1ST YEAR B.SC NURSING FUNDAMENTAL NURSING BLUEPRINT QUESTION BANK SOLUTION (GNM)RGUSH

NURSING FOUNDATIONS-BASIC BSc NURSING I YEAR
QUESTION BANK
UNIT I
INTRODUCTION
SHORT ANSWERS
1.Define health?
A) World Health Organization defines health as a state of complete physical, mental
and social well-being and not merely the absence of disease or infirmity.
2.Define illness?
A) “Illness is a condition characterized by a deviation from a normal health state which is
manifested by physical & psychological symptoms.” – Kozier
3.Define hospital?
A) Hospital is an institution for the care, cure, and treatment of the sick and wounded, for the
study of diseases and for the training doctors and nurses. (Steadman’s medical dictionary)
4.List out four risk factors for developing illness?
A) The major risk factors include:
• tobacco use
• the harmful use of alcohol
• raised blood pressure (or hypertension)
• physical inactivity
• raised cholesterol.
• overweight/obesity
• unhealthy diet
• raised blood glucose.
5.Define immunity?
A) Immunity is referred to the resistance exhibited by the host towards injury caused
by microorganisms and their products.

6.Differentiate between active and passive immunity?
A) Active immunity is created by the antibodies by the individual’s body. Passive
immunity, on the other hand, is mediated by antibodies produced outside. Passive can
be used to generate a rapid immune response. Antibodies were among the primary
tools used to treat specific infectious diseases. At the moment, antibodies play a vital
role in fighting infectious diseases.
7.Enlist the healthcare team members?
A) The health care team consists of Physicians, nurses, social workers ,auxiliary personnel
,village health guides, trained dais, health assistants, radiologist.
8.Define primary health care?
A) Primary healthcare is a term used to describe the first contact a person has with
the health system when they have a health problem or issue that is not an emergency. It is
the part of the health system that people use most and may be provided, for example, by a
general practitioner (GP), physiotherapist or pharmacist.
9.List down any four functions of hospital?
1) Provides quality medical care services to as many outpatient as possible.
2) Provides the widest coverage of quality health care for the people not for
curative only.
3) Ensures that health services are always available to the people.
4) Provides health services that is within the financial capability of the people.
10.Mention the levels of prevention?
A) 1) Primordial Prevention
2) Primary Prevention
3) Secondary Prevention
4) Tertiary Prevention

UNIT II
NURSING AS A PROFESSION
SHORT ESSAYS
1. Describe characteristics of nursing profession?
A) a. specialized education
b. body of knowledge
c. servicesD.autonomy
E. code of ethics
F. research orientation
G. service orientation
H. professional organization
a) Body of knowledge: - as a profession, nursing is establishing a well - defined
body of knowledge and expertise. A number of nursing conceptual frameworks
contribute to the knowledge base of nursing and give direction to nursing practice,
education, and ongoing research.
b) Service orientation: -nursing as a tradition of service to others. These services,
however, must be guided by certain rules, policies, or code of ethics. Today,
nursing is also an important component of the health care delivery system.
c) Code of ethics: - ethical code change as the needs and values of society
change. Nursing has developed its own code of ethics and is most instances has
set up means to monitor the professional behavior of its members.
d)Autonomy: - a profession is autonomous if it regulates itself and sets standards
for its members. Providing autonomy is one of the purposes for a professional
association.to the autonomous,
e) A professional group must be granted legal authority to define the scope of it
practice, describe it particular function and roles and determine its goals and
responsibilities in delivery of its services.

2. Explain the functions of Nurse?
A) a. Care giver –
i) as a care giver, the nurse helps the client to regain health through healing process.
ii) she preserves dignity of client.
Ili) nurse address the holistic health care needs of client.
Iv) she accepts client as person not merely as mechanical beings.
B. Clinical and ethical decision maker
i) nurse use critical thinking skill thought out the nursing process to provide effective
care
Ii) nurse make decision in collaboration with client & family.
Iii)she also collaborate & be consult with other health professionals.
C. Protector
i) she provides safe and conductive environment to the clients
Ii) she takes step to prevent injury for client.
Iii) she asks about any allergy to medicine or food.
Iv) she provides immunization against diseases.
D. Manager
i) as a manager, nurse co- ordinates the activities of other members of health care
team.
Ii) she manages the nursing care of not only one client but also of families and in
communities.
Iii) she delegates the nursing activities to auxiliary worker & worker & another nurse.
E. Communicator – i) she covey information verbally as well as through
documentation.

Ii) nurse communicates verbally at change of shift.
Iii) she reports while shifting the client from one unit to another.
F. Comforter
i) as a comforter, nurse provide comfort to the client by considering him as an individual
with unique feelings and needs.
Ii) she motivates clients to reach therapeutics goals.
Iii) she promotes comfort to client by staying near the patient.
G. Leader
i) nursing leadership is defined as mutual process of interpersonal influence through
which nurse helps the client in making decisions for establishing and for achieving the
goals.
J. Teacher
i) she determines that the clients fully understood.
Ii) she also evaluates client’s progress in learning.
Iii) she gives health education on diet, about preventive measure of diseases.
3. Describe qualities of Nurse?
A) Nurse should have following qualities:
i) Self confidents: A professional nurse have elf confidence. Because of this,
she is able to take decision and provides holistic care.
ii) Humble and Honest: with these qualities, nurse develops rapport and gains
trust of the client.
iii) Loyal: Nurse accept the as he is. she recognizes the client as a person and
understands empathically his feelings.
iv) Co – operative: As an individual, nurse plays many role in hospital. She works
cooperatively with health team members as well as with family member.

v) Good Listener – This is the best quality of nurse, by which she understands
clients view. By active listening, she identifies client’s needs provides care accordingly.
vi) Keen observer – while dealing with client a nurse, by which she understands
client’s as nonverbal commands / behavior.
vii) Good administration – Because of this quality a professional / registered
nurse executes and evaluates the junior nursing staff.
viii) Good supervisor –A professional nurse work works as supervisor to the junior
nursing staff as well other employees while performing their duties.
ix) Impartial – professional nurse treats each client without any prejudice /
personal interest. She provides care fairly to every client.
x) Capable – A nurse is competent enough and has a capability to give care
effectively
xi) Advocate – A nurse supports and speaks in favour of client and provide
information to client / family for making informed decision.
4. Justify Nursing as Profession?
A. professions are those occupation based on specialized intellectual study and
training the purpose of which is supply skilled service with ethical components
to others, for definite fee or salary.
B. Professional is a type of occupation that is meets certain criteria that raise it to
a level above that of an occupational
C. Nursing is the protection, promotion, and optimization, of health and abilities,
prevention of illness and injury, alleviation of suffering through the diagnosis
treatment of human response and advocacy in Carew of individuals, families,
communities, and populations.
a. The services provided are vital to humanity and the welfare of society.
b. There is a special body of knowledge that is continually enlarged through
research.
c. The services involve intellectual activities; individuals responsibity is a
strong feature.

d. Practitioners are relatively independent and control their own policies
and activities.
e. Practitioners are motivated by service and consider their work an
important component of their lives.
f. There is a code of ethics to guide the decision and conduct of
practitioners.
g. There is an organization that encourages and supports high standards
of practice.
5.Enumerate ethical principles of Nursing?
A) Autonomy – It refers to right to make one’s own decision. Respect for autonomy
means that nurse recognize the individual’s uniqueness, the right to be what that
person is and the right choose personal goals people may have “inward autonomy” if
they have the ability to make choice s as well as may have “outward autonomy” if their
choices are not limited or imposed by others. Nurses should follow the principle of
autonomy and respect a client’s right to make decision even when those choices seem
not to be client’s best interest.
Justice – The principle of fairness is the basis for the obligation to treat all clients
equally and fairly. Justice is the foundation for decisions about resources allocation
throughout the society or a group. Health care system provides care on the basis of
medical need rather than ability to pay, social status, race or gender.
Non maleficence – non-maleficence is the avoidance of harm or hurt. So, it is an
obligation to nerve deliberately harm another. The nurse tries to balance the risk and
benefits of plan of care. In health care ethics, it is important to remember that ethical
practice involves not only they will do good but also equal commitment not to do harm.
Beneficence – It means promoting good or doing good. In others words, refers to
taking positive actions to help others. SO, practice of beneficence encourages the urge
to do good for other. For example, a child’s immunization may cause discomfort during
administration, but the benefit of protection from diseases both for the individual and
for the society, outweigh the temporary discomfort.

Fidelity- It means to keep promise. Nurse have an obligation to follow through with
nursing care She should avoid abandonment of clients, even when clients goal differs
from health care provide goals. For example, pain management plan.
6.Classify and explain importance of values in Nursing?
A) TYPES OF VALUES
We can speak of universal values, because ever since human being have lived in
community, they have had to establish principles to guide their behavior towards
others. In this sense, honesty, responsibility, truth, solidarity, cooperation, tolerance,
respect, and peace, among others are considered universal values. However, in order
to understand them better it is useful to classify values acc. To the following criteria :
I. Personal values: these considered essential principles on which we build our
life and guide us to relate with other people. They are usually a blend of family values
and social cultural values, together with our own individual ones. To our experiences.
Ii. Family values: these are valued in a family and are considered either good or
bad. these derive from fundamental beliefs of the parents who, use them to educate
their children. They are the basic principles and guidelines of our initial behavior in
society, and are conveyed through our behavior in the family, from the simplest to the
most complex.
Iii. Social cultural values: these are the prevailing values of our society, which
change with time, and either coincide or not with our family or personal values. They
constitute a complex mix of different values, and at times they contradiction another,
or pose a dilemma. For example, if work is not valued socially as a means of personal
fulfillment, then the society is directly fostering ‘ anti values’ like dishonesty,
irresponsibility, or crime.
Iv. Material values: these values allow us to survive, and are related to our basic
needs as human beings, such as food and clothing and protection from the
environment. They are web that is created between personal, family, and social
cultural values.

V. Spiritual values: they refer to importance we give to non – material aspects in
our lives. They are part of our human needs and allow us to feel fulfilled. They add
meaning and foundation to our life, as do religious beliefs.
Vi. Morals values: the attitudes and behaviors that a society considers essential
for coexistence, order, and general well.
values in professional nursing:
Professional values are the guiding beliefs and principles that influence your work
behavior. Your professional: values are usually an extension of your personal values
such honesty, generosity, and helpfulness.
Nurse professional values are acquired during socialization in nursing from codes of
ethics, nursing experiences teacher s and peers.
the American association of college of nursing ( acne, 1998) identified five values
essential for nursing:
I) altruism
Ii) autonomy
Iii) human dignity
Iv) integrity
V) social justice
7.Describe Professional conduct of a nurse?
A) CODE OF PROFESSIONAl CONDUCT FOR NURSES-
I) PROFESSIONAL RESPONSIBILITY AN ACCOUNTABILITY-
a. Carries out responsibility within professional boundaries.
b. Practices healthful behavior.
c. Is responsible for own decision and actions.
d. Is responsible for continuous improvement of current practices.

ii) NURSING PRACTICE-
a. Provides care in accordance with set standards of practice
b. Respect’s individual and families need to promote healthy practices and
discouraging harmful practices.
c. Promotes participation of individuals and significant others in the care.
iii) COMMUNICATION AND INTERPERSONAL RELATIONSHIP-
a. Establishes and maintains effective interpersonal relationship with individual,
families, and communities.
b. Co –operates with other health professionals to meet the needs of the
individual, families, and communities .
iv) VALUING HUMAN BEING –
a. Takes appropriates action to protect individuals from harmful unethical practice.
b. Encourage and supports individual in their right to speak for themselves on
issues affecting their health and welfare.
c. Respect and support choices made by individuals.
v) MANAGEMENT-
a. participates appropriates allocation and utilization of available resources.
b. participates in evaluation of nursing services.
8.Discuss on scope of Nursing?
A) Staff nurse: It provides direct patient care to one patient or a group of patients.
Assist ward management and supervision.
II) Ward sister or nursing supervisor – she is responsible to the nursing
superintendent for the nursing care management of ward or unit. Take full charge of
ward.

III) Department supervisor /assistant nursing superindent: she is responsible
to the nursing superindent and deputy nursing superindent for the nursing care and
management.
IV) Deputy nursing superindent: she is responsible to the nursing superintendent
and assists in the nursing administration of the hospital.
V) Nursing superintendent: she is responsible to medical superintdent for safe
and efficient management of hospital nursing services.
VI) Director: she is responsible for both nursing service and nursing education
within a nursing teaching hospital.
VII) Community health nurse (CHN): services rendered mainly focusing
reproductive child health programme.
9.Discuss categories of Nursing Personnel in hospital?
A) Types of nursing in hospital-
I) Registered Nurse (RN)
A. Education requirement: associates degree or Bachelor of Science degree
B. Expected job growth: 15% increases
C. Employment locations: Hospitals, residential care facilities, etc.
D. Relevant certificate: State Nursing License
E. Salary range: $60,000 - $75,900
Registered nurse (RN) provides and coordinate patient care, educate patients and the
public about various health conditions, and provide advice and emotional support to
the patients and their family members. Most registered nurses work team with
physician and other health care specialists in various setting.
Ii) Cardiac nurse-
A. Education requirement: associates degree or BSc, registered nursing license
(RN)

B. Expected job growth: 16% increase
C. Employment locations: hospitals, in home care and rehab centers
D. Salary range: $67, 490 medsian annually
One of the leading causes of death in the United States today is heart diseases. The
demand for cardiac nurses continues to grow with the rising number affected with heart
problems.
Iii) Certified registered nurse anesthetist (CRNA)-
A. Education requirement: master’s degree (MSN) , registered nurse license (RN)
and one year in acute care setting.
B. Salary -$153,780
A certified registered nurse anesthetist (CRNA) is highly trained nurse that specializes
in assisting with anesthesia during surgeries. CRNA’s make up some of the highest
– paid nurse specialties in the medical field due to high demand of these nurses in
surgical setting.
Iv) Clinical nurse specialist (CNS)-
A. Education requirement: master’s degree and sometime a doctoral degree.
B. Expected job growth: 15% (much faster than average)
C. Relevant certification: N/A
D. Salary range: $ 85,723
Clinical nurse specialty are type of advanced practice registered nurse (APRN), who
provide direct patients care by working with other nurses and staff to improve the
quality care of patient receives.
10.Discuss on contribution of Florence Nightingale in Modern Nursing?
A) Florence’s nightingale. The era of modern nursing commences with the work of
Florence Nightingale in the Crimean war (1854-1856.) She was born on May 12, 1820.
She was the second daughter of wealthy English parents. She felt that God had called

her to fulfil ‘mission of Mercy”. She thought of nursing or education work. She observed
the life of poor and tried to relieve the sick.
Nursing contributions –
A. Appointed resident lady superintendent of an establishment for Gentle women
During illness
B. In 1854 assembled party of 38 nurses to serve in Crimean war
C. Founded the Nightingale school and home for nurses at saint Thomas hospital
in London.
D. Wrote Notes on nursing, the first textbook for nurse.

UNIT-III
HOSPITAL ADMISSION AND DISCHARGE
SHORT ANSWERS
1. Expand LAMA
Ans. LAMA: Leave Against Medical Advice.
The patient will leave the hospital against the Doctors advice even though after
explains patient health condition.
Consent for LAMA I am leaving the hospital ward against medical advice. Doctor
explained me about my disease condition and ill effects of discharge against
medical advice. Doctors and Nursing staffs will not be responsible for any ill effects
happening after my departure”.
2. Define abscond
Ans. ABSCOND: Abscond from Hospital
Absconding refers to the departure of patients from hospital wards without
permission. The definition of absconding can vary depending on the length of time
required for an absence to be considered absconding, and on the method of
departure (e.g. leaving a locked ward, leaving the hospital grounds, or failing to
return from day leave). Absconding status is influenced by the patient’s admission,
whether it be voluntary, involuntary, or legally detained. There are significant
implications of absconding for patients, carers and family members.
Absconding: where patients under an involuntary mental health order leave
hospital without permission, can result in patient harm and emotional and
professional implications for nursing staff. Patients absconded early in
admission.
3. Expand MLC
ANS. Medico-legal cases (MLC) are an integral part of medical practice that is
frequently encountered by Medical Officers
Definition:
MLC is defined as “any case of injury or ailment where, the attending doctor after
history taking and clinical examination, considers that investigations by law
enforcement agencies (and also superior military authorities) are warranted to
ascertain circumstances and fix responsibility regarding the said injury or ailment
according to the law”.

4. List down the types of discharge
Ans. Types of Discharge
1. PLANNED DISCHARGE: Patient completes the initial, actual management in
the hospital and now he or she need not to be under direct supervision of that
hospital.’
2. DAMA/LAMA: Discharge/Leave Against Medical Advice
3. TRANSFER: Transfer to other unit or hospital
4. ABSCOND: Abscond from Hospital
5. REFFERAL: Referred for further management
5. What is the meaning of referral?
Ans. Any hospital, including a district hospital, will receive referrals from lower
levels of care. Indeed, referral can be defined as any process in which health care
providers at lower levels of the health system, who lack the skills, the facilities, or
both to manage a given clinical condition, seek the assistance of providers who are
better equipped or specially trained to guide them in managing or to take over
responsibility for a particular episode of a clinical condition in a patient.
The process of directing or redirecting(as a medical case or a patient) to an
appropriate specialist or agency for definitive treatment. 2 : an individual that is
referred.
6.List down any four medico legal issues in admission of a patient ?
Ans.
✓ Attempted suicide
✓ Sexual Offences
✓ Burns and Scalds
✓ Poisoning, Alcohol Intoxication
✓ Cases of trauma with suspicion of foul play
✓ Electrical injuries
✓ Accidents like Road Traffic Accidents
7. Mention any two responsibilities of a nurse in discharge procedure
Ans..
• Planning in the beginning.
• See doctor’s written order
• Teach nursing procedures to be continued at home, get it’s practice done.
• Inform other departments regarding discharge

• Confirm bill paid.
• Check and receive any hospital property.
• Hand over personal belongings.
• Explanations..
• Plan for rehabilitation and follow-up need.
• Arrangement for transport.
8. Enlist medico legal issues in discharge of a patient
ans. Police have to be informed before the said patient leaves the hospital.
• If the patient is not serious and can take care of himself, he may be discharged
on his own request, after taking in writing from him that he has been explained
the possible outcome of such a discharge and that he is going on his own
against medical advice.
• Failure to do so renders the doctor liable for “negligence” and “deficiency of
service”. 
• While discharging or referring the patient, care should be taken to see that he
receives the Discharge Card/Referral Letter, complete with the summary of
admission, the treatment given in the hospital and the instructions to the patient
to be followed after discharge.  It is always better to inform the police through
the casualty of the hospital where the medico-legal register is usually
maintained and necessary entries can be made in it. 
• Whenever a medico-legal case is discharged, the same should be intimated to
the nearest police station at the earliest. 
9. Enlist types of referrals?
Ans. They are mainly two types of referral systems
1. Internal referral
2. External referral
Internal referrals indicates transfer of patient in same hospital from one speciality
to another speciality for diagnostic purpose and for treatment
External referral indicates transfer from hospital to other higher centers for
advanced treatment with good skilled staff and high technology equipped
technology.
10. What is planned discharge?
Ans. Planned Discharge: Patient completes the initial, actual management in the
hospital and now he or she need not to be under direct supervision of that hospital.
Patient can go to home with follow up instructions.

UNIT IV
COMMUNICATION AND NURSE PATIENT RELATIONSHIP
SHORT ANSWERS
1. Define communication?
A) Communication is sending and receiving information between two or more
people. The person sending the message is referred to as the sender, while the
person receiving the information is called the receiver. The information
conveyed can include facts, ideas, concepts, opinions, beliefs, attitudes,
instructions and even emotions.
2. Enlist the levels of communication?
A) 1. Intrapersonal
2. Interpersonal
3. Small Group Communication
4. Public Communication
5. Mass Communication
6. Intrapersonal Communication
3. List down the elements of communication?
A) 1. Source
2. Message
3. Channel
4. Receiver
5. Feedback
6. Environment
7. Context
8. Interference
4. Enlist types of communication?
A) • Interpersonal communication
• Intrapersonal communication
• Group Communication
• Mass Communication

• Verbal Communication
• Non-Verbal Communication
• Meta- Communication
• Formal communication
• Informal communication
• Downward communication
• Upward communication
• Horizontal communication
• Diagonal communication
5. Define empathy?
A) Empathy is the ability or practice of imagining or trying to deeply understand
what someone else is feeling or what it’s like to be in their situation. Empathy is
often described as the ability to feel what others are feeling as if you are feeling it
yourself. To feel empathy for someone is to empathize.
6. List out the modes of communication?
A) There are three modes of communication:
• Interpretative Communication
• Presentational Communication
• Interpersonal Communication
7. Enlist steps of communication process?
A) Sender, Message, Encoding, Media, Receiver, Feedback, Noise.
8. List down factors influencing communication.
1. Cultural Diversity.
2. Misunderstanding of Message.
3. Emotional Difference.
4. Past Experiences.
5. Educational and Intellectual Difference.
6. Group Affiliations.
7. Positional Differences among the Personnel.
8. Functional Relationship between Sender and Receiver.

9. List down any four purposes of patient teaching
A) ◘ The system establishes a unit of measure for nursing.
◘ Program costing and formulation of the nursing budget.
◘ Tracking changes in patients care needs.
◘ Determining the values of the productivity equations
◘ Determine the quality.
10.Enlist four barriers to effective communication.
A) Language Barriers, Psychological Barriers, Physiological Barriers, Attitudinal
Barriers, Systematic barriers, Cultural Barriers of Communication, Perceptual
Barriers, Technological Barriers & Socio-religious Barriers.

UNIT –V
THE NURSING PROCESS
SHORT ESSAYS
1. Explain ASSESMENT as first step of nursing process
Ans. ASSESSMENT
Definition Assessment is the systematic and continuous collection, organization,
validation, and documentation of data (information).
Types of assessment: The four different types of assessments are;
1. Initial nursing assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed reassessment
1. Initial nursing assessment: Performed within specified time after admission.To
establish a complete database for problem identification. Eg: Nursing admission
assessment
2. Problem-focused assessment: To determine the status of a specific problem
identified in an earlier assessment. Eg: hourly checking of vital signs of fever patient
3. Emergency assessment: During emergency situation to identify any life
threatening situation. Eg: Rapid assessment of an individual’s airway, breathing
status, and circulation during a cardiac arrest.
4. Time-lapsed reassessment: Several months after initial assessment. To compare
the client’s current health status with the data previously obtained.
2. Explain the types and sources of Data collection
Ans. Data collection is the process of gathering information about a client’s health
status. It includes the health history, physical examination, results of laboratory and
diagnostic tests, and material contributed by other health personnel.
Types of Data Two types: subjective data and objective data.

1. Subjective data, also referred to as symptoms or covert data, are clear only to the
person affected and can be described only by that person. Itching, pain, and feelings
of worry are examples of subjective data.
2. Objective data, also referred to as signs or overt data, are detectable by an
observer or can be measured or tested against an accepted standard. They can be
seen, heard, felt, or smelled, and they are obtained by observation or physical
examination. For example, a discoloration of the skin or a blood pressure reading is
objective data.
Sources of Data collection: Sources of data are primary or secondary.
1. Primary: It is the direct source of information. The client is the primary source of
data.
2. Secondary: It is the indirect source of information. All sources other than the client
are considered secondary sources. Family members, health professionals, records
and reports, laboratory and diagnostic results are secondary sources.
3. Describe various methods of the data collection
Ans. Methods of the data collection: The methods used to collect data are
observation, interview and examination.
Interview method: An interview is a planned communication or a conversation with
a purpose.
There are two approaches to interviewing: directive and nondirective.
• The directive interview is highly structured and directly ask the questions. And the
nurse controls the interview.
•A nondirective interview, or rapport building interview and the nurse allows the client
to control the interview.
STAGES OF AN INTERVIEW: An interview has three major stages:
1. The opening or introduction
2. The body or development

3. The closing
Observation Method: It is gathering data by using the senses. Vision, Smell and
Hearing are used.
Examination Method: The physical examination is a systematic data collection
method to detect health problems. To conduct the examination, the nurse uses
techniques of inspection, palpation, percussion and auscultation.
4. Differentiate between medical and nursing diagnosis with examples.
Ans. Difference between Nursing Diagnosis from Medical Diagnosis
Nursing diagnosis Medical diagnosis
A nursing diagnosis is a statement of
nursing judgment that made by nurse, by
their education, experience, and
expertise, are licensed to treat.
A medical diagnosis is made by a
physician.
Nursing diagnoses describe the human
response to an illness or a health
problem.
Medical diagnoses refer to disease
processes.
Nursing diagnoses may change as the
client’s responses change.
A client’s medical diagnosis remains the
same for as long as the disease is
present.
Ex: Ineffective breathing pattern Ex: Asthma
Activity intolerance Cerebrovascular accident
Acute pain Appendicitis
Disturbed body image Amputation
5. Explain the steps of nursing care plan for the client with suitable examples
Ans. The are 5 steps of nursing care plan:
1. Assessment
2. Nursing diagnosis

3. Planning
4. Implementation
5. Evaluation
EX. 1 : the patient with fever planed the nursing care plan
assessment Nursing
diagnosis
Planning Implementation Evaluation
Subjective
data: the
client
complained
that he feels
warm and
producing
heat out
from body.
Objective
data:
Body
temperature
highly
recorded by
measuring
temperature
Hyperthermia
related to
illness as
evidenced by
body
temperature
recording.
➢ Assess the
vital signs of
the client.
➢ Provide
hygienic
care.
➢ Administer
medications
like
antipyrutics.
➢ Give cold
compression
for 15 min
➢ Provide
plenty of
fluids.
➢ Educate on
nutritious
diet and
personal
hygiene.
➢ Encourage
rest and
sleep
➢ Assessed the
vital signs of
the cltent.
➢ Provided
hygienic care.
➢ Administered
the medication
tab. Pct 650
mg.
➢ Given cold
compression
for 15 min .
➢ Provided
plenty of fluids
➢ Educated on
nutritious diet
and personal
hygiene
➢ Encouraged to
take rest and
sleep
➢ Reassessed
the vital signs
and recorded.
Body
temperature
reduced after
implementing
all measures.

➢ Reassess
the vital
signs.
6. Explain the steps in planning as a part of nursing process
Ans. The planning process
1. Setting priorities
2. Establishing client goals /desired outcome
3. Selecting nursing interventions
4. Writing individualized interventions on care plan
Setting priorities
• The nurse begin planning by deciding which nursing diagnosis requires attention
first, which second, and so on.
• Nurses frequently use Maslow’s hierarchy of needs when setting priorities.
Establishing client goals/desired outcomes
• After establishing priorities, the nurse set goals for each nursing diagnosis. Goals
may be short term or long term.
Nursing interventions
• A nursing intervention is any treatment, that a nurse performs to improve patient’s
health.
TYPES OF NURSING INTERVENTIONS
1. Independent interventions are those activities that nurses are licensed to initiate on
the basis of their knowledge and skills.
2. Dependent interventions are activities carried out under the orders or supervision
of a licensed physician.
3. Collaborative interventions are actions the nurse carries out in collaboration with
other health team members
Writing Individualized Nursing Interventions
• After choosing the appropriate nursing interventions, the nurse writes them on the
care plan.
• Nursing care plan is a written or computerized information about the client’s care.
7. Define nursing diagnosis and discuss the types of nursing diagnosis with
examples

Ans.
Definition • The official NANDA definition of a nursing diagnosis is: “a clinical
judgment concerning a human response to health conditions/life processes, or a
vulnerability for that response, by an individual, family, group, or community.”
Status of the Nursing Diagnosis: The status of nursing diagnosis are actual, health
promotion and risk.
1. An actual diagnosis is a client problem that is present at the time of the nursing
assessment.
2. A health promotion diagnosis relates to clients’ preparedness to improve their health
condition.
• A risk nursing diagnosis is a clinical judgement that a problem does not exist, but the
presence of risk factors indicates that a problem may develop if adequate care is not
given.
Components of a NANDA Nursing Diagnosis
A nursing diagnosis has three components:
(1) The problem and its definition
(2) The etiology
(3) The defining characteristics.
1. The problem statement describes the client’s health problem.
2. The etiology component of a nursing diagnosis identifies causes of the health
problem.
3. Defining characteristics are the cluster of signs and symptoms that indicate the
presence of health problem.
Formulating Diagnostic Statements
The basic three-part nursing diagnosis statement is called the PES format and
includes the following:
1. Problem (P): statement of the client’s health problem (NANDA label)
2. Etiology (E): causes of the health problem
3. Signs and symptoms (S): defining characteristics manifested by the client.
Example: Acute pain related to abdominal surgery as evidenced by patient discomfort
and pain scale.

8. Define nursing process. Explain the purpose and importance of nursing
process
Ans. Definition: Nursing process is a critical thinking process that professional nurses
use to apply the best available evidence to care giving and promoting human functions
and responses to health and illness.
Purposes of nursing process
❖ To identify a client’s health status and actual or potential health care problems
or needs.
❖ To establish plans to meet the identified needs.
❖ To deliver specific nursing interventions to meet those needs.
Importance of nursing process:
➢ The nursing process is important to ensure quality care and to get the preferred
outcome.
➢ In the nursing process, critical thinking is used to recognize the issue and come
up with a logical solution to solving it.
➢ One important aspect of the nursing process is that the plan is not set in stone;
it is meant to be manipulated in order to better suit the patient.
➢ Nurses must be able to think critically in order to recognize the issue, develop a
way to correct it, and be able to communicate the issue to others.
➢ Throughout the nursing process, critical thinking is used to determine the best
plan of care for a patient based on their diagnosis.
9. Define nursing intervention and discuss the types of nursing intervention
Ans.
Health system nursing interventions are actions nurses take as part of a
healthcare team to provide a safe medical facility for all patients, such as following
procedures to reduce the risk of infection for patients during hospital stays.
i)Types of Nurse Intervention:
• Intensive: is reserved for catastrophic cases where medical recovery is
expected to extend over long or indefinite periods of time
• Moderate: combines both phone calls and face-to-face interaction (Field
Nurses).
• Limited: consists of telephone interaction only (COP Nurses).

ii)Types of nursing interventions
I. Independent interventions Activities nurses are licensed to initiate (i.e., physical
care, ongoing assessment)
II. Dependent interventions Activities carried out under primary care provider's orders
or supervision, or according to specified routines
III. Collaborative interventions Actions nurse carries out in collaboration with other
health team members.
10. Explain the steps of evaluation in nursing process
Ans. Evaluation is defined as the judgment of the effectiveness of nursing care to meet
client goals; in this phase nurse compare the client behavioral responses with
predetermined client goals and outcome criteria.
1. Collecting the data related to the desired outcomes
2. Comparing the data with outcomes
3. Relating nursing activities to outcomes
4. Drawing conclusion about problem status
5. Continuing, modifying, or terminating the nursing care plan
Collecting the data: The nurse collects the data so that conclusion can be drawn
about whether goals have been met. It is usually necessary to collect both subjective
& objective data. Data must be recorded concisely and accurately to facilitate the next
part of the evaluating process.
Comparing the data with outcomes: If the first part of the evaluation process has
been carried out effectively, it is relatively simple to determine whether a desired
outcome has been met. Both the nurse and client play an active role in comparing the
client’s actual responses with the desired outcomes.
Relating nursing activities to outcomes The third aspect of the evaluating process
is determined whether the nursing activities had any relation to the outcome.

Drawing conclusion about problem status: The nurse uses the judgement about
goal achievement to determine whether the care plan was effective in resolving,
reducing or preventing client problems. When goals have been met the nurse can draw
one the following conclusions about the status of the client’s problem.
Continuing, modifying , or terminating the nursing care plan: After drawing
conclusion about the status of the client’s problems , the nurse modifies the care plan
as indicated. Whether or not goals were met, a number of decision need to be made
about continuing, modifying or terminating nursing care for each problem.
Before making individual modification, the nurse must first determine why the plan as
a whole was not completely effective. This require a review of the entire plan.

T. PAVITHRA
M.Sc (N), M.Sc (psy)
UNIT-VI
DOCUMENTATION AND REPORTING
SHORT ANSWERS
1. List down types of records in hospital
ANS. Types of Records
1) Patients Clinical Record.
2) Individual Staff Records
3) Ward Records
4) Administrative Records with Educational Value.
2. What is incidental Report
Ans. In a health care facility, such as a hospital, nursing home, or assisted living,
an incident report or accident report is a form that is filled out in order to record details
of an unusual event that occurs at the facility, such as an injury to a patient. The
purpose of the incident report is to document the exact details of the occurrence while
they are fresh in the minds of those who witnessed the event. This information may be
useful in the future when dealing with liability issues stemming from the incident.
3. Differentiate Record and Report
Ans. RECORDS A record is a permanent written communication that documents
information relevant to a client’s health care management, e.g. a client chart is a
continuing account of client’s health care status and need.
REPORTS can be compiled daily, weekly, monthly, quarterly and annually.• Report
summarizes the services of the nurse and/ or the agency.• Reports may be in the form
of an analysis of some aspect of a service.
4. State four guidelines for Reporting
Ans. Provide only essential background data on patient (e.g name, age, gender,
diagnosis, and history)
• Describe objective measurements about patient condition an response of health
problem
• Evaluate results of nursing or medical care measures.

T. PAVITHRA
• Be clear on priorities to which oncoming staff must attend.
• Don’t review all routine care and procedure or tasks
• Don’t review all biographical data already available in written form
5. What is transfer Report
Ans. Transfer report:
Transfer report is given whenever the patient is transferred to other health care unit.
It can happen between: • Nursing unit-to-nursing unit transfer
• Nursing unit to diagnostic area.
• Special settings (operating room, emergency department).
• Discharge and inter-facility transfer
6. What is progress note
Ans. Progress Notes are the part of a medical record where healthcare professionals
record details to document a patient's clinical status or achievements during the course
of a hospitalization or over the course of outpatient care.
7. State four guidelines for recording
Ans.
➢ Use complete, concise descriptions of care.
➢ Record all facts and enter only factual data.
➢ Correct all errors promptly, to avoid error, avoid rushing to complete charting.
➢ Do not write critical comments about client or care by other health care
professionals.
➢ Enter only objective description of client’s behavior, client comments should be
quoted.
➢ Do not erase, apply correction fluid, or scratch out errors made while recording.
So for any error, just strike over it and sign the name or initials.
8. What is the meaning of documentation
Ans. Document is described as any written or electronically generated information
about a patient status or the care or the service provided to that patient. Nursing
documentation is the record of nursing care that is planned and delivered to individual
client.

T. PAVITHRA
9. What is the meaning of computerized Documentation
Ans. Computerized clinical documentation systems (CDS) provide for
the documentation of patient care using computers. For example, the CDS records the
vital signs directly from the cardio-respiratory monitors, while other documentation,
such as nursing assessments are entered by the clinician.
10. List the cases to be included under medico legal records.
Ans. Cases that are to be treated as medico legal are:
(1) All cases of injuries and burns - the circumstances of which suggest commission
of an offense by somebody (irrespective of suspicion of foul play);
(2) all vehicular, factory, or other unnatural accident cases specially when there is a
likelihood of patient′s death .

UNIT-VII
VITAL SIGNS
SHORT ESSAY
1. Define pyrexia. explain nursing care of a client with pyrexia
Ans.
When body temperature rises above 99 degree f. or 37 degree c. It is called pyrexia
or fever.
Nursing Care of patient With Pyrexia
OBJECTIVES-
• Promoting balance between heat production and heat loss.
• Prevent complication
• Reduce heat production
• To increase heat loss Objectives
ASSESSMENT-
• Assess for contributing factors such as dehydration, infection environmental
temperature
• Obtain frequent temperature reading
• Assess for presence of thirst, malaise
• Assess skin colour and temperature
• Obtain all vital signs
• Identify physiological response to fever
• Observe for shivering and diaphoresis
• Assess clients comfort and wellbeing
NURSING INTERVENTION OF FEVER-
• minimize heat production- reduce the frequency of activities that increases
oxygen demand, such as excessive turing and ambulation, allow rest period,
limit physical activity
• Maximize heat loss-minimize external covering on clients body, keep clothing
and bed linen dry, prevent patient from getting draughts. Expose patient to cool
air by an electrical fan
• Maximize heat loss- Administration of cool drinks
• Application of cold compress and ice bags
• Cold sponging and cold packs.
• Cold bath
• Use of hypothermic blanket

• Prevent shivering-shivering is prevented because it increases metabolic activity
Produces heat, increases oxygen demand, and circulation. May cause
hyperventilation and respiratory alkalosis.
• Promote client comfort
• Encourage oral hygiene,
• Prevent dehydration
• Control temperature of environment. Provide complete bed rest
• The clothing should be light, loose, smooth, cotton, non irritating.
• Satisty supplement for increased metabolic rate- provide supplemental oxygen
therapy .
• Replace fluid lost
• Provide high caloric diet- because oxygen consumption in body tissues
increases.
• Diet should be easily digestible and palatable
• Fluid intake upto3000ml.
• Encourage patient to take plenty of fluid.
• Maintain intake output chart.
• Provide small frequent feeds.
• Make food palatable.
• Plenty of fluid and fruits will help to evacuate bowel regularly.
• Maintenance of personal hygiene—Frequent mouth care Care of skin and
pressure points.
• Give sponge bath daily. If temperature remains high cold sponging is given to
bring down the temperature.
• Safety of patient—Never leave a patient alone.
• Rigor and convulsions may occur at any time constant observation is important
Evaluate urine output periodically.
2. Explain characteristics and factors affecting pulse
Ans.
Pulse is a wave of blood created by the contraction of left ventricle. pulse reflects
the heart beat.
Characteristics of pulse
1. Pulse rate: It is the number of pulse beats per minute. Normal pulse rate in adults
varies from 72 to 80 beats per minute.
2. Rhythm or regularity: It is the time interval between pulse beats. Normally the
time intervals between pulse beats are equal or regular.

3. Tension: It is degree of compressiblty and depends upon the resistance of the
wall of the artery.
4. Strength/volume: It is the fullness of artery. It is force of blood felt at each beat.
Factors affecting pulse
1. Age
• The normal range of the pulse in an adult is 60 to100 BPM
• The average pulse rate of an infant ranges from100 to 160 BPM
2. Sex:
• After puberty the average males PR is slightly lower than female
• Autonomic Nervous system activity
• Stimulation of the parasympathetic nervous system results in decrease in
the PR
• Stimulation of sympathetic nervous system results in an increased pulse
rate
• Sympathetic nervous system activation occurs on response to a variety of
stimuli including
✓ Pain , anxiety ,Exercise ,Fever
✓ Ingestion of caffeinated beverages
✓ Change in intravascular volume
3. Exercise: PR increase with exercise
4. Fever: increases PR in response to the lowered B/P that results from peripheral
vasodilatation – increased metabolic rate
5. Heat: increase PR as a compensatory mechanism
6. Stress: increases the sympathetic nerve stimulation
7. Position changes:
• a sitting or standing position blood usually pools in dependent vessels of the
venous system. B/c of decrease in the venous blood return to heart and
subsequent decrease in BP increases heart rate
8. Medication
• Cardiac medication such as digoxin decrease heart rate
• Medications that decrease intravascular volume such as divretics may
increase pulse rate
• Atropine in habits impasses to the heart from the parasympathetic nervous
system, causing increased pulse rate
• Propranolol blocks sympathetic nervous system action resulting in
decreased heart rate sites used for measuring pulse rate.

3. Explain characteristics and factors affecting respiration.
Ans. Respiration is the act of breathing and includes the intake of oxygen and removal
of carbon-dioxide.
Characteristics
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
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
Apnea - temporary cessation of breathing
Tachypnea - fast breathing
Bradypnea- slow respiration
Eupnea- normal breathing rate and depth
Rhythm:
Is the regularity of expiration and inspiration
Normal breathing is automatic & effortless.
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.
Factors affecting respiration:
• Medications Narcotics decrease respiratory rate
• Age Normal growth from infancy to adult hood results in a larger lung capacity.
As lung capacity increases, lower respiratory rates are sufficient to exchange
• Stress or strong emotions increases the rate and depth of respirations

• Exercise increases the rate & depth of respirations
• Altitude The rate & depth of respirations at higher elevations (altitude) increase
to improve the supply of oxygen available to the body tissues
• Fever increases respiratory rate
• Gender Men may have a lower respirations rate than women because men
normally have a larger rung capacity than women.
4.. Explain characteristics and factors affecting blood pressure
Ans. Blood pressure is the force exerted by the blood against the wall of blood vessel
Characteristics
➢ Cardiac output : It is the amount of blood ejected by heart in 1 minute
➢ Stroke volume: It is the amount of blood ejected by heart in 1 cycle. Normally
heart eject 70-80 ml blood in 1 cycle
➢ Cardiac output = stroke volume Χ heart rate
➢ Peripheral vascular resistance: It is the resistance to the blood flow determined
by the tone of vascular muscle’s & the diameter of blood vessels ,smaller the
lumen greater the resistance ,ultimately blood pressure raises. That is why
vasoconstriction leads to elevation of blood pressure
➢ Blood volume : as soon as the blood volume increases, pressure exerted
against arterial wall also increases. That is why giving intravenous fluid in
hypotension increases the blood pressure .with hemorrhage & bleeding , blood
volume decreases & automatically Blood pressure falls
Factors affecting blood pressure
• Age: blood pressure varies throughout the age. As age increases, BP also
raises.
❖ Infant blood pressure: 65-115/42-80 mm Hg
❖ 7 year child: 87-177/48-64 mmHg
❖ Normal adult: 120/80 mmHg
❖ Older people, systolic pressure rises with decreased elasticity
• Body size/obesity: It is observed that as the body size increases, BP also
fluctuates. Heavier & taller child have higher BP than the smaller child of same
age
• Emotions/stress: anxiety, fear , pain , stress, sympathetic nervous system get
activated, causing vasoconstriction , increases heart contraction & ultimately
raises blood pressure
• Gender: After puberty , male have higher blood pressure than females. But
after menopause , women tend to have high BP than male of same age
• Ethnicity: African – Americans have higher incidence of high blood pressure
than European- Americans

• Diet: people taking diet rich in salt & unsaturated fatty acids, having higher
blood pressure. Cocaine use also increases blood pressure. Caffeine intake
also increases blood pressure.
• Smoking: due to nicotine blood pressure increases
• Exercise: Regular exercise, decreases the blood pressure. Helps in keeping
BP normal
• Diurnal variations: usually, person have low BP in early morning & gradually
rises & peaks in evening
• Medications: medications such as opioid analgesics, antihypertensive drugs
have greater effect on BP
• Chemicals: such as epinephrine, ADH , Angiotensin II cause vasoconstriction
, thus elevating BP. Histamine, kinens cause vasodilation , thus decrease BP.
5. Define hypothermia. Discuss nursing measures for hypothermia.
Ans.
1. Hypothermia occurs when the body temperature drops below 36.5 degree
Celsius (97.7 degree F), the lower limit of normal range of 36.5 - 37.5 degree
Celsius (97.8-99.5 degree Fahrenheit)
2. If the temperature falls below 95degree f. Or 35 degree c. The condition is
called hypothermia.
Nursing care for hypothermia
• Patient is re-warmed by placing him in a warm room, with warm blankets
and drinks.
• Prevent a further decrease in body temperature removing wet clothes,
replacing them with dry cloth.
• If possible give hot liquids such as soup.
• Avoid alcohol and caffeinated fluid . keep the head covered.
• For a new born: An important objective of appropriate care of the newborn
is to avoid hypothermia from the moment of birth, by using procedures that
will prevent heat loss and maintain the temperature within the normal range,
thus conserving the infant’s energy for growth and development.
• Placing indirect skin-to-skin contact with mother. Covering both (mother &
baby) with heavy and clean blanket.
• Maintain input output chart frequently
• Promote client comfort
• Safety of patient—Never leave a patient alone.
6. Discuss on abnormal pulse?

Ans. Abnormal Findings In Pulse
Abnormality can be in the:
❖ Rate
❖ Rhythm
❖ Volume
❖ Character
❖ Condition of vessel wall
❖ Radio femoral delay
RATE
Tachycardia(Pulse Rate>100 bpm)
.Bradycardia(Pulse Rate<60 bpm)
RHYTHM IF IRREGULAR:
Irregularly Irregular
Regularly Irregular
Occasionally irregular
✓ Occasionally Irregular Pulse • Extrasystole
✓ Regularly Irregular Pulse • Ectopic beat occurring at a regular interval
• Second degree atrioventricular block
• Sinus arrhythmia
✓ Irregularly Irregular Pulse • Atrial Fibrillation
• Multiple ectopics
VOLUME
High Volume Pulse
Low Volume Pulse
Varying Volume
✓ High Volume Pulse Physiological causes:
 Increased Environmental Temperature
 Advanced Age
 Pregnancy
 Exercise
✓ Low Volume Pulse Causes:

Pericardial Effusion  Severe Aortic Stenosis
 Shock  Peripheral arterial disease
 Hypovolemia  Left Ventricular Failure
✓ Varying Volume:
 Ventricular Tachycardia
 Atrial fibrillation
 Seen in:
 Combination of low, normal or high volume pulse in varying manner
CHARACTER OF PULSE
 Dicrotic pulse  Anacrotic pulse
 Pulsus paradoxus  Pulsus alternans
 Pulsus bigeminus  Pulsus parvus et tardus
 Pulsus bisferiens  Slow rising pulse
 Collapsing pulse
CONDITION OF VESSEL WALL CAN BE:
 Elderly due to arthrosclerosis
 Thickened-firm to hard and cord-like
 Normal-Soft
RADIO-FEMORAL DELAY
Most common cause: Coarctation of aorta
Children:
: Reduced volume lower limb pulses
Upper limb pulses are usually normal
Adults
 Usually presents hypertension and heart failure
Other causes:
• Atherosclerosis of aorta

• Thrombosis or embolism of aorta
7. Discuss on pattern of abnormal respiration?
Ans. pattern of abnormal respiration: They are different patterns of respiration listed
billow:
➢ Apnea : Absence of breathing. (Ap-knee-a)
➢ Eupnea : Normal breathing (Eup-knee-a)
➢ Orthopnea: Only able to breathe comfortable in upright position (such as sitting
in chair), unable to breath laying down, (Or-thop-knee-a)
➢ Dyspnea : Subjective sensation related by patient as to breathing difficulty.
Paroxysmal nocturnal dyspnea - attacks of severe shortness of breath that wakes a
person from sleep, such that they have to sit up to catch their breath - common in
patient's with congestive heart failure.
➢ Hyperpnea: Increased volume with or without and increased frequency (RR),
normal blood gases present.
➢ Hyperventilation: "Over" ventilation - ventilation in excess of the body's need
for CO2 elimination.Results in a decreased PaCO2, and a respiratory alkalosis.
➢ Hypoventilation: Decreased rate (A) or depth (B), or some combination of
both.
• "Under" ventilation - ventilation that is less than needed for CO2 elimination,
and inadequate to maintain normal PaCO2. Results in respiratory acidosis.
• Can be a slow rate with normal tidal volumes such that the total minute
ventilation is inadequate.
• Can be a normal rate but with such low tidal volumes that air exchange is only
in the dead space and not effective.
➢ Tachypnea: Increased frequency without blood gas abnormality
➢ Kussmaul's Respiration: Kussmaul's respiration. Increased rate and depth of
breathing over a prolonged period of time. In response to metabolic acidosis,
the body's attempt to blow off CO2 to buffer a fixed acid such as ketones.
Ketoacidosis is seen in diabetics.
➢ Cheyne-Stokes respirations (CSR):
• Gradual increase in volume and frequency, followed by a gradual decrease in
volume and frequency, with apnea periods of 10 - 30 seconds between cycle.
Described as a crescendo - decrescendo pattern. Characterized by cyclic
waxing and waning ventilation with apnea gradually giving way to hyperpneic
breathing.
• Seen with low cardiac output states (CHF) with compromised cerebral perfusion

• Creates lag of CSF CO2 behind arterial PaCO2 and results in characteristic
cycle. Delayed sensitivity to CO2 changes- during apnea the CO2 increase
above the threshold for stimulus but the brain is slow to respond, then it over
shoots by hyperventilating and the signal to reduce ventilation is slow to be
recognized.
➢ Biot's respiration:
• Similar to CSR but VT is constant except during apneic periods. Short episodes
of rapid, deep inspirations followed by 10 - 30 second apneic period.
• Seen with patients with elevated ICP as seen in meningitis
➢ Apneustic breathing (previously described): Indicates damage to pons
➢ Central neurogenic hyperventilation:
• Persistent hyperventilation
• May be caused by head trauma, severe brain hypoxia, or lack of cerebral
perfusion
• Mid brain and upper pons damage
➢ Central neurogenic hypoventilation:
• Medulla respiratory centers are not responding to appropriate stimuli.
• Associated with head trauma, cerebral hypoxia, and narcotic suppression
➢ CO2 and Cerebral Blood Flow (CBF):
• CO2 plays an important role in autoregulation of CBF mediated through its
formation of H+
.
• Increased CO2 dilates cerebral vessels and vice versa.
• In traumatic brain injury (TBI), the brain swells acutely. Head is a fixed volume
container - cannot expand. When bleeding or swelling occurs in the brain
pressures rapidly increase. Raising ICPs exceed cerebral arterial pressure and
brain perfusion stops.
• Cerebral hypoxia/ischemia - brain death
• Mechanical hyperventilation can lower PaCO2, which results in vasoconstriction
in cerebral vessels, reduction of swelling and ICP.
• Controversial as reduces O2 and CBF to injured brain.
• Only effective for the first 24 hours.
• Current practice is to treat perfusion pressures pharmacologically rather then
use hyperventilation.
• All agree must avoid hypoventilation in TBI patients.
8. Discuss on types of fever

Ans. Fever: a body temperature abovethe normal ranges 38 0c – 410 c (100.4 –
105.8 F)
Types of fever
1. Intermittent fever: the body temperature alternates at regular intervals between
periods of fever and periods of normal or subnormal temperature.
2. Remittent fever: a wide range of temperature fluctuation (more than 2 0c) occurs
over the 24 hr period, all of which are above normal
3. Relapsing fever: short febrile periods of a few days are interspersed with periods
of 1 or 2 days of normal temperature.
4. Constant fever: the body temperature fluctuates minimally but always remains
above normal
9. Classify cold and hot application. Discuss on purpose and indication of both?
Ans. Classification of cold and hot applications :

PURPOSE OF COLD APPLICATION:
Cold application is the application of a cold agent cooler than skin either in a
moist or dry form, on the surface of the skin;
➢ To reduce pain and body temperature
➢ To anaesthetize an area
➢ To control hemorrhage
➢ To control the growth of bacteria
➢ To prevent gangrene
➢ To prevent edema and
➢ To reduce inflammation.
PURPOSE OF HOT APPLICATION:
Hot application is the application of a hot agent , warmer than skin either in a moist
or dry form on the surface of the body;
➢ To relive pain and congestion
➢ To provide warmth
➢ To promote suppuration
➢ To promote healing
➢ To decrease muscle tone and
➢ To soften the exudates.

INDICATION OF COLD AND HOT APPLICATION:
➢ Cold application assists with extra-vasation following canulation of an AV
fistula or graft.
➢ Heat may relieve muscle cramps that can occur in 20 % of haemo-
dialysis treatments, due to rapid fluid shifts.
➢ The application of heat is a non-medically prescribed therapy, used with
therapeutic intent. Dialysis Unit
➢ Therapeutic effects of heat can assist in relieving sore, stiff muscles or
joints.
➢ Safe heat or cold applications will be provided to patients / residents as
part of pain management programs wherever these applications are
appropriate and effective.
10. Define blood pressure. Explain steps in measuring blood pressure.
Ans.
Definition: Blood pressure is the force exerted by the blood against the wall of
blood vessel.
Two measurements:
• Systolic blood pressure: is force exerted by arterial walls during systole. It is the
maximum pressure during ventricle contraction
• Diastolic blood pressure: is the force exerted by blood against arterial wall during
diastole. It is the maximum pressure when the ventricles are relaxed
• Unit of measuring blood pressure is (mmHg) millimeters of mercury
• Normal blood pressure is 120/80 mm of Hg
• Here , systolic pressure is 120 mmHg & diastolic pressure is 80 mmHg
• Pulse pressure is the difference between systolic & diastolic pressure
• Normally, The pulse pressure is 40 mmHg
Steps in measuring blood pressure:
➢ Collect all the articles
➢ Wash hands
➢ Explain procedure to the client. Ex: you are going to monitor his BP
➢ Provide comfortable position. Ex : sitting , supine while keeping his upper
arm at heart level ,palm up
➢ Ensure that mercury level of sphygmomanometer is at zero
➢ Ensure cuff width against client’s arm

➢ Ensure mercury meniscus is at your eye level
➢ Palpate brachial artery pulse
➢ Ensure no air in the cuff & wrap it evenly around client’s arm centering arrow
over brachial artery
➢ Place lower edge of cuff about 1 inch above antecubital fossa
➢ Tuck the end of wrap under cuff
➢ Ensure that connecting tubings are free of each other. Estimate systolic
pressure by palpating the artery with finger tips of one hand while inflating
cuff, rapidly to pressure 30 mmHg above point when pulse reappears.
Deflate cuff fully & wait for 30 secs
➢ Place earpiece of stethoscope in ears & bell/diaphragm on brachial artery
➢ Close valve of pressure bulb clockwise until tight
➢ Rapidly inflate cuff to 30mmHg above palpated systolic pressure
➢ Slowly release the pressure bulb valve & allow the mercury to fall at rate of
2-3 mmHg/sec
➢ Listen & watch mercury level drop. when first clear :”tap tap” (karot koff)
➢ Sound is heard , note the systolic blood pressure
➢ Continue to deflate the bulb & when sound disappears, note the diastolic
blood pressure
➢ Listen for 10-20 mmHg after the last sound & then escape air quickly
➢ Remove cuff
➢ Inform client of his BP reading as needed
➢ Reposition client comfortably
➢ Record reading immediately
➢ Replace articles: Clean earpiece & bell/diaphragm of stethoscope with
alcohol swab. Discard used alcohol swabs . Place articles to their correct
place.
➢ Wash hands
Add on points:
➢ As record is a legal document, It protects the hospital as well as client.
➢ Nurse must document the reading of vital signs any deviations
➢ While documenting vital signs, she should follow organizations policies
procedure
➢ Vital sign can be documented on graphic sheet notes in case of abnormality
detected. Such as elevated temp, tachycardia, shortness of breath. Also
document the actions taken for identified problems.
➢ Recording vital signs & Vital signs are documented on vital chart as well as
graphic sheet.

UNIT –VIII
HEALTH ASSESSMENT
SHORT ESSAY
1)Explain the purpose of health assessment
Definition
A health assessment is a plan of care that identifies the specific needs of a person
and how those needs will be addressed by the healthcare system or skilled nursing
facility. Health assessment is the evaluation of the health status by performing
a physical exam after taking a health history. It is done to detect diseases early in
people that may look and feel well.
Health assessment helps to identify the medical need of patients.
Patients health is assessed by conducting physical examination of patient.
A health assessment is a plan of care that identifies the specific needs of a person
and how those needs will be addressed by the healthcare system or skilled nursing
facility.
Purpose of Health Assessment
 Establish a data base
o strengths/weaknesses
o physiological status
o knowledge base
o motivation
o support systems & coping ability
o other factors that may influence health positively or negatively
2) Explain the preparation of patient unit for physical examination?
Preparing Patients for Physical Examination:
This duty entails the following:

 Escorting patients from the waiting room to the examination rooms
 Interviewing the patient, including leading a discussion of medical history
and recent tests performed
 Recording the patients’ vital signs
 Measuring the patients’ heights and weights
 Measuring the patients’ blood pressure as needed
 Conducting one’s self in a polite and professional manner at all times with
patients
Purpose of Physical Examination:
 To understand the physical and mental health of the patient.
 To detect disease in its early stage.
 To find out the cause and the extent of disease.
 To understand the changes in the condition of diseases, any improvement or
regression.
 To define the nature of the treatments or nursing care needed for the patient.
 To safeguard the patient and his family by noting the early signs especially
in case of a communicable disease.
3) Discussion on methods of physical examination
physical assessment, will use four techniques: inspection, palpation, percussion,
and auscultation. Use them in sequence—unless you're performing an
abdominal assessment. Palpation and percussion can alter bowel sounds, so you'd
inspect, auscultate, percuss, then palpate an abdomen.
Inspection
Performed first, inspection is the most repeated of the four physical examination
methods. Teaching students about inspection emphasizes using sight and smell to
check specific areas for normal color, shape, and consistency.
Sight

Make sure that your students arrange clothing accordingly and use adequate
lighting to fully observe the body parts they are inspecting.
Smell
Because certain infections give off a stench, smell is vital to inspection. You may
simulate smell by using a scent-laden cheese to give students real-life experience
with smell inspection.
Palpation
Palpation is the act of touching a patient to feel for abnormalities anywhere in the
body. There are two different types: light and deep palpation.
Light Palpation
As the name suggests, light palpation is soft and gentle. Nurses may find
information on skin texture and moisture, masses, fluid, muscle guarding, and
superficial tenderness by using light palpation.
Deep Palpation
Deep palpation explores the body’s internal structures to a depth of 4-5
centimeters. This technique can inform nurses about the position of organs and
masses, as well as their size, shape, mobility, consistency, and areas of discomfort.
Percussion
Percussion includes tapping one’s hands on a patient’s body to produce sound
vibrations. The sounds made can confirm the presence of air, fluid, and solids,
along with organ size, shape, and position. Percussion can be practiced almost
anywhere to analyze the intensity, duration, pitch, frequency, quality, and location
of sound.
Auscultation
The final method is auscultation, which is listening to the heart, lungs, neck, or
abdomen to gather information. There are two types of auscultation: direct and
indirect.

Direct Auscultation
Listening with the unaided ear. This may include listening to the patient from a
distance or right on the patient’s skin.
Indirect Auscultation
Using amplification or a mechanical device, such as a stethoscope. An acoustic
stethoscope does not amplify the body sounds but blocks out environmental
sounds.
4) Discuss the significance of History collection in Health assessment
Plan strategies to encourage continuation of healthy patterns, prevent
potential health problems and alleviate or manage existing health
problems. Establish a data base for the clients normal abilities risk factors,
and any current alterations in function.
Purposes of health assessment
1. To idientify need for health teaching
2. To identify client’s strengths  To identify the health problems
3. To organize the collected information
4. To determine client’s normal function
5. To gather information regarding client’s health Formulating conclusion or a
problem statement such as a nursing diagnosis.
6. Provide the holistic view of the clients
TYPES OF ASSESSMENT
INTIAL ASSESSMENT It is performed within specified time after
admission to a hospital. The establish a complete data base for problem
identification , reference and future comparison. e.g. Nursing admission
assessment.e.g. Hourly assessment of client’s fluid intake and output chart
Purpose The main purpose of ongoing or focused assessment to determine

the status of a specific and to identify new or overlooked problem  on
going or focused assessment is ongoing process integrated with nursing care.
FOCUS or ONGOING ASSESSMENT
E.g a rapid asessment of person’s airway b breathing ,and cirulation during
cardiac arrest Purpose . To identify life- threatining problems  Emergency
assessment is life saving assessment the major purpose of emergency
assessment is save the patient or client’s life.
EMERGENCY ASSESSMENT
Purpose. To compare the client’s current status to baseline data previously
obtained. e.g Reassessment of a client’s functional health patterns in a
home. Time lapsed assessment involves assessment several days after first
initial assessment.
5) Explain the assessment of Gastro intestinal system using techniques of
physical examination?
Inspection
The patient is placed supine on an examining table or bed. It is helpful to place a
small pillow beneath the knees to relax the abdominal musculature. The head
should rest comfortably on a small pillow. The patient's arms should rest
comfortably at the sides. Drapes should be placed over the breasts and groins just
below the inguinal regions to preserve modesty. The examiner stands on the
patient's right.
Palpation
Palpation of the abdomen involves using the flat of the hand and fingers, not the
fingertips to detect palpable organs, abnormal masses, or tenderness. Again, an
orderly approach is necessary to prevent oversights. One should begin in the right
upper quadrant with palpation of the liver. The flat of the right hand is placed on

the abdominal wall with the fingertips pointing toward the right shoulder. The
fingertips should be 2 to 3 cm below the costal margin The patient is asked to
inspire deeply, bringing the liver edge down to the fingertips. One should note the
consistency of the liver and whether there is tenderness. It should be noted whether
the edge of the liver is sharp, blunted, or nodular.
Percussion
Percussion of the abdomen is performed to check liver size, spleen size, and any
abnormal gas collections. The size of the liver is estimated by determining the span
of liver dullness by percussion. This is performed by percussing just below the
breast in the midclavicular line. A resonant note should be obtained because of the
underlying air Percussion then proceeds caudally from the dome of the liver until
dullness is noted. Percussion is then continued caudally until resonance returns,
indicating that the examiner has reached the hepatic flexure of the colon at the
hepatic edge). A normal liver span is 10 to 12 cm. If dullness is absent over the
liver, this may be a sign of intra-abdominal gas, as might occur with a perforated
viscus.
Auscultation
In abdominal examination auscultation is performed before palpation, as palpation
may alter the bowel sounds. Starting in the right upper quadrant, the examiner
listens over the liver for rubs or bruits and over the free abdominal wall for bowel
sounds. One moves next to the left upper quadrant, again listening for bowel
sounds and then over the spleen to detect rubs or bruits. One should next auscultate
in the periumbilical regions for aortic or renal bruits and for bowel sounds and then
in the left and right lower quadrants for bowel sounds or iliac bruits. If, during the
course of auscultation, no bowel sounds are detected, one should auscultate in the
periumbilical region for 3 full minutes before determining that bowel sounds are

absent. Important points to note on bowel sounds are the pitch, intensity, and
duration of the sounds.
6) Explain the assessment of respiratory system using techniques of physical
examination?
Palpation is the use of physical touch during examination. During palpation, the
physician checks for areas of tenderness, abnormalities of the
skin, respiratory expansion and fremitus.
The four steps of the respiratory exam are inspection, palpation, percussion,
and auscultation of respiratory sounds, normally first carried out from the back of
the chest
Inspection
The examiner then estimates the patient's respiratory rate by observing how many
times the patient breathes in and out within the span of one minute. This is
typically conducted under the pretext of some other exam, so that the patient does
not subconsciously change their baseline respiratory rate, as they might do if they
were aware of the examiner observing their breathing. Adults normally breathe
about 14 to 20 times per minute, while infants may breathe up to 44 times per
minute
Palpation
Palpation is the use of physical touch during examination. During palpation, the
physician checks for areas of tenderness, abnormalities of the skin, respiratory
expansion and fremitus.[

 To assess areas of tenderness, palpate areas of pain, bruises, or lesions on the
front and back of the chest. Bruises may indicate a fractured rib, and
tenderness between the ribs may indicate inflamed pleura.[16]
 Palpate any abnormal masses or structures on the front and back of the chest.
Abnormal masses or sinus tracts may point to infections.
Chest percussion
Percussion over different body tissues results in five common "notes".
1. Resonance: Loud and low pitched. Normal lung sound.
2. Dullness: Medium intensity and pitch. Experienced with fluid.
o A dull, muffled sound may replace resonance in conditions
like pneumonia or hemothorax.
3. Hyper-resonance: Very loud, very low pitch, and longer in duration.
Abnormal.
o Hyper-resonance can result from asthma or emphysema
4. Tympany: Loud and high pitched. Common for percussion over gas-filled
spaces.
o Tympany may result in pneumothorax.
5. Flatness: Soft and high pitched.
Ascultation
The areas of the lungs that can be listened to using a stethoscope are called
the lung fields, and these are the posterior, lateral, and anterior lung fields. The
posterior fields can be listened to from the back and include: the lower lobes
(taking up three quarters of the posterior fields); the anterior fields taking up the
other quarter; and the lateral fields under the axillae, the left axilla for the lingual,
the right axilla for the middle right lobe. The anterior fields can also be auscultated
from the front

7) Write in detail regording of physical examination findindgs from head to
toe?
Definition
A head-to-toe assessment refers to a physical examination or health assessment,
and it becomes one of the many important components of understanding a patient’s
needs and problems.
The Order of a Head-to-Toe Assessment
1. General Status
 Vital signs
 Heart rate
 Blood pressure
 Temperature
 Pulse oximetry
 Respiratory rate
 Pain
2. Head, Ears, Eyes, Nose, Throat
 Observe color of lips and moistness
 Inspect teeth and gums
 Assess buccal mucosa and palate
 Examine Tongue
 Examine at uvula
 Examine tonsils
 Palpate nose and assess symmetry
 Check Septum and inside nostrils
 Verify patency of nares
 Check patient’s sense of smell
 Palpate sinuses

 Assess patient hearing with whisper test
 Tuning Fork test (Weber’s test, Rinne test)
 Look inside ear
 Assess ear discharge and tympanic membrane
 Check conjunctive and sclera
 Assess eye symmetry
 PERRLA
 Check vision with Snellen Chart
 Check six cardinal positions of the gaze
3. Neck
 Palpate lymph nodes
 Observe and palpate trachea and neck
 Check for Jugular Venous Distention
 Check neck range of motion
 Check shoulder shrug with resistance
4. Respiratory
 Listen to lung sounds front and back
 Assess respiratory expansion level
 Ask about coughing
 Palpate thorax
5. Cardiac
 Palpate the carotid and temporal pulses bilaterally
 Listen to heartbeat
6. Abdomen
 Inspect abdomen
 Listen to 4 quadrants of abdomen for bowel sounds
 Palpate 4 quadrants of abdomen for pain/tenderness

 Ask about problems with bowel or bladder
7. Pulses
 Check pulses in arms/legs/feet including,
o Radial
o Femoral
o Posterior tibial
o Dorsalis pedis
8. Extremities
 Assess range of motion and strength in arms/legs/ankles
 Assess sharp and dull sensation on arms/legs
 Check capillary refill on fingernails/toenails
9. Skin
 Check skin turgor
 Check for lesions, abrasions, rashes
 Check for tenderness, lumps, lesions
 Check if patient is pale, clammy, dry, cold, hot, flushed
10. Neurological
 Oriented x3
 Assess gait
 Check coordination
 Assess reflexes
 Check Glasgow Coma Scale score
8) Explain the assessment of cardio vascular system using techniques of
physical examination
The cardiac examination consists of evaluation of (1) the
carotid arterial pulse and auscultation for carotid bruits; (2) the jugular venous

pulse and auscultation for cervical venous hums; (3) the precordial impulses and
palpation for heart sounds and murmurs; and (4) auscultation of the heart.
Examination of the Heart
Carotid Arteries
Begin the cardiovascular examination by assessing the carotid arterial pulses .
They are ordinarily examined while the patient is breathing normally and reclining
with the trunk of the body elevated about 15 to 30 degrees. In order to examine the
carotid arteries, the sternocleidomastoid (SCM) muscle should be relaxed and the
head rotated slightly toward the examiner. The examiner places the forefinger or
thumb, depending on individual preference, slightly over the artery in the groove
just lateral to the trachea. Care should be taken always to palpate in the lower half
of the neck in order to avoid the area of the carotid bulb, lest a hypersensitive
carotid sinus reflex be evoked with resultant bradycardia and hypotension.
Jugular Veins
The jugular venous pulse is usually examined next. It includes observation of
venous wave form, assessment of the response of the venous pressure to abdominal
compression, estimation of the central venous pressure (CVP), and auscultation for
cervical venous hums. Venous pulsations are examined by inspection of either the
external or internal jugular veins, although the latter are generally more reliable
because they more directly reflect right atrial hemodynamics.
Precordial Movements and Thrills
The precordial examination, performed next, consists of inspection and palpation
of the anterior chest wall. Precordial movements should be evaluated at the apex
(left ventricle), lower left parasternal edge (right ventricle), upper left (pulmonary
artery) and upper right (aorta) parasternal edges, and epigastric and
sternoclavicular areas It is best to examine the precordium with the patient supine
because if the patient is turned on the left side, the apical region of the heart is

displaced against the lateral chest wall, distorting the chest movements. Inspect the
chest wall by positioning yourself on the patient's right side and looking
tangentially across the fourth, fifth, and sixth intercostal spaces. Ask the patient to
take a deep breath and then to exhale slowly as you look for a discrete area of
apical movement. The following are the factors to be considered about any
precordial movement that can be seen or felt: (1) location; (2) amplitude; (3)
duration; (4) time of the impulse in the cardiac cycle; and (5) contour.
9) What are the methods of health assessment explain in detail any one
method
Purpose of health assessment
 The purpose of health assessment is to get a general understanding of the state
of your healt
 5 Principles health assessment techniques
 Accountability. ...
 Performance-Based Assessment. ...
 Evidence-Based Assessment. ...
 Validity and Reliability in Assessment. ...
 Participation and Collaboration.
AUSCULTATION
 The final method is auscultation, which is listening to the heart, lungs, neck,
or abdomen to gather information. There are two types of auscultation:
direct and indirect.
 Direct Auscultation
 Listening with the unaided ear. This may include listening to the patient
from a distance or right on the patient’s skin.
 Indirect Auscultation

 Using amplification or a mechanical device, such as a stethoscope. An
acoustic stethoscope does not amplify the body sounds but blocks out
environmental sounds.
10) Explain methods of palpation with examples
Palpation
Palpation is the act of touching a patient to feel for abnormalities anywhere in the
body. There are two different types: light and deep palpation.
Light Palpation
As the name suggests, light palpation is soft and gentle. Nurses may find
information on skin texture and moisture, masses, fluid, muscle guarding, and
superficial tenderness by using light palpation.
Deep Palpation
Deep palpation explores the body’s internal structures to a depth of 4-5
centimeters. This technique can inform nurses about the position of organs and
masses, as well as their size, shape, mobility, consistency, and areas of discomfort.
Have students role-play using different scenarios to train them to palpate
effectively. Encourage short fingernails and warm hands to boost patient comfort
during palpation.

UNIT: 9
MECHINARY, EQUIPMENT, AND LINEN
SHORT ANSWER
1. Define inventory
ANS: Inventory means all the materials, parts, supplies, expenses, and in process or
finished products recorded on the books by an organization and kept in its stocks,
warehouse, or plant for some period of time.
2. What is the meaning of indent?
ANS: An indent is an official order or requisition for medicine and supplies from the
medical store. The nurse acquires the equipment and supplies based on the need
estimation, availability, and the budget.
3. Distinguish between disposable and reusable articles.
ANS: Disposable articles means the items used only once, discarded after use and
new items are used for every patient. On the other hand, Reusable equipment’s means
the items and equipment’s used for a very long time, they are cleaned, disinfected, and
sterilized before and after each use.
More care should be given to reusable items than disposable items.
4. Mention types of Equipment’s.
ANS: A. Self-care equipment’s (for patients’ daily life)
B. Electronic equipment’s (ECG Monitor, ventilator etc.)
C. Diagnostic equipment’s (tools used to test)
D. Surgical equipment’s (stainless steel tools, OT tools)

E. Acute care equipment’s (dressing material etc.)
F. Storage and transport equipment’s.
5. Mention any four equipment’s used in oral care.
ANS: Articles needed for conscious patient:
a. Face towels
b. Toothbrush
c. Toothpaste
d. Disposable gloves
Log of tepid water
Articles needed for unconscious patient:
a. Face towel
b. Disposable gloves
c. Artery forceps
d. Dissecting forceps
e. Tongue depressor
6. Name any dour rubber goods?
Ans. The rubber goods in common use are:
1. Mackintosh
2. Hot water bottles
3.Rubber tubes and Clothier
4.Gloves
7. Lost down types of rubber catheter?
Ans. There are three types of catheters:

1. Indwelling catheters (urethral or suprapubic catheters)
2. External catheters (condom catheters)
3. Short- term catheters (intermittent catheters)
8. what is the meaning of condemnation of article?
Ans. Condemnation is the act of declaring something awful or evil. If your little brother
does, something unspeakably awful, express your condemnation so he will learn not to
do it again.
9. Expand CSSD?
Ans. CSSD- The central sterile services department (CSSD), also called sterile
processing department (SPD), or central supply, is an integrated place I'm hospital and
other health care facilities that performs sterilization and other actions on medical
devices, equipment and consumable.
10. What is Autoclaving?
Ans. Autoclaving- The autoclave is a pressure cooker that sterilizes or kills all
microorganisms and their spores. Autoclaves are used in hospital by surgeon's to
sterilizes surgical tools. They are also used in medical facilities and dentist's offices in
order to sterilize instruments such as speculums, scopes, and scrappers.

UNIT X
MEETING NEEDS OF THE PATIENT
LONG ESSAYS
1. a. Enlist effects of neglected mouth?
Ans. Some of the effects of neglected mouth are.
*Leading to bad breath.
*Gum disease
*Tooth abscesses and infections
*Loss of teeth.
Complication of Neglected Mouth care
*Halitosis
*Stomatitis
*Pyorrhea
*Root abscess
*Tonsillitis
*Sinusitis
*Parotitis
*Glossitis

*Sores and crust
*Inhalation pneumonia
*Joint disease
*Rheumatic heart disease
*Loss of appetite
b. Explain the procedure of oral care in an unconscious patient.
Ans. The patient is unconscious, oral care will be needed more frequently. Unconscious
patients usually breathe through the mouth, causing secretions to dry. It is a vital aspect of
patient care that needs to be carried out consistently by a nurse. The nurse plays an important
role in providing effective oral care and promoting oral hygiene of an unconscious patient.
Nurses should be aware of risk factors associated with poor oral health and be able to assess
and help patients maintain oral hygiene.
Supplies and Equipment for Unconscious Patient:
A tray containing supplies and equipment needed for oral care or mouth care are listed
in the following:
1. Small mackintosh 1,
2. Towel—1,
3. Kidney tray 2,
4. Gauze piece or cotton balls,
5. Mouth wash solution (0.12% Chlorhexidine or 05% Cetylpyridinium
Chloride),
6. Galipot-1(Denture soaking solution),
7. Gloves,
8. The aseptic syringe or irrigating bulb,

9. A suction catheter with a suction apparatus,
10.A cotton ball with artery forceps,
11.Gauze padded tongue depressor,
12.Mouth gag (if patients unconscious to open the mouth),
13.Plain water in a mug,
14.Paper bag.
Mouth Care Procedure for Unconscious Patient:
Oral care procedures are used for patients who are unconscious or who are not able to
eat or drink.
1. Arrange all equipment on the bedside cabinet or an overbed table.
2. Set the patient’s bed in a comfortable position and lower one side rail.
3. Place a bulb syringe or suction machine with a suction machine nearby.
4. Place the client in a side-lying position and raise the level of the bed on
one side so that the patient is in a partial sitting position.
5. Rinse your hands properly with antiseptic soap and lukewarm water.
6. Wear gloves after drying hands.
7. Place towel or waterproof pad under the client’s chin and wrap the
patient’s chest.
8. Keep the kidney tray under the patient’s cheek or remove secretions from
the mouth by the suction catheter.
9. Use a padded tongue blade to open teeth gently. Never put your fingers in
an unconscious patient’s mouth.
10.Turn the head of the patient towards you in a very gentle manner.
11.A clean mouth, gums, teeth, and tongue with toothbrush and toothpaste.
12.Use an Asepto syringe or irrigating bulb without a needle to rinse the oral
cavity. Swab or use oral suction to remove pooled secretions.
13.Clean immediately after brushing and Suction the saliva and toothpaste
from the mouth of the patient.
14.Wipe out the extra water on the mouth with a clean small towel.

15.Removes basin dries face and mouth and applies water-soluble lip
moisturizer.
16.Bring the patient back to a comfortable position.
17.Raise side rail and lower bed position.
18.Dispose of gloves in a paper bag and wash hands properly.
19.Report & documents oral findings and procedure.
2.a. Mention types of bed making.
Ans. TypeS of bed making :
a) closed bed :
• Made following discharge of patient
• purpose to keep clean untill new patient admitted
b) open bed :
• fan fold the tapsheets to foot of bed to convert closed bed to open bed
• Fanfold means to fold the sheets like accerdian plats
• done to welcome patient or for patient who are ambulatory or out of the bed
c) occupied bed:
• bed is made while patient is in it
• usually done after morning bath
d) admission bed:
• This bed prepared to receive the newly admitted patient.
Purpose:
1. To welcome patient

2. To provide the immediate care,safety and comfort
3. To protect the bed linen while giving with on admission.
b. Explain preparation of post-operative bed in detail?
A) Bed which is prepared for the patient you are in the effect of anesthesia and following
surgery.
Purpose:
1. To recive patient conveniently
2. To Prevent of shock
3. To prevent Injury.
4. To prevent soiling of the bed
5. To meet an emergency.
PROCEDURE:
Postoperative bed-making is to permits easy patient transfer from surgery and promotes
cleanliness and comfort. To make such a bed takes the following steps:
1. A simple bed is made as per normal procedure making.
2. Strip on the bed and turn the mattress.
3. The upper bedding is fan-folded to one side accurate the stretcher.
4. The top sheet does not tuck at the foot part. (In cold weather the hot water bottle
is placed in the middle of the bed and covered with fan-folded top bedding).
5. The temperature of water in a hot water bottle should not exceed 50°C.
6. Fanfold together the top sheet and blanket towards the side away from the door.
7. The small mackintosh sheet covered with a towel is open side at top of the bed.
8. Place the bath towel over the small mackintosh sheet.
9. Instead of a pillow, place a small protective sheet and a towel on the head end of
the bed.

10.The basin for the collection of vomits is placed on the bed stand.
11.The transfusion stand is kept ready at the bedside.
12.BP instrument, pulse meter can be kept ready at bed stand.
13.Place the necessary articles on the bedside table and the irrigating stand, suction
machine, and oxygen set-up adjacent to the bed.
14.Keep the tray on the locker or table nearby and shock blocks on the floor near
the foot end of the bed ready in case of necessity.
15.Adjust the height of the bed to the level of the stretcher.
16.After the patient is transferred to the bed, position the pillow for patient comfort.
17.Ensure safety cover by pulling the top point of the sheet and blanket over the
patient.
18.Open the folds after covering the patient tuck in the linens at the foot of the bed
and miter the corners.
19.Bottom sheet useful to absorb moisture and stop dislocation of the bottom sheet.
20.When the patient is transferred to bed, keep a kidney tray on the bed near the
mouth, and pin-up the paper bag with the bottom sheet on the side.
3. Discuss the procedure of bed bath in a bed ridden patient?
A) Definition of Bed Bath: Bed Bath Means cleaning Patients Body from Head to
toe, or Removing of dirt and Promoting Skin Care and Promote Personal hygiene.
Types of Bed Bath
 Partial Bed Bath
 Complete Bed Bath
 Towel Bath
 Tub Bath
 Bag Bath
PURPOSE OF BED BATH:
1. To remove accumulated waste products and dirt from the skin.
2. To stimulate the functions of the skin.
3. To sooth and refresh the body.
4. To observe and to detect abnormalities.
5. To stimulate circulation of Skin.

6. To Promote relaxation and comfort
EQUIPMENT:
Bed Bathing Equipments need for Procedure
1.A tray containing:
– Spirit or skin lotion
– Powder
– Comb
– Coconut oil
– Kidney tray with paper bag
– Sponge bag or wash clothes – 2
– Soap dish with soap
– Nail cutter or scissors
– Nail brush
– Duster
– Bath towel

– Equipment for mouth care if needed
– Paper squares
– Basin
– Jugs 2 (One with hot water and other with cold water)
– Bucket
– Lotion thermometer
– Patient clothes and linen for making if required.
Bed Bath Nursing Procedure Steps
1. Explain the procedure to the patient.
2. Collect articles, take to bed side, and provide privacy.
3. Switch off the fan.
1. Place the patient in comfortable position.
2. Give mouth care if needed.
3. Remove the counter pane, and blanket, fold and place over the foot end of the
bed if weather permits.
4. Undress the patient, fold and place it over railing of head end if needed.
5. Take water half full in a basin, test the temperature of water by placing the back
of the hand in the water.
6. Place towel on the chest, wash rinse and dry the eyes, face, ears and neck.
Place towel under the far arm wash, rinse and dry forearm, upper arm and axilla.
1. Place basin or towel, dip the hand in water wash, rinse, and dry. Repeat the arm
nearest to the nurse provide nail care if needed.

1. Fold the top sheet upto the waist. Cover chest with towel wash.
2. Fold the top sheet up to pubis. Wash rinse and dry abdomen. Replace the sheet.
3. Place the towel under the a leg. Wash rinse and dry the thigh and repeat for the
leg nearest to the nurse.
4. Place basin on the towel. Flex the far knee and place the foot in the basin wash
with the brush rinse and dry. Repeat for the foot nearest to the nurse.
5. Turn the patient to the side facing away from the nurse. If the assistants available
otherwise turn the patient to the side facing towards the nurse. Place the towel to
the bed along with side line of the back, wash rinse and dry back and rub with
spirit(sacrum to medial area of the back shoulder, sides and buttocks with
circular movements) or skin lotion or powder or oil depending upon condition of
the skin and policy of the institution.
6. Make half of the bed.
7. Let the patient wash, rinse and dry the public area.
8. Help the patient to put on clothes.
9. Complete the bed.
10.Assist with the care of hair if needed.
11.Remove screen.
12.Take equipment for cleaning to the dirty area wash dry and replace. Boil the
sponge bags. Dry and replace them.
13.Record observation and reactions of the patient.
4. A.What is the meaning of nasogastric tube feeding?
A) DEFINITION.
Nasogastric tube feeding is defined as the delivery of nutrients from the nasal route into the
stomach vein of feeding .
B.Explain the steps of nasogastric tube feeding
PROCEDURE _ NASOGASTRIC INSERTION:

1. wash hands thoroughly.
2. measure distance of tube from tip of patient's ear lobe to nose to tipoff xiphoid process .
3. Mark the distance of the tube .
4. Lubricate the tube of about 6 to 8 inches with the lubricate using a ring pieces or a paper
square .
5. Hold the tube coiled in the right hand introduce the tip into the left nostril .
6. Pass the backwards momentary resistance may occur as the tube is passed into the naso_
pharynx.
7. When the tube reaches to pharynx the patient may gag . Allow him to rest for a
movement.
8. Have the patient lake the sips of water on command advance the tube 3_4 _ inches each
Time swallows .
9. Make sure tube is in stomach .
10. Once location of NG tube insured close other end of with spigot sec adhesive in T or
butter.
5. A.Define urinary catheterization?
A) DEFINITION: A urinary catheter is a tube placed in the body to drain and collect
urine from the bladder.
B.Explain the steps of urinary catheterization in a female patient?
A) Place the patient in the supine position with the knees flexed and separated and feet flat on
the bed, about 60 cm apart.
If this position is uncomfortable, instruct the patient either to flex only one knee and keep the
other leg flat on the bed, or to spread her legs as far apart as possible.
A lateral position may also be used for elderly or disabled patients.

With the thumb, middle and index fingers of the non-dominant hand, separate the labia majora
and labia minora. Pull slightly upward to locate the urinary meatus. Maintain this position to
avoid contamination during the procedure.
With your dominant hand, cleanse the urinary meatus, using forceps and chlorhexidine
soaked cotton balls. Use each cotton ball for a single downward stroke only.
Place the drainage basin containing the catheter between the patient’s thighs.
Pick up the catheter with your dominant hand.
Insert the lubricated tip of the catheter into the urinary meatus.
Advance the catheter about 5-5.75 cm, until urine begins to flow then advance the
catheter a further 1-2 cm.
Note: If the catheter slips into the vagina, leave it there to assist as a landmark. With
another lubricated sterile catheter, insert into the urinary meatus until you get urine
back. Remove the catheter left in the vagina at this time.
 Attach the syringe with the sterile water and inflate the balloon. It is
recommended to inflate the 5cc balloon with 7-10cc of sterile water, and to inflate
the 30cc balloon with 30-35cc of sterile water.
 Improperly inflated balloons can cause drainage and leakage difficulties.
 Gently pull back on the catheter until the balloon engages the bladder neck.
6. A.Define enema : During a cleansing enema, a water-based solution with a small
concentration of stool softener, baking soda, or apple cider vinegar is used to stimulate the
movement of the large intestine. A cleansing enema should stimulate the bowels to quickly
expel both the solution and any impacted fecal matter.
Classify enema:

 Evacuent enema Simple Evacuent enema Medicated Evacuent enema Oil
enema Purgative enema Astringent enema Anthelminthic enema Carminative
enema Cold enema Retained enema Stimulant enema Nutrient enema Emollient
enema Sedative enema
 Anaesthetic enema
 These are given to cause the bowel to contrast activelyPurgative Enema & Its
acts by their irritating effect on the mucus lining, stimulate peristalsisto
evacuate its contents & The stretching of the intestine due to this inflow of fluid
causes the intestine to contractcause the evacuation of bowel & leads to the
evacuation of bowels
 Anthelmintic enema & Before the treatment is given the bowel should be
cleansed by a soap water enema so that the drug may come in direct contact
with the wormsexpel the worms from the intestines & Amount of the solution :
250 ml Hypertonic saline solution : sodium chloride 60 ml with 600 ml of water
 Infusion of quassia : 15gms of chips to 600 ml of water  The treatment is
given until the worms are destroyed Solution : the lining of the intestine
 To stimulate defecation Purpose : Simple evacuant enema & To stimulate
uterine contraction To relieve the retention of urine by reflex stimulation of the
bladder  To relieve the gaseous distention by stimulating the peristalsis to
treat constipation & To cleanse the bowel prior to x-ray studies , visualization of
the bowels (ex: sigmoidoscopy) , surgeryto hasten the child birth & retention
enemas
 Oil enema
o These are given to soften faecal matter in case of severe constipation
 Before the 1st bowel movement after operation on the rectum or perineum. To
avoid straining These are given to soften faecal matter in case of severe
constipation Oil enema & injury to the sutures & It should then be followed by

a soap It should be retained for half an hour to 1 hour to soften the faeces
wounds & water enema to open the bowels
o Astringent enema & the blood vessels , checks bleeding & inflammation ,
lessens the amount of mucus discharge & It is usually given in colitisgives a
temporary relief in the inflamed area & The solution is allowed to run in
slowly They are usually given in the form of rectal or colonic irrigations
dysentery & return quickly to avoid distension , pain & irritation of the
inflamed wall
o Abdominal cramps Hypothermia  Complications :  It is given in the form of
colonic irrigation  This is given to decrease the body temperature in
hyperpyrexia and heat stroke
c. Explain the steps with scientific principles in enema
1. The amount of the solution to be administered depends upon the type of the
enema and the age The temperature of the solutions needs to be adjusted
according to the purpose of enema  The rectal tube is lubricated with water
soluble lubricant  the rectal tube needs to be smooth and flexible  The
appropriate size catheter or rectal tube need to be used General instructions &
The height f the can should be adjusted to regulate the flow of the solution
according to the type of the enema The distance to which the tube is inserted
depends upon the age and the size of the client  When enema is administered,
the client usually assumes a left lateral position size of the person
2. 33. Prepacked enemas will have their own instructions which Listen to the
complaints of the client and should not ignore  If the rectum is impacted, attempt
to remove the faecal matter with gloved finger.  Regulate the flow of fluid
according to the type of the enema, give retention enema very slowly, usually by
a Murphy drip.  Make sure the whole apparatus used for the administration of
enemas is in a good working condition  The length of time that the enema
solution is retained will depend upon the purpose of enema and the ability of the

client to contract the external sphincter to retain the solution General
instructions.
7. a .Define bedsore?
a) Bed sore: A painful, often reddened area of degenerating, ulcerated skin caused by
pressure and lack of movement, and worsened by exposure to urine or other irritating
substances on the skin. Untreated bed sores can become seriously infected or
gangrenous. Bed sores are a major problem for patients who are confined to bed or a
wheelchair. They can be prevented by moving the patient frequently, changing bedding,
and keeping the skin clean and dry.
b. What are the causes of bed sore?
A) Three primary contributing factors for bedsores are:
 Pressure. Constant pressure on any part of your body can lessen the blood flow
to tissues. Blood flow is essential for delivering oxygen and other nutrients to
tissues. Without these essential nutrients, skin and nearby tissues are damaged
and might eventually die.
 Friction. Friction occurs when the skin rubs against clothing or bedding. It can
make fragile skin more vulnerable to injury, especially if the skin is also moist.
 Shear. Shear occurs when two surfaces move in the opposite direction. For
example, when a bed is elevated at the head, you can slide down in bed. As the
tailbone moves down, the skin over the bone might stay in place — essentially
pulling in the opposite direction.
Risk factors
Your risk of developing bedsores is higher if you have difficulty moving and can't change
position easily while seated or in bed. Risk factors include:

 Immobility. This might be due to poor health, spinal cord injury and other
causes.
 Incontinence. Skin becomes more vulnerable with extended exposure to urine
and stool.
 Lack of sensory perception. Spinal cord injuries, neurological disorders and
other conditions can result in a loss of sensation. An inability to feel pain or
discomfort can result in not being aware of warning signs and the need to change
position.
 Poor nutrition and hydration. People need enough fluids, calories, protein,
vitamins and minerals in their daily diets to maintain healthy skin and prevent the
breakdown of tissues.
 Medical conditions affecting blood flow. Health problems that can affect blood
flow, such as diabetes and vascular disease, can increase the risk of tissue
damage such as bedsores.
c. Explain the nursing management of patients with bedsore?
A) The treatment may include:
1. Removing pressure from the affected area.
2. Keep the wound protected with medicated gauze or similar special dressings.
3. Control incontinence as much as possible.
4. Ensuring proper nutrition.
5. Keeping the wound clean.
6. Apply dressing.
7. Removing the infected, damaged and dead tissue (debridement)
8. a. Define comfort

 A) Relief in affliction; consolation; solace:Her presence was a comfort to him.
 A feeling of relief or consolation:Her forgiveness afforded him great comfort.
 Aperson or thing that gives consolation:She was a great comfort to him.
 Acause or matter of relief or satisfaction:The patient's recovery was a comfort to
the doctor.
b. Enlist the factors influencing comfort?
 A) Thermal Factors
The average temperature inside a building is 19-21 degrees and outside is -1
degrees, but there are two different thermal factors that affect the temperature of
the room and human comfort; they are physical and personal factors. The
physical factors include; air temperature, mean radiation temperature, relative
humidity and air velocity. The air temperature inside of a building will change
depending on the temperature outside the building and the k-values of the
materials used to build the walls and insulation.
 Physical and Personal Factors
There are also personal factors that can affect the human comfort in a building,
they include; age, gender, state of health, clothing and the level of activity. The
age of a person greatly affects the temperature of a room; older people give off
less heat then younger people. Gender is also a factor that affects the
temperature given off by people, females give off less heat than males, and they
give off 85% of what the male body gives off. The state of health of the person
also affects the heat that they give off and the temperature of the room, a person
who is sick or has an illness gives off less heat that a person who is physically
healthy. The clothing you are wearing also affects the temperature that you need
to be comfortable, depending on the weight of the clothing you will need different
temperatures to feel comfortable e.g. swimwear 29 degrees, light clothing 25
degrees, suit, jumper 22 degrees, coat, glove, hat 14 degrees.
 Visual / Lighting Factors
The final factor that affects human comfort is light intensity. If the light levels are
too low or too high then it will not be as suitable. Light travels in rays and

bounces off objects and into the eye. The rays cannot bend so they must go in
straight lines, but light can be refracted through certain materials which can bend
the beam slightly. The light needs to be the right intensity so that the eyes don’t
have to strain too much if it is too dark or if the light is too bright it may blind.
Light can be controlled by letting certain amounts of natural light through
windows and also by the brightness of the artificial light from the light bulbs.
c. Explainthe types and usage of comfort devices
A) TYPES OF COMFORT DEVICES (Role of Nurse in Comfort Measures)
Comfort is concerned with rest, with exercise, with the relation of one part of the body to
another, with the bed and the whole environment. Comfort is a phase of every
procedure as it is an aspect of the total care of the patient.
Comfort devices are invented articles which would add to comfort of patient when used
in appropriate manner.
These devices relieve the discomfort and help in maintaining correct posture. Various
comfort devices are used for giving comfort to the patient, such as: pillows, back rest,
foot rest, bed block, bed cradles, sand bags, air cushion, rubber and cotton rings, air
and water mattresses and knee rest.
PILLOWS
Pillows are used to give comfortable position to the patient. These are most commonly
used to support various body parts.
Purpose
 To maintain proper body alignment
 To support body part in good alignment
 Help to reduce pressure
 It can be folded, rolled or tucked firmly against the body to maintain position

 It is used to support head, neck, arms, legs and part of the back adds to the
physical comfort
BACK REST
Back rest is a mechanical device which provides a suitable support and rest for the back
of the patient in sitting position
Purpose
 To support back
 To facilitate easy breathing
 It is given especially for heart patients and asthma patients
 Used in postoperative period
ROLLS
 Hand rolls are made of cloth that rolled into a cylinder’ about 4-5 inches long and
2-3 inches in diameter and stuffed firmly
Purpose
These used to keep the fingers from being held in a tight fist leading to flexion
contracture in patients who are unable to move hands due to paralysis, injury or
disease. Thigh rolls are made by folding a sheet to the desired length of 2-3 feet and
then rolled into a tight cylinder.
Thigh rolls are used to support hips and thighs preventing them from outward rotation
and keeping the feet in good alignment in case of paralysis, fracture of femur of hip
surgery.
FOOT RESTS
Foot rests are the mechanical device used to give rest to feet. Sands bags or foot board
may be substituted.

Purpose
 It helps to maintain the normal position of feet
 It is used for the comfort
 To prevent foot drop
SAND BAGS
Sand bags are canvas, rubber or plastic bags filled with sand and are 1, 5 and 10 lbs in
weight. Sand bags are used to immobilize a part.
Purpose
 To relieve discomfort
 Used to support the body part
 Used to immobilize the body part
 Used to support as in fractures bones
 To prevent foot drop or wrist drop
AIR AND WATER MATTRESSES
Air and water mattresses are used for very thin or obese patients and for those who are
prone to get pressure sores. The principles is that pressure exerted by the body, will be
distributed equally in all directions.
Air and water mattresses are plastic mattresses with two sets of chambers. To use them
place the mattress on the bed and fill air or water in the compartment. Cover the
mattress with light bottom clothes.
Purpose
 To improve circulation
 To provide comfort

 To prevent pressure sores
 Used in very thin or very obese patients
 Used in chronic bed ridden patients
Caution
Avoid punctures in the mattress with needles, pins or other sharp objects
RINGS
Air rings are made of rubber. The air rings is inflated about half full tested for leakage,
covered and the placed under the patient’s hip in such a way that the value is on side
and not in contact with body.
Cotton rings are made wrapped with bandage. These are placed under the bony
prominences such as heels and fastened in place if necessary.
Purpose
 Used to lift the hip from bed to prevent bed sores
 It helps to prevent direct pressure on bony prominence
 It improves the circulation
BED CRADLES
Bed cradles vary widely in size and in material. Bed cradles are of wooden, metal or
electronic. The bed cradles support and take off the weight of the bedding.
Bed cradle are semi-circular in shape made of wood or metal or entirely made of metal
tubing or slats.
Purpose
 Used to prevent the top cloth is coming in contact with the patients especially in
burns patients

 To apply heat in case of dying plaster casts
 Electronic bed cradles are used to supply the desired warm to the case of shock
BED BLOCKS
Bed blocks are made up of wood size; it may be high or low. These are placed under
the foot of bed for various reasons.
Purpose
 To prevent shock
 To arrest hemorrhage
 To retain enema
 After spinal anesthesia
 After tonsillectomy
 To provide traction
 To position in postural drainage
AIR CUSHION
Air cushions are round in shape and made up of rubber. These can be inflated with air.
These are used to take off the weight of the body.
Air cushion should not be applied directly in contact with skin. They should have a
cover.
Purpose
 To relieve pressure on certain parts of the body
 It provides relaxation as it yields to shift off body weight and it relieves pressure
on certain parts of the body

Uses: air cushion vehicles work by creating a large force of those points to the ground.
This lifts the vehicle off the ground letting it ride on a cushion of air.
CARDIAC TABLE
A table is in the hospital for patient’s use during hospitalization. It is used to maximize
safety of both patients and staff. Improve patient’s surrounding by modifying the current
cardiac table to one that can be kept and folded.
 Bed table placed in front with a pillow on it, patient can lean forward and take rest
 Table without pillow is used for writing and meals
 Used for patients with cardiac conditions and asthma
 Position should be changed to relieve fatigue
Purpose
 Patient can rest over the table with the help of pillow
 Helps to take meals and in writing
TRAPEZE BAR
An overhead trapeze is a triangle-shaped metal bar. It hangs from a metal frame, which
is attached to the headboard and footboard of the bed. A trianglular metal apparatus
above a bed, used to help the patient move and support weight during transfer or
position change.
Trapeze bar is suspended from an overhead frame that extends from the foot to head of
bed. Patient can grasp the bar to raise the trunk off the bed surface or to move up in
bed.
ROLE OF NURSE IN COMFORT MEASURES
 Nurse identify comfort needs of patients and family members
 Nurses design interventions to meet identified needs

 Intervening variables are considered when designing interventions
 When interventions are delivered in a caring manner and are effective, and when
enhanced comfort is attained, interventions are called ―comfort measures‖
 Patients and nurse agree on desirable and realistic health seeking behaviors
 If enhanced comfort is achieved, patients and family members are more likely to
engage in health-seeking behaviors these further enhance comfort
 When patients and family members are given comfort care and engage in health-
seeking behaviors, they are more satisfied with health care and have better
health-related outcomes.
 When patients, families, and nurses are satisfied with health care in an
institution, public acknowledgement about that institution’s contributions to health
care will help the institution remain viable and flourish.
9. A.Define rest and sleep?
A) Sleep – the natural resting state in which the body is not active and the mind does
not think.
Rest – to cease work or movement. Relaxation – the state of being free from tension
and anxiety.
b. What are the stages of sleep?
 A) Stage 1 non-REM sleep is the changeover from wakefulness to sleep. During
this short period (lasting several minutes) of relatively light sleep, your heartbeat,
breathing, and eye movements slow, and your muscles relax with occasional
twitches. Your brain waves begin to slow from their daytime wakefulness
patterns.
 Stage 2 non-REM sleep is a period of light sleep before you enter deeper
sleep. Your heartbeat and breathing slow, and muscles relax even further. Your
body temperature drops and eye movements stop. Brain wave activity slows but

is marked by brief bursts of electrical activity. You spend more of your repeated
sleep cycles in stage 2 sleep than in other sleep stages.
 Stage 3 non-REM sleep is the period of deep sleep that you need to feel
refreshed in the morning. It occurs in longer periods during the first half of the
night. Your heartbeat and breathing slow to their lowest levels during
sleep. Your muscles are relaxed and it may be difficult to awaken you. Brain
waves become even slower.
 REM sleep first occurs about 90 minutes after falling asleep. Your eyes move
rapidly from side to side behind closed eyelids. Mixed frequency brain wave
activity becomes closer to that seen in wakefulness. Your breathing becomes
faster and irregular, and your heart rate and blood pressure increase to near
waking levels.
c. Describe the factors affecting sleep?
 A) Lighting: Our body clock gets adjusted according to the changes we observe
in our environment. Therefore, it automatically starts to wind down as the
brightness levels start to decrease. Bright lights can trick the body clock to
assume that it is still day. This makes the body clock to delay sleep timing.
 Sleep environment: Environmental factors can affect your sleep. These include
the feeling of safety at the place of your sleep, and how comfortable the bed is.
Most people find it difficult to fall asleep, when they move to, or visit a new place.
 Jetlag: As earlier explained, the body clock might suffer if there are changes in
exposure to light to the eyes. Jetlag also has the same effect on the body. It
takes time to adjust to different time zones, thus disturbing our sleep timings.
 Shift-based work: Shift-based work affects the sleep quality the same way as
jetlag. This is because the body clock is not able to work properly. Variations in
the sleep timings every other week or month confuses the body’s clock, and this
results in bad sleep.
 Medication: Many chemicals like such as caffeine and nicotine disturb the sleep
quality. Many medications like anti-depressants also have some chemicals which
interfere with the healthy course of sleeping.

Internal factors that affect your sleep:
 Body aches or other pains: Certain pains like muscle or joint pain, or even
headaches can keep you awake at night. These conditions bring discomfort to a
person, which makes it difficult to fall or remain asleep for long.
 Anxiety or stress: Our bodies are built in such a manner that they respond to
stressful or dangerous situations by remaining awake. Same happens in during
stress, depression or anxiety, where the person finds it difficult to get a complete
sleep at night. Most of the times in such cases, a person gets more REM sleep
than deep sleep.
10 .a. Write the factors affecting oxygenation?
A) Factors Affecting Oxygenation
 Decreased oxygen-carrying capacity.
 Hypovolemia.
 Decreased inspired oxygen concentration.
 Increased metabolic rate.
b. List the methods of oxygen administration?
A) Low flow delivery method
Low-flow systems include:
 Simple face mask
 Non re-breather face mask (mask with oxygen reservoir bag and one-way valves
which aims to prevent/reduce room air entrainment)
 Nasal prongs (low flow)
 Tracheostomy mask
 Tracheostomy HME connector

 Isolette - neonates (usually for use in the Neonatal Intensive Care Unit only)
Note: In most low flow systems the flow is usually titrated (on the oxygen flow meter)
and recorded in litres per minute (LPM). Where the Airvo2 is used as an oxygen
delivery device the flow from this device is independent to the flow of oxygen.
High flow delivery method
See also below guidelines for additional information:
 PICU high flow
 Ward based High Flow Nasal Prong Therapy nursing guideline
High flow systems include:
 Ventilators
 CPAP/BiPaP drivers
 Face mask or tracheostomy mask used in conjunction with an Airvo2 Humidifier
 High Flow Nasal Prong therapy (HFNP)
 NB: There is separate CPG for HFNP use in the NICU (see NICU HFNP
CPG)
Humidification
Oxygen therapy can be delivered using a low flow or high flow system. All high flow
systems require humidification. The type of humidification device selected will depend
on the oxygen delivery system in use, and the patient's requirements. The humidifier
should always be placed at a level below the patient's head.
Indications:
 Patients with thick copious secretions
 Non-invasive and invasive ventilation

 Nasal prong flow rates of greater than 2 LPM (under 2 years of age) or 4 LPM
(over 2 years of age)
 Nasal prong flow rates of greater than 1 LPM in neonates
 Facial mask flow rates of greater than 5 LPM
 Patients with tracheostomy
Simple Nasal Prongs
Nasal prongs without humidification
This system is simple and convenient to use. It allows the oxygen therapy to continue
during feeding/eating and the re-breathing of CO2 isn't a potential complication.
Simple nasal prongs are available in different sizes. To ensure the patient is able to
entrain room air around the nasal prongs and a complete seal is not created the prong
size should be approximately half the diameter of the nares.Select the appropriate size
nasal prong for the patient'sageandsize.
For nasal prong oxygen without humidification a maximum flow of:
 2 LPM in infants/children under 2 years of age
 4 LPM for children over 2 years of age.
 1 LPM for neonates
Nasal prongs with humidification system
If the required flow rate exceeds those as recommended above this may result in nasal
discomfort and irritation of the mucous membranes. Therefore, humidification of nasal
prong oxygen therapy is recommended.
Humidification can be provided using either the MR850 Humidifier or the AIRVO 2
Humidifier. Follow the manufacturer’s Instructions for use for each device and setup.

ptiflow Nasal Prongs Humidification using MR850 Humidifier
Optiflow nasal prongs are compatible for use in humidified low or high flow oxygen
delivery.
Fisher and Paykel Optiflow nasal cannula junior range
Four sizes of prongs:
1. Premature
2. Neonate
3. Infant
4. Paediatric
High flow (in approved areas only, see relevant guidelines)
 Flow of 2 L/kg/min up to 12kg, plus 0.5 L/kg/min for each kg above 12kg (to a
maximum of 50 LPM)
 FiO2 21-50% (blender must be used)
 FiO2 above 50% requires PICU review (except if patient is in NICU)
c. Write the procedure of oxygen administration through nasal cannula in detail
A) Purpose
1. Deliver low to moderate levels of oxygen to relieve hypoxia.
Assessment/Preparation
 Assess respiratory status (i.e., breath sounds, respiratory rate and depth,
presence of sputum, arterial blood gases if available).
 Assess past medical history, noting chronic obstructive pulmonary disease
(COPD). For clients with COPD, hypoxemia is often the stimulus to breathe

because they chronically have high blood levels of carbon dioxide. If
additional oxygen is needed, a low-flow system is essential to maintain slight
hypoxemia so breathing is stimulated.
 Assess for clinical signs and symptoms of hypoxia: anxiety, decreased level
of consciousness, inability to concentrate, fatigue, dizziness, cardiac
dysrhythmias, pallor or cyanosis, dyspnea.
Equipment
 Oxygen source
 Flowmeter
 "No smoking" sign
 Humidifier and distilled water (for high-flow O2 therapy)
 PROCEDURE
 Review chart for physician's order for oxygen to ensure that it includes method of
delivery, flow rate, titration orders; identify client.
 Rationale: Prevents potential errors.
 Wash your hands.
 Rationale: Handwashing reduces transmission of microorganisms.
 Identify client and proceed with 5 rights of medication administration (Fig. 1).
Explain procedure to client. Explain that oxygen will ease dyspnea or discomfort,
and inform client concerning safety precautions associated with oxygen use.
Encourage him or her to breathe through the nose.
 Rationale: Oxygen is a drug and administering using the 5 rights avoids potential
errors. Teaching helps ensure compliance with therapy.
 Assist client to semi- or high Fowler's position, if tolerated.
 Rationale: These positions facilitate optimal lung expansion.

 Insert flowmeter into wall outlet Attach oxygen tubing to nozzle on flowmeter. If
using a high O2 flow, attach humidifier.Attach oxygen tubing to humidifier
 Rationale: Oxygen in high concentrations can be drying to the mucosa.
 Turn on the oxygen at the prescribed rate. Check that oxygen is flowing through
tubing
 Rationale: Oxygen must be administered as prescribed.
 Hold nasal cannula in proper position with prongs curving downward
 Place cannula prongs into nares
 Wrap tubing over and behind ears
 Adjust plastic slide under chin until cannula fits snugly
 Place gauze at ear beneath tubing as necessary
 Rationale: Proper placement in nares ensures accurate administration. Note: The
cannula permits some freedom of movement and does not interfere with the
client's ability to eat or talk.
o If prongs dislodge from nares, replace promptly.
 Rationale: To ensure correct oxygen delivery and prevent hypoxemia.
 Assess for proper functioning of equipment and observe client's initial response
to therapy.
 Rationale: Assessment of vital signs, oxygen saturation, color, breathing pattern,
and orientation helps the nurse evaluate effectiveness of therapy and detect
clinical evidence of hypoxia.
 Monitor continuous therapy by assessing for pressure areas on the skin and
nares every 2 hours and rechecking flow rate every 4 to 8 hours.
Rationale: Permit early detection of skin breakdown or inadequate flow rate
11.a .Enlist the areas of pressure points?
A) The most common sites are the back of the head and ears, the shoulders, the
elbows, the lower back and buttocks, the hips, the inner knees, and the
heels. Pressure injuries may also form in places where the skin folds over itself. And
they can occur where medical equipment puts pressure on the skin.

Common sites of pressure ulcers
For people who use wheelchairs, bedsores often occur on skin over the following sites:
 Tailbone or buttocks
 Shoulder blades and spine
 Backs of arms and legs where they rest against the chair
 For people who need to stay in bed, bedsores may happen on:
 The back or sides of the head
 The shoulder blades
 The hip, lower back or tailbone
 The heels, ankles and skin behind the knees
b. Explain the nursing management for prevention of bedsore in a bed ridden patient?
A) PREVENTION
We can help prevent bedsores by frequently repositioning yourself to avoid stress on
the skin. Other strategies include taking good care of your skin, maintaining good
nutrition and fluid intake, quitting smoking, managing stress, and exercising daily.
Tips for repositioning
Consider the following recommendations related to repositioning in a bed or chair:
 Shift your weight frequently. Ask for help with repositioning about once an
hour.
 Lift yourself, if possible. If you have enough upper body strength, do
wheelchair pushups — raising your body off the seat by pushing on the arms of
the chair.
 Look into a specialty wheelchair. Some wheelchairs allow you to tilt them,
which can relieve pressure.
 Select cushions or a mattress that relieves pressure. Use cushions or a
special mattress to relieve pressure and help ensure that your body is well
positioned. Do not use doughnut cushions, as they can focus pressure on
surrounding tissue.
 Adjust the elevation of your bed. If your bed can be elevated at the head, raise
it no more than 30 degrees. This helps prevent shearing.

 Tips for skin care
 Consider the following suggestions for skin care:
 Keep skin clean and dry. Wash the skin with a gentle cleanser and pat dry. Do
this cleansing routine regularly to limit the skin's exposure to moisture, urine and
stool.
 Protect the skin. Use moisture barrier creams to protect the skin from urine and
stool. Change bedding and clothing frequently if needed. Watch for buttons on
the clothing and wrinkles in the bedding that irritate the skin.
 Inspect the skin daily. Look closely at your skin daily for warning signs of a
pressure sore.
12. A.DefinePediculosis?
A) Pediculosis is an infestation of lice (blood-feeding ectoparasitic insects of the
order Phthiraptera). The condition can occur in almost any species of warm-blooded
animal (i.e. mammals and birds), including humans. Although pediculosis in humans
may properly refer to lice infestation of any part of the body, the term is sometimes used
loosely to refer to pediculosis capitis, the infestation of the human head with the
specific head louse.
b. Explain the procedure of head wash in a bedridden patient?
The procedure
1. Review the patient’s care plan for hygiene needs and check there are no
contraindications to positioning the patient flat in bed.
2. Ensure someone will be available to help position the patient during the
procedure if required.
3. Decontaminate your hands in line with the WHO’s 5 moments for hand hygiene.
4. Discuss the procedure with the patient, ask about their usual hair routine and
gain their informed consent for the procedure.

5. Check whether the patient has any pain. Administer analgesia if necessary and
ensure it has taken effect before starting the procedure, to help relieve any pain
associated with moving the patient.
6. Ensure the patient’s privacy and check that the environment is warm and free of
draughts.
7. Check whether the patient needs to empty their bowel/bladder before the
procedure.
8. Assemble your equipment and ensure everything is to hand to minimise the
amount of time the patient is lying flat.
9. Ensure the bed is at the correct working height.
10.Decontaminate your hands and put on an apron to reduce the risk of infection.
11.Remove the patient’s clothes from their upper body and cover them with a sheet
to maintain dignity.
12.Remove the pillows from behind the patient’s head so they are lying flat. This
allows water to drain away from the eyes and ears during the procedure
(Dougherty and Lister, 2015). Ask the patient to let you know if they feel
uncomfortable in this position at any time.
13.Remove the head of the bed so you can access the patient’s hair easily (Fig 3a).
14.Place a plastic sheet under the patient’s head and shoulders, and wrap a towel
around their shoulders (Fig 3b).
15.Position the patient’s head on the shampoo tray, ensuring you follow
manufacturer’s instructions carefully (Fig 3c). A towel can be placed under the
neck for support (Dougherty and Lister, 2015).
16.Following manufacturer’s instructions, ensure the receptacle that will collect the
water from the shampoo tray is positioned under the drainage spout.

17.Fill a disposable wash bowl with warm water and allow the patient to check the
temperature.
18.If required, cover the patient’s eyes with a disposable washcloth to protect them
from water and shampoo.
19.Using a disposable jug, take water from the disposable bowl and wet the
patient’s hair. Start at the front hairline and allow the water to drain down and
away from the face, avoiding the eyes and ears
20.Apply the shampoo and massage it into the hair.
21.Using the jug, rinse the patient’s hair with water.
22.Apply conditioner, if required by the patient, and rinse the hair again.
23.Check, regularly, the patient is comfortable and can maintain their position.
24.Pat the hair with a towel to remove the excess water – avoid pulling on the hair
as this can be uncomfortable.
25.Remove the shampoo tray and wrap a towel around the patient’s head to dry the
hair and ensure they do not feel cold.
26.Dry the surrounding skin, paying particular attention to skin folds in the neck.
27.Change any wet bed linen. Dispose of soiled bedlinen directly into the linen skip.
28.Replace the bedhead and reposition the patient so they are comfortable
13. a. Differentiate mobility and immobility?
A) Differentiate mobility and immobility
Mobility:refers to a persons ability to move freely
Immobility:refers to a persons inability to move freely

B. State the principles of body mechanics
.Spread your feed apart to provide a wide base of support
.Place your feet appropriately in the direction in which the movement occurs
.Keep objects to be moved close to the body
.Push pull role or slide objects rather than lifting thrm whenever possible
.When pushing or pulling an objects use the body's weight to counteract the weight of the
object
.Avoid twisting the spine by pushing or pulling objects directly away from or toward the body
anf squarely facing the direction of movement
.When lifting objects distribute the weight between large muscles of the legs and arms.
C. Describe the complications of Imbobility
1.Pressure Ulcer
.A pressure ulcer is a specific tissue injury caused by in relieved pressure that result in
underlying tissue.
Pressure ulcer occur most commonly over prominenses
.Risk factors include
1.Immobility
2.Manutrition
3.Incontienence
4.Compromised peripheral circulation
.The elderly are especially at risk because of a loss of clean body mass and changes in body
tissye and pripheral circulation.

Stage1: Redness of intact skin
Stage2:Abrasion,Creater or blisters ulcer shallow
Stage3:Damage to subcutaneous tissue extending down the fascia, deep crater possibly with
drainage
Stage 4:Damage to muscle bon tender or joint capsule small or large surface wound but with
extensive tunneling and foul smelling discharge.
SHORT ESSAYS
1. Explain complications of neglected oral hygiene
Ans. There are many health risks associated with poor oral hygiene. It’s
unbelievable how many people are unaware of the effects the mouth and
gums have on your overall health. Doctors believe inadequate oral hygiene
is a contributing factor to a variety of serious health issues. Many health
problems essentially originate from negligent oral hygiene. Periodontal
disease is the leading factor associated with aiding chronic conditions in
the human body.
Poor oral hygiene can lead to many different symptoms such as:
 Bone loss
 Cancer
 Inflammation of blood vessels
 Hardened arteries

 High blood pressure
 Blood clots
 Fertility problems
Most of these complications can be prevented simply by taking care of
your mouth. Listed below are a few debilitating chronic conditions and
health problems that are believed to be associated with poor oral hygiene.
Chronic Conditions Associated with Poor Oral Hygiene
 Heart Disease: Endocarditis and Cardiovascular Disease
 Diabetes
 Cancer, specifically Pancreatic and Oropharyngeal
 Alzheimer’s and Dementia
 Osteoporosis
 Pregnancy Problems – Preterm birth, low birth weight, or infections
of the newborn.
Health Problems Caused by Gum Disease
Endocarditis - Bacteria gains entry from another part of the body (in this
case, the mouth) into the bloodstream and attaches itself to areas of the
heart. This bacterium infects the inner lining of the heart, its chambers,
and valves. The infection can become fatal if not treated immediately.
Cardiovascular Disease - Plaque gains entry from the mouth to the heart,
arteries, and blood vessels. Plaque usually builds up in the blood vessels.
This build-up leads to clogged arteries and blood clots.
Diabetes - Inflammation in the mouth, from periodontal disease, begins to
weaken the body’s ability to utilize insulin and process sugars in the
blood. Inflammation prevents the body from using insulin to convert sugar
into energy. Due to the lack of insulin used, the body’s blood pressure
tends to build.

Cancer - Many studies have shown a strong correlation between people
with gum disease and cancer. The strongest relationships are between
gum disease and pancreatic cancer, and gum disease and oropharyngeal
cancer. Even though experts undeniably believe there is a relationship
between the two, the correlation between the cause-and-effect factors
have not been scientifically proven yet.
Alzheimer’s Disease / Dementia - Currently there are studies attempting
to link gum disease and dementia. Experts believe this happens when the
brain is repeatedly exposed to bacteria or other harmful agents from the
gums. This bacterium causes immune responses which lead nerve cells to
die resulting in potentially memory loss.
Osteoporosis - A loss of bone tissue is present in both osteoporosis and
periodontal disease. Osteoporosis mainly affects the bones in the hip,
back and wrist, while gum disease mainly occurs in the teeth and jawbone.
Clinical studies are trying to prove that inflammation from periodontal
disease affects the bones throughout the body, not just the jawbone and
teeth.
Pregnancy - Due to hormonal fluxes in the body’s chemistry, pregnancy
sometimes causes periodontal disease. Periodontal disease then allows
plaque and bacteria into the blood stream reaching and affecting the
foetus. Gum disease has been linked to low birth weights, premature
births, and infections in new-borns.
2. Explain role of nurse in prevention of physical hazards
Ans. As health care evolves, nurses continue to play a vital role in patient care and
disease prevention. school nurse provides for the safety of the environ-ment by
participating in environmental safety monitoring (playgrounds, indoor air quality, and
potential hazards).

1ST YEAR B.SC NURSING FUNDAMENTAL NURSING BLUEPRINT QUESTION BANK SOLUTION (GNM)RGUSH

1ST YEAR B.SC NURSING FUNDAMENTAL NURSING BLUEPRINT QUESTION BANK SOLUTION (GNM)RGUSH

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