed with the headboard up or down. The majority of hospital beds are powered by electrical motors, but some are run manually (using a crank) or by hydraulic methods. The bed's position is typically changed by using electrical controls that may be located on the side or foot of the bed, in a bedside table, or on a pendant. The electrical controls enable patients to reposition the bed with very little effort. Patients should be instructed how to use the bed controls. They should also be cautioned against raising the bed to a position that may contribute to injuries or falls. At its lowest level, a hospital bed is usually about 26–28 inches (65–70 cm) above the floor. with the patient in the bed Various safety features are present on hospital beds. These features include: Wheel locks: These should be used whenever the bed is stationary. Side rails: They help to protect patients from accidentally falling out of bed, as well as provide support to the upper extremities as the patient gets out of bed. Removable headboard: This feature is important during emergency situations, especially during cardiopulmonary resuscitation. Most hospital beds have water-repellent mattresses. However, a number of specially designed beds, frames, and mattresses have been created to aid in caring for bed-bound patients. Some of these beds help to turn the immobile patient, and may make it easier for nurses to lift or reposition the patient. The major categories of specialized beds are: Air-fluidized beds: These are also known as bead beds, sand beds, and high-air-loss beds. Air is circulated via silicone microspheres, creating a fluid-like state. Low-air-loss beds. These beds have interconnected air cells with a minimum depth of five inches (12–13 cm). They allow air to escape from the surface of the bed. There are also a variety of support surfaces that can be placed on top of the existing mattress, or specialized mattresses that can reduce the risk of pressure ulcer formation. These surfaces and mattresses include: Static air-filled overlays Alternating air-filled mattress overlays Gelor water-filled mattress overlays Foam mattresses Low-air-loss replacement mattresses
  27. 27. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 27 The rot kinetic bed is used primarily for severely immobilized patients or patients with spinal cord injuries. The bed can rotate a patient up to 270°. Bariatric beds are available for especially obese patients. Preparation The nurse normally makes the bed in the morning after a patient's bath, or when the patient is out of the room for tests. The nurse should straighten the linens throughout the day, making certain they are neither loose nor wrinkled. Any sheets that become wet or soiled should be changed promptly. When changing bed linen, the nurse should keep the soiled linen away from the uniform, and place it in the appropriate linen bag or other designated container. Never fan or shake linens, which can spread microorganisms and, if any of the sheets touch the floor, they should be replaced. The bed can be made in a variety of ways, depending on the particular patient situation. The categories of unoccupied bed making include: Open unoccupied: In an open bed, the top covers are folded back so the patient can easily get back into the bed. Closed unoccupied: In a closed bed, the top sheet, blanket, and bedspread are pulled up to the head of the mattress and beneath the pillows. A closed bed is done in a hospital bed prior to the admission of a new patient. Surgical, recovery, or postoperative: These techniques are similar to the open unoccupied bed. The top bed linens are placed so that the surgical patient can transfer easily from the stretcher to the bed. The top sheets and bedspread are folded lengthwise or crosswise at the foot of the bed. The other method of making a hospital bed is an occupied bed, where the patient is in the bed while the linens are being changed. The nurse should perform the following when making the occupied bed: Raise the bed to a comfortable working height. Loosen the top linens, and help the patient assume a side-lying position. Roll the bottom linens toward the patient. Place the bottom sheet on the mattress, seam side down, and cover the mattress. Miter the corners of any non-fitted sheets. Place waterproof pads and/or a draw sheet on the bed. Tuck in the remaining half of the clean sheets as close to the patient as possible. Assist the patient to roll over the linen. Raise the side rail, and go to the other side of the bed. Remove the dirty linen and dispose of appropriately. Slide the clean sheets over and secure. Pull all sheets straight and taut. Place the clean top sheets over the patient and remove the used top sheet and blanket. Miter the corners of the top linens at the foot of the bed. Loosen the linens at the foot of the bed for the patient's comfort. Change the pillowcase. Return the patient's bed to the appropriate position, at its lowest level. The nurse also needs to place the bed into one of the following positions, considering the particular needs of each patient: Fowler's: The head of the bed is raised to an angle of 45° or more; a semi sitting position. This position is appropriate when the patient is eating. It is also used during nasotracheal suctioning or during nasagrastic tube placement. Semi-Fowler: In this position, the head of the bed is raised about 30°. This position helps to promote adequate lung expansion. Trendelenburg: The entire bed frame is tilted with the head of the bed down. This helps to promote postural drainage or to promote venous return in patients with poor peripheral circulation.
  28. 28. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 28 Reverse Trendelenburg: The entire bed frame is tilted with the foot of the bed down. This position is not frequently used, though it may help to prevent esophageal reflux. Flat: Keeping the bed flat is appropriate for some patients with spinal injuries, and for those in cervical traction. It may also be used for patients with hypotension. It is a position preferred by many for sleeping. Aftercare After preparing the hospital bed, the patient should be assessed for comfort and safety. Health care team roles Selecting and preparing a bed for the patient are important responsibilities for the nurse. The nurse or nursing assistant normally makes up the bed, but it is important that all health care professionals be aware of the positive impact an appropriate, well-made bed has on a patient's care, safety, and sense of comfort. KEY TERMS  Draw sheet—A sheet placed over the bottom sheet to help lift or move a patient and to protect the bottom sheet from soiling.  Fowler's position—A bed position where the head of the bed is raised to an angle of 45° or more; a semi sitting position.  Trendelenburg—a bed position where the entire frame of the bed is tilted with the head of the bed down. POSITIONING A PATIENT FOR MEDICAL EXAMINATION OR TREATMENT OR REST Patients are put in special positions for examination, for treatment or test, and to obtain specimens. You should know the positions used, how to assist the patient, and how to adjust the drapes. 1.1. Horizontal Recumbent or Decubitus Position. Used for most physical examinations. Patient is on his back with legs extended. Arms may be above the head, alongside the body or folded on the chest. 1.2. Dorsal Recumbent Position. Patient is on his back with knees flexed and soles of feet flat on the bed. Fold sheet once across the chest. Fold a second sheet crosswise over the thighs and legs so that genital area is easily exposed. 1.3. Fowler's Position. Used to promote drainage or ease breathing. Head rest is adjusted to desired height and bed is raised slightly under patient's knees 1.4. Dorsal Lithotomy Position. Used for examination of pelvic organs. Similar to dorsal recumbent position, except that the patient's legs are well separated and thighs are acutely flexed. Feet are usually placed in stirrups. Fold sheet or bath blanket crosswise over thighs and legs so that genital area is easily exposed. Keep patient covered as much as possible. 1.5. Prone Position. Used to examine spine and back. Patient lies on abdomen with head turned to one side for comfort. Arms may be above head or alongside body. Cover with sheet or bath blanket.  NOTE: An unconscious patient or one with an abdominal incision or breathing difficulty usually cannot lie in this position. 1.6. Sim's Position. Used for rectal examination. Patient is on left side with right knee flexed against abdomen and left knee slightly flexed. Left arm is behind body; right arm is placed comfortably. NOTE: Patient with leg injuries or arthritis usually cannot assume this position.
  29. 29. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 29 1.7. Knee-Chest Position. Used for rectal and vaginal examinations and as treatment to bring uterus into normal position. Patient is on knees with chest resting on bed and elbows resting on bed or arms above head. Head is turned to one side. Thighs are straight and lower legs are flat on bed. NOTE: Do not leave patient alone; he/she may become dizzy, faint, and fall. Anatomical position that of the human body standing erect with palms turned forward, used as the position of reference in designating the site or direction of structures of the body. Bozeman's position the knee-elbow position with straps used for support. Decubitus position Dorsal decubitus: lying on the back.
  30. 30. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 30 Lateral decubitus: lying on one side, designated right lateral decubitus when the subject lies on the right side and left lateral decubitus when it lies on the left side. Decubitus ulcer: an ulcer due to local interference with the circulation; called also pressure sore. The ulcer usually occurs over a bony prominence such as that of the sacrum, hip, heel, shoulder or elbow. Excessive or prolonged pressure produced by the weight of the body or limb is the primary cause. Ventral decubitus: lying on the stomach. Fowler's position: that in which the head of the patient's bed is raised 18–20 inches above the level, with the knees also elevated. Knee-chest position: the patient resting on knees and upper chest. Knee-elbow position: the patient resting on knees and elbows with the chest elevated. Lithotomy position: the patient supine with hips and knees flexed and thighs abducted and externally rotated. Mayer position: a radiographic position that gives a unilateral superoinferior view of the temporomandibular joint, external auditory canal, and mastoid and petrous processes. Rose's position: a supine position with the head over the table edge in full extension, to prevent aspiration or swallowing of blood.
  31. 31. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 31 Semi-Fowler position: one similar to Fowler's position but with the head less elevated. Sims position: the patient on the left side and chest, the right knee and thigh drawn up, the left arm along the back. Trendelenburg position: the patient is supine on a surface inclined 45 degrees, head at the lower end and legs flexed over the upper end. Verticosubmental position: a radiographic position that gives an axial projection of the mandible, including the coronoid and condyloid processes of the rami, the base of the skull and its foramina, the petrous pyramids, the sphenoidal, posterior ethmoid, and maxillary sinuses, and the nasal septum. Waters' position: a radiographic position that gives a posteroanterior view of the maxillary sinus, maxilla, orbits, and zygomatic arches. The squatting posture: is used for squat toilets. It is also commonly used for defecation in the absence of toilets or other devices TYPES OF INTRA VENOUS FLUIDS AND THEIR ACTION and Intravenous Fluid Selection LEARNING OBJECTIVES  Describe and differentiate colloid and crystalloid IV fluids  Understand osmosis as it pertains to water movement with IV therapy  Define tonicity and the actions of isotonic, hypotonic, andhypertonic crystalloids in the body  Identify the three most common IV solutions used in theprehospital setting, and classify them as isotonic, hypotonic,or hypertonic
  32. 32. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 32  Describe how an IV fluid is packaged and important information  located on the label of the IV fluid KEY TERMS 5% Dextrose in water—A carbohydrate solution that uses glucose (sugar) as the solute dissolved in sterile water. Five percent dextrose in water is packed as an isotonic solution but becomes hypotonic once in the body because the glucose (solute) dissolved in sterile water is metabolized rapidly by the body’s cells. Colloid solutions—IV fluids containing large proteins and molecules that tend to stay within the vascular space (blood vessels). Crystalloid solutions—IV fluids containing varying concentrations of electrolytes. D5W—See 5% dextrose in water. Extracellular space—Space outside the cells consisting of the intravascular and interstitial spaces. Hypertonic crystalloid—A crystalloid solution that has a higher concentration of electrolytes than the body plasma. Hypotonic crystalloid—A crystalloid solution that has a lower concentration of electrolytes than the body plasma. Intracellular space—Space within the cells. Intravascular volume—Volume of blood contained within the blood vessels. Intravenous fluids—chemically prepared solutions that are administered to a patient through the IV site. Isotonic crystalloid—A crystalloid solution that has the same concentration of electrolytes as the body plasma. Lactated Ringer’s (LR), Ringer’s lactate —an isotonic crystalloid solution containing the solutes sodium chloride, potassium chloride, calcium chloride, and sodium lactate, dissolved in sterile water (solvent). Normal saline solution—an isotonic crystalloid solution that contains sodium chloride (salt) as the solute, dissolved in sterile water (solvent). The specific concentration for normal saline solution is 0.9%. Osmosis—The movement of water across a semi-permeable membrane from an area of lower solute concentration to an area of higher solute concentration. This movement of water allows the equalization of the solute-to-solution ratio across the membrane. Osmotic pressure Fluid therapy also affects osmotic pressure. Osmosis is often defined as "the diffusion of water across a semi permeable membrane from an area of high concentration to an area of low concentration. But it may be easier to understand when put this way: Water moves into the compartment with the higher concentration of particles, or solute. Water is actually pulled into the compartment in the same way that a sponge soaks up a spill. This pull is called osmotic pressure. While the size of particles distinguishes the two major types of fluid—crystalloid (small) or colloid (large)—it's the number of particles in each compartment that keeps water where it's supposed to be.6 Nurses give fluids with more (or fewer) particles than blood plasma to pull fluid into the compartment that needs it most. So how do you know where the water is needed? To assess water balance, you'll measure the osmolality of blood plasma. Osmolality is the number of particles (osmoles) in a kilogram of fluid; osmolality is the number of particles in a liter of fluid. These terms are often used interchangeably because the density of water is 1 kg/L. Normal serum osmolality is around 300 mOsm/L. Oncotic pressure Oncotic pressure is a form of pressure in the circulatory system which encourages water to cross the barrier of the capillaries and enter the circulatory system. In patients with low Oncotic
  33. 33. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 33 pressure, fluid will tend to accumulate in the tissues, resulting in edema. This phenomenon is part of a complex interconnected system which is designed to keep the body in a state of homeostasis, working together with hydrostatic pressure to keep the level of fluids in the blood stable. The walls of the circulatory system are semi-permeable. Fluids can pass across these membranes, but larger materials such as proteins, also known as colloids, cannot. Hydrostatic pressure is the force which pushes fluids over this membrane and out of the circulatory system, while oncotic pressure is the force which brings fluids back into the circulatory system. When these two forces are in balance, there is no net loss or gain of fluid from the circulatory system. When they are not, a patient can develop medical problems. Oncotic pressure occurs as a result of osmosis. When fluids move across the membrane of the capillaries due to hydrostatic pressure, they leave behind a concentration of solutes which were too big to cross the membrane. Fluids tend to flow from areas of low concentration to areas of high concentration, which means that when the solute level rises as fluid leaves the capillaries, fluids are pulled across the membrane and into the capillaries to balance the concentration of the solution on both sides of the barrier. Oxygen-carrying solutions—chemically prepared solutions that can carry oxygen to the cells. Plasma—Fluid surrounding the cells of the body. Solute—Particles that are dissolved in the sterile water (solvent) of an IV fluid. Solvent—the liquid portion of an IV solution that the solute(s) dissolves into. The most common solvent is sterile water. Total body water—Water contained within the cells, around the cells, and in the bloodstream. Water comprises about 60% of the body’s weight. TYPES OF IV FLUIDS  Dextrose (5%, 10%, 25%)  Normal Saline(NS) (0.9%Nacl)  DNS (5% Dex with 0.9% NaCl)  ½ NS(0.45%Nacl)  ½ DNS(5% Dex with 0.45% NaCl)  RL (Ringer’s Lactate)  Isolyte- G  Isolyte - M  Isolyte – E  Isolyte-P  Albumin (20%,25%)  Gelatin Polymers (Haemaccel) INTRODUCTION Intravenous fluids are chemically prepared solutions that are administered to the patient. They are tailored to the body’s needs and used to replace lost fluid and/or aid in the delivery of IV medications. For patients that do not require immediate fluid or drug therapy, the continuous delivery of a small amount of IV fluid can be used to keep a vein patent (open) for future use. IV fluids come in different forms and have different impacts on the body. Therefore, it is important to have an understanding of the different types of IV fluids, along with their indications for use. How Intravenous Fluids are Created There are several types of IV fluids that have different effects on the body. Some IV fluids are designed to stay in the intravascular space (intra= within, vascular= blood vessels) to increase the intravascular volume, or volume of circulating blood. Other IV fluids are specifically designed so the fluid leaves the intravascular pace and enters the interstitial and intracellular spaces. Still others are created to distribute evenly between the intravascular, interstitial, and cellular spaces. The property that an IV solution has within the body depends on how it is
  34. 34. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 34 created and the specific materials it contains. It also determines the best type of IV solution to use in relation to the patient’s needs. The majority of an IV solution is sterile water. Chemically, water is referred to as a “solvent.” A solvent is a substance that dissolves other materials called “solutes.” Within IV solutions, the solutes can be molecules called electrolytes (charged particles such as sodium (Na+) potassium( +), and chloride(Cl-) )and/or other larger compounds such as proteins or molecules. Together, the solvent (water) and solutes (electrolytes, proteins, or other molecules dissolved in the water) create the IV solution. Consider a cup of coffee to which sugar is added for sweetness. The coffee is the solvent, which dissolves the solute sugar. Intravenous Fluids IV fluids come in four different forms: Colloids Crystalloids Blood and blood products Oxygen-carrying solutions Understanding these IV fluids is important because each has a different impact on the body and particular indications for use: Colloid Solutions: Colloid solutions are IV fluids that contain solutes in the form of large proteins or other similarly sized molecules. The proteins and molecules are so large that they cannot pass through the walls of the capillaries and into the cells. Accordingly, colloids remain in the blood vessels for long periods of time and can significantly increase the intravascular volume (Blood volume). The proteins also have the ability to attract water from the cells into the blood vessels. However, although the movement of water from the cells into the bloodstream may be beneficial in the short term, continual movement in this direction can cause the cells to lose too much water and become dehydrated. Colloids are useful in maintaining blood volume, but their use in the field is limited. Colloids are expensive, have specific storage requirements, and have a short shelf life. This makes their use more suitable in the hospital setting. However, familiarity is important because in a mass casualty incident the EMT may be required to assist with the administration of colloids either in a field hospital or during the transport of critically injured patients. Commonly used colloid solutions include plasma protein fraction, salt poor albumin, dextran, and heptastich. Colloids: Types  Albumin: e.g. 4.5-5%, 20-25% human albumin solution  Dextran: e.g. 6% Dextran 70
  35. 35. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 35  Gelatin: e.g. 3.5% polygeline (Haemaccel), 4% succinylated gelatin (Gelofusion)  Hydroxyethyl starch: e.g. 6% hetastarch (Elo-HAES, Hespan), 6 & 10 pentastarch (Pentaspain, HAES-steril) Uses  Used for maintenance of plasma volume and acute replacement of plasma volume deficit.  Short term volume expansion (gelatin, dextran)  Medium term volume expansion (albumin, pentastarch)  Long term volume expansion (hetastarch) Routes: IV (Intra Venous) Side effects  Dilution coagulopathy  Anaphylaxis  Interference with blood cross matching (Dextran 70) Notes  Smaller volumes of colloid are required for resuscitation with less contribution to oedema. Maintenance of plasma colloid osmotic pressure (COP) is a useful effect not seen with crystalloids but they contain no clotting factors or other plasma enzyme systems.  Albumin is the main provider of COP in the Plasma and has a number of other functions. However, there is no evidence that maintenance of plasma albumin levels, as opposed to maintenance of plasma COP with artificial plasma substitutes, is advantageous. Crystalloid Solutions: Crystalloid solutions are the primary fluid used for pre-hospital IV therapy. Crystalloids contain electrolytes (e.g., sodium, potassium, calcium, chloride) but lack the large proteins and molecules found in colloids. Crystalloids come in many preparations and are classified according to their “tonicity.” A crystalloid’s tonicity describes the concentration of electrolytes (solutes) dissolved in the water, as compared with that of body plasma (fluid surrounding the cells). When the crystalloid contains the same amount of electrolytes as the plasma, it has the same concentration and is referred to as “isotonic” (iso= same, tonic= concentration). If a crystalloid contains more electrolytes than the body plasma, it is more concentrated and referred to as “hypertonic” (hyper, high; tonic, concentration). Crystalloids: Types Saline e.g. 0.9% saline, Hartmann’s solution 0.18% saline in 4% glucose. Glucose: e.g. 5% glucose, 10% glucose, 20% glucose. Potassium chloride Sodium bicarbonate: e.g. 1.26%, 8.4%. Crystalloids: Uses  Crystalloids fluids are used to provide the daily requirements of water and electrolytes. They should be given to critically ill patients as a continuous background infusion to supplement fluids given during feeding or to carry drugs  Higher concentration glucose infusions are used to prevent hypoglycemia.  Potassium chloride is used to supplement crystalloid fluids.  Correction of metabolic acidosis (sodium bicarbonate)  Extracellular expander  Limited volume expansion  Maintain urine output  Reduce plasma oncotic pressure  Variable electrolyte content  Cheap!
  36. 36. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 36 Consider the example of TEA and sugar. The more sugar that is added to the coffee, the more concentrated the sugar becomes relative to the amount of tea , and the sweeter tasting the tea becomes. Conversely, when a crystalloid contains fewer electrolytes than the plasma, it is less concentrated and referred to as “hypotonic” (Hypo=low, Tonic= concentration).The less sugar a cup of TEA contains, the lower its concentration or tonicity, and the less sweet the TEA may taste. Depending on their concentration, crystalloids can affect the distribution of water within the body. To better understand this, the EMT must first know what total body water (TBW) is. TBW describes the entire amount of water contained within the body and accounts for approximately 60% of body weight. It is distributed among the intracellular and extracellular compartments. The intracellular space is the space within all the body cells (intra= within; cellular= cell). The extracellular space is the space outside the cells (extra= outside; cellular= cells). The extracellular compartment can be further divided into the intravascular space (space within the blood vessels) and the interstitial space (space between the cells but not within the blood vessels). The different compartments are separated by membranes through which the body water can easily pass. As a general rule, body water is pulled toward the solution with a higher concentration of dissolved molecules. The movement of water across a semi-permeable membrane that selectively allows certain structures to pass while inhibiting others (i.e., a capillary wall or cellular wall) is known as osmosis. The osmotic movement of water occurs as the body attempts to create a balance between the different solute concentrations that exist on either side of a semipermeable membrane. What this means is that the water will easily cross the semipermeable membrane from the side that has a lower concentration of particles to the side that has a higher concentration of particles. The net movement of water stops when each side of the membrane becomes equal in its concentration of water and particles. With this in mind, isotonic, hypertonic, and hypotonic IV fluids cause the following shifts of body water: Isotonic Isotonic crystalloids have a tonicity equal to the body plasma. When administered to a normally hydrated patient, isotonic crystalloids do not cause a significant shift of water between the blood blood vessels and the cells. Thus, there is no (or minimal) osmosis occurring (Figure -1). 01. Isotonic solutions do not result in any significant fluid shifts across cellular or vascular membranes. (Figure -1) 02. A hypertonic solution given IV will draw fluids from the cells and interstitial spaces into the vasculature. (Figure -2)
  37. 37. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 37 03. A hypotonic solution given IV will cause fluids to leave the vasculature for the interstitial and intracellular spaces. (Figure -3) Hypertonic crystalloids have a tonicity higher than the body plasma. The administration of a hypertonic crystalloid causes water to shift from the extravascular spaces into the bloodstream, increasing the intravascular volume. This osmotic shift occurs as the body attempts to dilute the higher concentration of electrolytes contained within the IV fluid by moving water into the intravascular space (Figure -2). Hypotonic crystalloids have a tonicity lower than the body plasma. The administration of a hypotonic crystalloid causes water to shift from the intravascular space to the extravascular space, and eventually into the tissue cells. Because the IV solution being administered is hypotonic, it creates an environment where the extravascular spaces have higher concentrations of electrolytes. The osmotic change results in the body moving water from the intravascular space to the cells in an attempt to dilute the electrolytes. Of the different types of IV solutions, crystalloids are the mainstay of IV therapy in the prehospital setting. The particular type of IV solution selected beyond this depends on the patient’s needs. For instance, based on the osmotic movement of water as described previously, a person with a low volume of blood may benefit from a hypertonic or isotonic crystalloid solution that will increase blood volume, whereas a hypotonic crystalloid would be more appropriate for a person suffering from cellular dehydration. The EMS system’s medical director will determine which crystalloids will be used for prehospital IV therapy. The most common isotonic solutions used in prehospital care are Lactated Ringer’s. Lactated Ringer’s (LR) is an isotonic crystalloid that contains sodium chloride, potassium chloride, calcium chloride, and sodium lactate in sterile water. Normal saline solution or Normal saline solution (NSS): is an isotonic crystalloid that contains 0.9% sodium chloride (salt) in sterile water. 5% Dextrose in water, 5% Dextrose in water (D5W): is packaged as an isotonic carbohydrate (sugar solution) that contains glucose (sugar) as the solute. D5W is useful in keeping a vein open by delivering a small amount of the fluid over a long period of time and/or supplying sugar, which is used by the cells to create energy. However, once D5W enters the body, the cells rapidly consume the glucose. This leaves primarily water and causes IV fluid to become hypotonic in relation to the plasma surrounding the cells. Accordingly, the now hypotonic solution causes an osmotic shift of water to and from the bloodstream and into the cells. In the prehospital setting, LR and NSS are commonly used for fluid replacement because of their immediate ability to expand the volume of circulating blood. However, over the course of about
  38. 38. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 38 1 hour, approximately two-thirds of these IV fluids eventually leave the blood vessels and move into the cells. Some authorities recommend that for every 1 liter of blood lost, 3 liters of an isotonic crystalloid be administered for replacement. This is only a guide, and the volume of IV fluid administered should be based on medical direction or local protocol, as well as the patient’s clinical response to fluid administration. Blood and Blood Products. Blood and blood products (e.g., platelets, packed red blood cells and plasma) are the most desirable fluids for replacement. Unlike colloids and crystalloids, the hemoglobin (in the red blood cells) carries oxygen to the cells. Not only is the intravascular volume increased, but the fluid administered can also transport oxygen to the cells. Blood, however, is a precious commodity and must be conserved to benefit the people most in need. Its use in the field is generally limited to aero medical services or mass casualty incidents. The universal compatibility of O-negative blood makes it the ideal choice for administration in emergent situations. To learn more about blood and blood products, consult a critical care or paramedic textbook. • Oxygen-Carrying Solutions. Oxygen-carrying solutions are synthetic fluids that carry and deliver oxygen to the cells. These fluids, which remain experimental, show promise for the prehospital care of patients who have experienced severe blood loss or are otherwise suffering from hypovolemia. It is hoped that oxygen-carrying solutions will be similar to crystalloid solutions in cost, storage capability, and ease of administration, and be capable of carrying oxygen, which presently can only be accomplished by blood or blood products.
  39. 39. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 39
  40. 40. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 40 Intravenous Fluid Packaging Most IV fluids are packaged in soft plastic or a vinyl bag of various sizes (10, 50, 100, 250, 500, 1,000, 2,000, and 3,000 milliliters) The EMT will most likely be using 250-, 500-, and 1,000- milliliter bags. Some IV solutions are premixed with medications that are not compatible with plastic or vinyl and must be packaged in glass bottles. Glass bottles are not common to prehospital IV therapy but may be encountered during interfacility or critical care transports. Every IV fluid container must contain a label. The label provides important information that you must examine before administering the fluid to a patient. This information includes  Type of IV fluid (by name and by type of solutes contained within).  Amount of IV fluid (expressed in milliliters or “mL”).  Expiration date. Always carefully read the label to ensure you are administering the correct IV solution. Many different IV fluids are packaged in similar containers, including those containing premixed medications. Administering an inappropriate IV fluid may be detrimental or even fatal to the patient, resulting in disciplinary and/or legal action. Like any other medication, IV solutions have a shelf life and must not be used after their expiration date .The IV fluid container contains a medication injection site and administration set port. Both ports are located on the bottom of the IV bag when holding it upright. The medication injection port permits the injection of medication into the fluid for use by Advanced Life Support (ALS) or hospital personnel after the EMT has initiated the IV. Things to remember  IV fluids are comprised of solutes dissolved in a solvent.  Although colloids are an effective IV solution for increasing a patient’s blood volume, their expense and specific  storage requirements limit their use in the prehospital setting.  Through osmosis, water is pulled from an area of lower solute concentration to an area of higher solute concentration.  Isotonic crystalloids have a tonicity that is equal to the plasma in the body. When administering an isotonic  crystalloid, the fluid will distribute evenly between the intravascular space and cells.  Hypertonic crystalloids have a tonicity that is greater than the plasma in the body. When administering a hypertonic crystalloid, the fluid will pull water from the cells into the intravascular space (blood vessels).  Hypotonic crystalloids have a tonicity that is less than the plasma in the body. When administering a hypotonic  Crystalloid, the fluid will quickly move from the intravascular space (blood vessels) into the cells.
  41. 41. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 41  The isotonic fluids 0.9% NSS and LR are the most common IV fluids used in the prehospital setting.  To ensure the right patient receives the right IV fluid, it is imperative that the EMT reads the label of the IV container prior to preparing and administering the fluid! Composition of common IV solutions(mEq/lit) Types of IV fluids D Na K Cl Acet. Lact. NH4Cl Ca Mg Hpo4 Citr mOsm/l it 5% Dextrose 50 - - - - - - - - - - - 0.9% Saline - 154 154 - - - - - - - 278 D5%,0.45% Saline 50 77 - 77 - - - - - - - 308 Dextrose Normal Saline(5%DNS) 50 154 - 154 - - - - - - - 432 Ringer’s Lactate(RL) - 130 4 109 - 28 - 3 - - - 586 Isolyte-G 50 63 17 150 - - 70 - - - - 274 Isolyte-M 50 40 35 40 20 - - - - 15 - 580 Isolyte-P 50 25 20 22 23 - - - - 3 3 410 Isolyte-E 50 140 10 103 47 - - 5 3 - 8 368 For every 1000ml(1 liter of fluid) in their respective units) MATHMATICS AND MATRIC SYSTEM AND UNITS The Short List 1 cup (c) = 8 ounces (oz) 1 dram (dr) = 60 grains (gr) 1 dram (fl dr) = 60 minims 1 gallon (gal) = 4 quarts (qt) 1 glass = 8 ounces (oz) 1 grain (gr) = 64.8 milligrams (mg) 1 gram (g) = 15.43 grains (gr) 1 inch (in) = 2.54 centimeters (cm) 1 kilogram (kg) = 2.2 pounds (lb) 1 liter (L) = 1.057 quarts (qt) 1 milliliter (mL) = 16.23 minims 1 minim = 1 drop (gt) 1 ounce (oz) = 2 tablespoons (tbsp) 1 ounce (oz) = 8 drams (dr) 1 ounce (fl oz) = 29.57 milliliters (mL) 1 pint (pt) = 16 ounces (oz) 1 pound (lb) = 16 ounces (oz) 1 quart (qt) = 0.946 liters (L) 1 quart (qt) = 2 pints (pt) 1 tablespoon (tbsp) = 3 teaspoons (tsp) 1 teacup = 6 ounces (oz) 1 teaspoon (tsp) = 4.93 mL The Long list 1 cental = 45,359 grams (g) 1 centimeter (cm) = 10 millimeters (mm) 1 cubic centimeter (cc) = 1 milliliter (mL) 1 cup (c) = 8 ounces (oz) 1 drachm = 3.55 milliliter (mL) 1 dram (dr) = 60 grains (gr) 1 dram (fl dr) = 60 minims 1 gallon (gal) = 4 quarts (qt) 1 gill = 4 ounces (oz) 1 glass = 8 ounces (oz)
  42. 42. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 42 1 grain (gr) = 64.8 milligrams (mg) 1 gram (g) = 1,000 milligrams (mg) 1 gram (g) = 1,000,000 micrograms (mcg) 1 gram (g) = 15.43 grains (gr) 1 hand = 4 inches (in) 1 inch (in) = 2.54 centimeters (cm) 1 kilogram (kg) = 1,000 grams (g) 1 kilogram (kg) = 2.2 pounds (lb) 1 liter (L) = 1000 milliliters (mL) 1 liter (L) = 1.057 quarts (qt) 1 meter (m) = 1,000 millimeters (mm) 1 meter (m) = 100 centimeters (cm) 1 milligram (mg) = 1,000 micrograms (mcg) 1 milliliter (mL) = 1 cubic centimeter (cc) 1 milliliter (mL) = 15 drops (gt) 1 milliliter (mL) = 16.23 minims 1 minim = 1 drop (gt) 1 ounce (fl oz) = 2 tablespoons (tbsp) 1 ounce (oz) = 20 pennyweights (dwt) 1 ounce (oz) = 24 scruples 1 ounce (oz) = 31.1 grams (g) 1 ounce (oz) = 480 grains (gr) 1 ounce (oz) = 8 drams (dr) 1 ounce, fluid (fl oz) = 29.57 milliliters (mL) 1 palm = 3 inches (in) 1 pennyweight (dwt) = 24 grains (gr) 1 pint (pt) = 16 ounces (oz) 1 pint (pt) = 4 gills 1 pound (lb) = 16 ounces (oz) 1 pound (lb) = 350 scruples 1 quart (qt) = 0.946 liters (L) 1 quart (qt) = 2 pints (pt) 1 scruple = 20 grains (gr) 1 stone = 0.14 centals 1 tablespoon (tbsp) = 3 teaspoons (tsp) 1 teacup = 6 ounces (oz) 1 teaspoon (tsp) = 60 drops (gtt) 1 teaspoon (tsp) = 4.93 mL
  43. 43. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 43 MEDICAL ABBREVIATIONS AND ACRONYMS Apothecary/Household/Metric Equivalents ABBREVATIONS & SYMBOLS Liquid List of Common Drug infusions and How They Are Given oz = mL minim = mL Read First! Medication Dosage 1 = 30 45 = 3 Aminophylline 0.5 - 0.7 mg/kg/hr 1/2 = 15 30 = 2 Amrinone 5 - 15 mcg/kg/min 15 = 1 Amiodarone 0.5 mg/min x 24hrs dram = mL 12 = 0.75 Bretylium 1 - 2 mg/min 2 1/2 = 10 10 = 0.6 Diltiazem 5 - 15 mg/hr 2 = 8 8 = 0.5 Dobutamine 2 - 20 mcg/kg/min 1 1/4 = 5 5 = 0.3 Dopamine 1 - 20 mcg/kg/min 1 = 4 4 = 0.25 Epinephrine 2 - 10 mcg/min 3 = 0.2 Esmolol 0.05 mg/kg/min Others 1 1/2 = 0.1 Isoproterenol 2 - 10 mcg/min 1 mi (minum) = 1 gtt (drop) 1 = 0.06 Labetalol 2 - 8 mcg/min 1T (tablespoon) = 15mL 3/4 = 0.05 Lidocaine 30 - 50 mcg/kg/min or 2-4 mg/min 1t (teaspoon) = 5mL 1/2= 0.03 Magnesium Sulfate 0.5 - 1 g/hr x 24 hrs 1 ml = 1 cc Nitroglycerin 10 - 20 mcg/min Weight Nitroprusside 0.1 - 5 mcg/kg/min grain = mg grain=mg Norepinephrine 0.5 - 30 mcg/min 15 = 1000 1/4 = 15 Procainamide 1-4 mg/min 10 = 600 1/6 = 10 7 1/2 = 500 1/8 = 8 5 = 300 1/10 = 6 4 = 250 1/15 = 4 Weight grain = mg grain=mg 2 1/2 = 150 1/30 = 2 2 = 120 1/40 = 1.5 1 1/2 = 100 1/60 = 1 1 = 60 1/100 = 0.6 3/4 = 45 1/120= 0.5 1/2 = 30 1/150 = 0.4 1/3 = 20 1/200 = 0.3 1/250= 0.25
  44. 44. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 44 ABG Arterial Blood Gas Ab Antibody ABCDE Airway, breathing, circulation, disability, expose and examine A.C. Before meal (ante cibum) ACTH Adreno cortico trophic hormone AD. As desired ADL Activities of daily living AIDS Acquire immeno deficiency yndrome AI Adequate intake AM. Morning AMALG Amalgam filling AMA Against medical advice A and P Auscultation and percussion APC Aspirin, Phenacetine & caffeine AP Apical pulse or antero- posterior AQ Aqueous A-R Apical radial pulse AROM Active range of motion; artificial rapture of membrane Ax Axillary BID Twice a day (bis in die) B.M Bowel movement B.M.R. Basal metabolic rate B.P Blood pressure BPM Beat per minute B.R.P. Bathroom privilege BUN Blood urea nitrogen Centigrade C.B. C Complete blood count CC Cubic centimeter C.N. S. Central nervous system Co2 Carbon dioxide C.S. F. Cerebro- spinal fluid CXR Chest X-ray D and C Dilatation and Curettage D/NS Dextrose in normal saline DPT Diphtheria, pertusis, tetanus D/W Dextrose in water Dx Diagnosis EEG Electro encephalogram E.E.N.T. Eye, ear, nose, throat ECG Electrocardiogram oF Fahrenheit F.B.S. Fasting blood sugar F.H.B. Fetal heartbeat G.I. Gastro intestinal G or Gm Gram gr. Grain gt. Drop (gutte) Gtt. Drops G.U. Genito urinary GYN. Gynecology HCL Hydrochloric acid Hb Hemoglobin HS At bed- time (hours of sleep) H2o Water I.V. Intravenous I.V.P Intravenous pyelogram KI. Potassium iodide L. P Lumbar puncture NaCl Sodium Chloride NOCTE At night N.P.O. Nothing by mouth (nothing by os) O.P.D. Out Patient Department O.R. Operating room PM After noon PRN As needed, when necessary Pt. Patient Q. Every Q.D. Every Day Q.H. Every Hour Q.I.D. Four times a day Q.N. Every night Q.O.D. Every other day R.B.C. Red blood count or red blood cell Rh. Rhesus factor Rx Prescription, take Sol. Solution SOS If necessary STAT Immediately -at once S.C Subcutaneous T. I.D Three times a day T.P.R. Temperature, pulse, respiration Tsp Teaspoon, tablespoon U.R. Upper right WBC White blood cells Wt. Weight U.R.Q. Upper right quadrant U.L.Q. Upper lower quadrant UTI Urinary tract Infection NURSING PROCEDURES AND TECHNIQUES INTRAVENOUS CANULISATION Peripheral IV’s for Beginners What is an intravenous? The bag It contains sterile fluid it may be NS,DNS,RL,MANNITOL,albumin,Bl ood etc. The tubing The whole fluid path from the spike to the needle is sterile. The spike
  45. 45. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 45 This one’s vented – you use this kind with bottle mixes; it lets air get into the bottle, so the fluid can come out, while with bag mixes, the bag just collapses closed. The drip chamber A little hard to see, but the one on the left is “maxi” drip, or ten drops per cc, and the one on the right is “mini” - 60 drops per cc. We never regulate constant infusions by eye anymore – most everything goes on an infusion pump nowadays. But for a rapid IV volume bolus of something (not meds) – normal saline, Ringer’s lactate, whatever, we still use gravity. Which one of these are you going to reach for? In other words, which one is going to run more rapidly? Roller clamps We only use gravity tubing in two situations nowadays: for rapid IV bolus infusions, and for blood. For boluses, the roller clamp has two positions: “all the way open”, and “closed”. For blood – mm… depends. For acute bleeds? – all the way open. Otherwise we titrate by eye to infuse the blood over an hour or two. Pump tubing They’re all different. The only thing to do is to learn the system where you’re at. One important thing that’s developed recently: ALL the sets have to self-clamp if they come out of the pump. Why? Buretrols and Solusets Interchangeable names for the same thing, so far as I know. I still use these once in a while for premixed meds – Flagyl comes to mind. The problem is that single doses of intravenous meds really need to be given over predictable periods of time – an hour is usually good for most doses of antibiotics. Vancomycin I usually give over two. The problem is that anything with a roller clamp is never going to be as precise in timed delivery as a pump, so these are rapidly vanishing. The ports:This is where things get plugged into the line. Are you running, say, normal saline at 53.7 cc’s per hour? And you want to plug in the patient’s dose of IV colace? This is where you go… Wait a second… IV what? What are needle-less connectors all about?
  46. 46. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 46 It’s been a LONG time since we used needled connectors, but it’s worth mentioning, I guess. Needles, or “sharps”, as we call them, are generally considered a Bad Thing. This doesn’t mean we don’t use them all the time for various things – we draw up meds with them, we give subcutaneous and intramuscular injections with them… but poking yourself with one – whether it’s been in contact with a patient or not – is pretty much a Bad Thing. People were getting hepatitis from patients, I think there were a few cases of HIV… so the word went out: the fewer needles, the better. And lo - non-needle connection systems were created. And they were pretty good… The connection to the catheter – what are Luer connectors? Not a bad picture of the end of the catheter. The tubing actually screws onto the yellow end there – except sometimes it’s blue, or green, or pink, or whatever, usually depending on the catheter size. But the screw technology is pretty uniform, all under the name of Luer connectors. That guy Luer – what a genius! So – what the heck part of the patient is that, anyhow? These syringes have female luer connections at the ends.
  47. 47. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 47 The catheter hub of the IV, the hubs of injection needles, the connector hubs at the ends of IV tubing – they all use the same size and type of connector, which was probably what developing the Luer standard was all about. The dressing We like to be able to see the site (why?), so we put a clear tegaderm over it… Change the dressing if it gets loose, or dirty. a. Filters Some infusions need filtering – this is an inline blood filter that a company makes, I guess for people who don’t use the filtered IV tube sets that we do. (You mean there are OTHER hospitals in the world? OMG!) Patient’s with PFO’s need air filters attached to ALL their IV lines. Why? Mannitol needs to be filtered. Crystals! There’s a special little filter thingy that goes on the end of the infusion line. Well – they SAID it was mannitol… TPN(Total parenteral nutrition) is always filtered – check with the pharmacy to make sure which filters to use for which. I.V.Canulas Definition: It is the introduction of a drug in solution form into a vein. Often the amount is not more than at a time
  48. 48. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 48 Sites for IV injection 1. Dorsal Venous network 2. Dorsal metacarpal Veins 3. Cephalic Veins 4. Radial vein 5. Ulnar vein 6. Baslic vein 7. Median Cubital vein 8. Greater saphenous vein I.V.Canula(venous section) 1. Firstly, Introduce yourself to the patient, explain what you are going to do and ask for consent. It is also worth explaining that cannulation may cause some discomfort but that this will be short lived.
  49. 49. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 49 2. As ever, ensure that you have all of your equipment ready. This is alcohol gel, gloves, an alcohol wipe, a tourniquet, an IV cannula, a suitable plaster, a syringe, saline and a sharps box. 3. Wash your hands with alcohol gel. 4. Position the arm so that it is comfortable for the patient and identify a vein. 5. Apply the tourniquet and re-check the vein. 6. Put on your gloves, clean the skin with the alcohol wipe and let it dry. 7. Remove the cannula from its packaging and remove the needle cover ensuring not to touch the needle. 8. Stretch the skin distally and tell the patient to expect a sharp scratch. 9. Insert the needle, bevel upwards at about 30 degrees. Advance the needle until a flashback of blood is seen in the hub at the back of the cannula. 10. Once this is seen, progress the entire cannula a further 2mm then fix the needle advancing the rest of the cannula into the vein. 11. Release the tourniquet, apply pressure to the vein at the tip of the cannula and remove the needle fully. Remove the cap from the needle and put this on the end of the cannula. 12. CAREFULLY dispose of the needle into the sharps box.
  50. 50. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 50
  51. 51. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 51 13. Apply the plaster to the cannula to fix it in place. 14. Having checked the Use By date, fill the syringe with saline and flush it through the cannula to check for patency. If there is any resistance, if it causes any pain or you notice any localised tissue swelling immediately stop flushing, remove the cannula and start again. 15. Ensure that the patient is comfortable and thank them. NB. As an extension to this you may be asked to set up an IV drip. Infusion IV Administration Set Basic IV Setup
  52. 52. Lectures on Basics of practical nursing for beginners BY Dr.Rastrapati Choudhury 52 Let's take a look at a the most basic possible setup for an IV: IVs are most often administered by bags of fluid that come premixed. The standard sizes of these bags can range from 50 mL to 1000 mL. The bag is hung from an IV pole, as we see in the picture above, and IV tubing is attached to the bottom of the bag; the IV tubing contains several important parts: The drip chamber is located just below the IV bag; inside this chamber we can see the fluid drip down from the bag into the IV tubing. This is where we measure the speed of a manual IV setup; we look at this chamber and count the number of drops we see per minute. So, for example, if we count 25 drops over the period of 60 seconds, we would say that the IV is infusing at a rate of 25 drops per minute, or 25 gtt/min. (In reality, we may not count the number of drops in a full minute; we can, for example, count the number of drops we see over a period of 15 seconds, and then multiply that number by 4 to get the number of drops in a full minute.) The drip chamber must always be half full. If the drip chamber is too full, we will not be able to see the drops to count them, and so we will be unable to determine the rate at which the IV is infusing. If the drip chamber is not full enough, then this will allow air to get into the IV tubing, which means that air would get into the patient's circulatory system, which could be very dangerous, blocking a blood vessel or stopping the heart.