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Bed Bath

Topic: Carry out proper patient's hygiene (PEX 1.6.1 - 1.6.6)

Carry out bed bath (PEX 1.6.1)

BED BATH Is bathing of a patient who is confined to bed and cannot or has no capability of self bathing.

Purpose:

To cleanse the body off dirt, debris and perspiration (sweating) and toxic substances.
To refresh (relieve fatigue) and provide tactile stimulation.
To stimulate circulation.
To provide comfort and relaxation.
To enhance self-concept (self esteem)
To regulate body temperature.
To induce sleep.
To prevent bed/pressure sores by minimizing skin irritation.
To give health instruction to the patient.
To prevent contracture by giving exercise-stretching of body muscles.

Types of patients needing a bed bath:

Unconscious or semi-conscious patients.
Post-operative patients
Patients with strict bed rest.
Paraplegic patients
Orthopedic patients in plaster cast and traction
Seriously ill patients

Types of cleansing bath:

Bed bath; it is the bathing of a patient who is confined to bed.
Therapeutic bath; doctor specifies the temperature of the water, medications to be added and the body part is to be treated.
Partial bath; it is the act of cleaning particular areas in the body for example face, axilla, genitalia, upper and lower limbs.
Self-administered bath; this is the same as in bed bath except the patient is assisting in taking the bath.
Tub bath or bathroom bath; this bath is allowed to the patient only if h/she has enough confidence for self help and is able to withstand the procedure.

Factors Affecting the Skin (Relevance to hygiene and pressure areas)

Impaired self care
Immobilization
Exposure to pressure and moisture
Vascular insufficiency
Reduced sensation
Nutritional alterations
Constrictive external device

Equipment for bed bath:

Top shelf:

Basin
2 large jugs (1 for hot water, 2^nd for cold water)
2 flannels (wash cloth)
Soap in soap dish
Nail brush and razor blade/nail cutter
Tooth brush/stick and tooth paste
Mug of clean water and receiver
Face towel
Comb and oil/Vaseline
Tray of pressure areas
Bowl of swabs or toilet paper
Bath thermometer

Bottom shelf:

2 bath towels
Clean bed linen
Clean patient’s gown/dress (depend on the sex)
Draw mackintosh and towel
Receiver for used swabs
Pail or bucket for dirty water
Gloves
Nurse’s apron

At the bedside:

Bedpan or + urinal with cover
Soiled linen container
Screens

Procedure:

Collect all the equipment needed always before beginning the procedure
Explain the procedure to the patient
Maintain the privacy of the patient by screening and closing the adjacent windows; and to prevent draught.
Give the patient a bedpan or urinal if required
Remove the top bed clothes and pillows, except the sheet and one pillow to maintain the position.
Remove the gown, wash and dry each part separately uncovering only the part to be washed.
Mix hot and cold water in a basin half full and check the temperature using the back of the hand or bath thermometer (temperature should be 110°F to 115°F)
Spread the face towel around the neck. Wet the sponge towel/flannels and remove excessive water then clean the body in the following order;

Face:

Wash the forehead, face, over and behind the ears and neck.
Clean the eyes from inner to outer end. Rinse the sponge towel and wipe the face.
Dry with the face towel thoroughly well to prevent chills.

Arms:

Place the towel lengthwise under the furthest arm. If there is I.V line do not disturb it.
Take soapy sponge and soap the arm and axilla.
Massage the pressure areas.
Rinse and dry well, paying attention to the skin under the breast.
Cover the finished parts to prevent draught.

Chest:

Expose only the part to be washed.
Wet and apply soap to the chest in rotator movement, paying attention to skin creases (folds)
Remove soap thoroughly by wiping from neck to chest and dry with a bath towel.

Abdomen:

Fold the top sheet to the suprapubic region and cover the chest with a bath towel.
Wet and clean the abdomen with soap.
Clean the umbilicus and dry it with a bath towel.
Cover the patient with the top sheet and remove the towel.

Back:

Turn the patient on side or lateral position close to the edge of the bed, with the back towards the nurse.
Expose the back and buttocks; spread the bath towel on the bed, close to the patient’s back.
Wet the area and apply soap with rotator movements, clean and remove soap and dry the area.
Treat pressure areas.
Straighten the under bed linen and in-put clean linen and mackintosh if necessary.
Help the patient to return to supine position.

Legs:

Uncover the furthest leg 1^st and place a towel and mackintosh under the leg.
Apply soap to the leg and make sure to give special attention to the groin.
Treat pressure areas/points.
Place the foot in the basin to wash.
Rinse and dry well, paying special attention in between the toes.
Repeat the procedure on the next/other leg.

Pubic region:

Clean the pubic region with swabs or toilet paper (for helpless patient), if able permit the patient to clean by him/herself.
Give perineal care and dry the perineum thoroughly well, apply Vaseline to provide comfort.
Clean the mouth if the patient is unable to do it. If able give a stick or tooth brush with tooth paste and mug of water. Hold the receiver for the patient.
Cut the nails if necessary and comb the hair.
Make the bed and leave the patient comfortable.
Clear away and wash hands.

Record the procedure and report any abnormality seen on the patient to the nurse in-charge.

Baby Bath

BABY BATH Is the washing of the baby’s body to maintain its hygiene. The nurse/midwife helps the parents in bathing the baby and teaches them to do it, highlighting on infant’s reaction to various stages of bathing.

Purpose:

To maintain the baby’s hygiene.
To teach the mother (parents) or care-takers on how to bath the baby.

Requirements:

Top shelf:

2 jugs (1 with hot water and 2^nd with cold water)
Baby’s soap in a soap dish
Galipot of sterile swabs
Normal saline
Bath thermometer
Temperature tray (containing; galipot of swabs, thermometer, galipot of solution/disinfectant, TPR chart and pen plus second hand ticker watch)
Tray for cord care (galipot of swabs, cord scissors in a receiver, N/S, cord ligature, 2 receivers: - for used swabs and used instruments)
A pair of sterile gloves

Bottom shelf:

Receiver for used swabs
Plastic apron for the nurse/midwife
Clean baby clothes
Two baby towels (bath towels)
Napkins/diapers
Draw mackintosh and towel
Barrier cream and powder if necessary
Weighing scale

On the stool or table:

Basin

On the floor next to the bath area:

2 pails (for soiled clothing and soiled napkins)
If diapers, a large receiver is required

NB. The requirements can be laid on a trolley or a table. The nurse/midwife may bath the baby while; sitting on a low stool or chair with the baby on his/her laps. Or Standing with the baby on the table.

Procedure:

Prepare/collect the necessary equipment.
Arrange the equipment on the trolley or the table for easy reach.
Explain the procedure to the parent(s) or care-taker.
Provide privacy by closing nearby/adjacent windows and doors in the vicinity of the bath.
Put on the apron and wash hands.
Check the baby’s temperature and record on the chart.
Put cold then hot water in the basin.
Test the temperature with bath thermometer if available (T° 37-38°C) or test using the elbow, it should feel warm not hot, if no thermometer is available.
Undress the baby leaving the napkin on or diaper if dry.
Weigh the baby
Wrap the baby firmly in a towel leaving the head exposed.
Put dirty linen/clothes and napkins in a bucket respectively.
Hold the baby firmly under the left arm supporting the head with left hand.
Lower the head over the basin and wash face using clear clean water without soap.
Clean the eyes and ears with cotton swabs and water. If there is a discharge, use normal saline to clean them using a swab once working from inside outwards for each eye or ear.
Discard the used swabs in the receiver.
Dry the face with a towel.
With the right hand, using soap/baby shampoo, make lather/foam and apply to the baby’s head. Massage gently and then rinse off the foam thoroughly taking care not to splash water in the baby’s face.
Dry the baby’s head with bath towel.
Unwrap the baby and remove the napkin or diaper and clean the buttocks with a swab if necessary.
Hold the baby across your lap with the left hand holding firmly while grasping the shoulder around the axilla/armpit at the same time supporting the head.
Soap the baby’s body, arms and legs, taking care on the skin folds. Turn the baby and soap the back and in between the buttocks.
As the skin is now slippery, great care should be taken in handling the baby. Hold the baby firmly with the left hand under the right axilla and the right hand supporting the buttocks and grasping the left thigh (legs), with the baby’s head resting or supported by the nurse’s left arm, then gently lower the baby into the basin.
While continuing to support the baby with left hand, using the right hand to rinse the baby thoroughly well paying attention on skin folds, in between the buttocks and groins.
Place the bath towel neatly over the laps or on the table and lift the baby onto it. Wrap the baby well to prevent from getting cold.
Dry gently and thoroughly seeing that all skin folds e.g. fingers, arms, neck, axial, groin, in between the buttocks are dry.
When the skin is dry, apply barrier cream e.g. petroleum jelly to the whole body. If necessary apply powder at the groins and in between the buttocks.
Clean the umbilical cord stamp with normal saline and shorten the ligatures if necessary.
Dress the baby in clean napkin/diapers and clothes, keeping the baby warm.
Discard the towel in the bucket
Give baby to the mother to feed before taking him/her to sleep.
Clear away the used articles.
Document the bath, family participation, condition of the baby, urine and bowel movement and report any abnormalities noted during the procedure e.g. bruises, rashes, excoriation (peeling of the skin)

General Rules (Baby Bath):

Safety should be observed by keeping the baby warm, lying in safe place.
Prevent falls, burns and aspiration of water.
Before bathing the baby, assess the family’s preference and home practices.
Allow parents to make their own decisions as much as possible and retain control.
Baby should be bathed prior feeding to reduce the risk of vomiting and aspiration.
Bathing should be postponed in cold weather unless the room is heated.
Powder is not recommended on baby’s skin especially when broken.

Carry out oral care/mouth care (PEX 1.6.2)

MOUTH CARE/ORAL HYGIENE Mouth care is the maintenance in the cleanliness of the mouth. It is important because the mouth is the portal entry of food and digestion starts from the mouth and the entry of any pathogen in the mouth directly affects the health of the person.

Purpose:

To maintain oral hygiene among bedridden patients.
To prevent and treat mouth infections.
To keep the mouth fresh and clean.
To prevent dental carries and tooth decay.
To prevent the mucous membrane from becoming dry and cracked, hence keeping mouth moist.
To prevent sordes and sores which result into ulceration.
To prevent infection of parotid glands.
To stimulate salivation and increase appetite.
To prevent complications such as stomatitis, glossitis, pyorrhea, parotitis etc.
To stimulate circulation in the gums thus maintaining healthy teeth.
To remove food debris
To prevent halitosis.
To create a feeling of general well being.

Patients who require frequent mouth care:

Unconscious, semi-conscious patients
Helpless or very ill patients
Patient with higher body temperature/high fevers
Malnourished and dehydrated patients
Patients having local diseases of the mouth
Paraplegic patients
Post-operative patients

Solutions commonly used for mouth wash:

Potassium permanganate (KMNO₄); 1 crystal to a glass of water
Sodium chloride; 1 teaspoon to a pint of water
Potassium chloride; 4 to 6 percent
Hydrogen peroxide (H₂O₂); 1:8 solution

Dentifrices used:

Glycerin with lime juice; equal parts
Sodium bicarbonate paste
Reliable tooth paste or powder

Emollient/lubricant commonly used:

Cream or butter
White Vaseline
Liquid paraffin
Glycerin borax
Olive oil

Requirements for mouth care: A tray containing;

Mackintosh and towel
Small jug/glass of warm water
Patient’s towel to protect the patient
Two receivers; for waste water and used swabs
Paper bag if a second receiver is not available
A bowl for dentures if necessary
A galipot with moistener/lubricant
A galipot with swabs
A galipot of sodium bicarbonate solution; 5g in ½ liter of water
Kidney dish containing; a pair of artery forceps, anon-toothed dissecting forceps, mouth gag, tongue depressor.
Face towel
Galipot of gauze
A towel to cover the tray

N.B: If the patient can clean his/her own tooth brush and paste or the nurse may give him or her a soft stick /tooth brush with tooth paste to clean his/her teeth and a glass of warm normal saline to gargle with or plain clean water.

Procedure:

Collect the equipment required and bring to the bedside of the patient.
Explain the procedure to the patient.
Position the patient and protect his clothes with the patient’s towel.
Place the small mackintosh with a towel underneath the patient’s chin to protect the bed (if on lying down position)
Position the pillow according to comfort of the patient.
Wash hands and remove patient’s dentures if any, keep safely.
Inspect the mouth, note and report any abnormality detected.
Pour antiseptic solution into the galipot.
Soak the swab in solution and squeeze out excess solution by using artery clamp or press against the side of the galipot to prevent dripping.
Clean using up and down movements from gums to crown, clean oral cavity (inside of cheeks) from proximal to distal, outer and inner aspect of the teeth and clean the tongue gently from inner to outer aspect, avoid touching the palate which may make the patient feel sick and want to vomit.
Change swabs as often as needed and discard used swabs into the receiver or paper bag.
Give the patient a glass of water if he can rinse his mouth. Instruct him to gargle and spill it to the receiver. If not able cleanse the mouth till it’s thoroughly clean.
Dry the face using a face towel.
Wipe the lips with dabbing movements and apply a lubricant using gauze.
Leave the patient comfortable, clean and replace the equipment to the storage place.
Wash hands
Document the time, solution used, date, condition of oral cavity, abnormalities noticed and patient’s condition to the chart and give/inform the findings to the nurse in-charge or physician.

Mouth Irrigation

MOUTH IRRIGATION It is the washing out or removal of plaque or food debris in between the teeth using streams of pulsating water jets.

Indications:

Fractures of the jaw in conscious patients only
Bleeding tooth sockets
Food debris

Requirements: Tray

Jug of lotion (1/2 - 1 litre) sodium bicarbonate
Large syringe (10-20ml)
Fine catheter in a kidney dish
Galipot of swabs or tissues (hand wipes/tissue)
Receiver for used lotion
Mackintosh and towel
Lotion thermometer
Gloves

Procedure:

Collect the equipment needed.
Explain the procedure to the patient.
Provide privacy to the patient.
Position the patient in a comfortable position (sit the patient up if possible or turn onto the side).
Wash hands and put on gloves.
Place the mackintosh and towel around the neck.
Draw up the lotion in the syringe and connect to the catheter.
Place the end of the catheter into the patient’s mouth and ask him/her to hold it about 1” from the mouth.
Hold the end of the catheter close to the syringe and inject the lotion slowly into the mouth.
Pinch the catheter between the finger, disconnect the syringe and refill it.
Reconnect the syringe and inject the lotion as before.
Remove the catheter and the syringe and place in the receiver and ask the patient to rinse the lotion around the mouth.
Hold the second receiver under the chin and ask the patient to spit the lotion into it.
Repeat the procedure until the mouth is clean.
On completion, make the patient comfortable, dry around the mouth with the tissue/swabs and smear a little moistener on the lips.
Clear away and wash hands.
Report and record the procedure and findings.

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Bed Making

Topic: Demonstrate bed making (PEX 1.4.1 - 1.4.9)

BED MAKING Bed making is a key nursing skill that is essential for the promotion of patient care, comfort, hygiene and wellbeing.

Bed making requires technical and practical skills and consideration should be given to issues of safety, moving and handling and infection control practices.

There are many types of beds to suit the different conditions of the patient.

Two nurses should work together to make a bed and should face each other. Work from top to bottom of the bed except when putting on a counter pane (bed cover.)

Purpose of Bed Making

To keep the ward neat and tidy.
To keep/make the patient comfortable.
To prevent cross infection and complications such as bed sores.
For treatment of certain conditions e.g. shock or quickening of healing of the patient.

Rule of Bed Making

All equipment should be collected before starting the procedure.
Any conversation during bed making should not be on personal matters between the nurses but should be focused on the patient.
Close adjacent windows to protect the patient from draught on a cold day.
Patient must never be exposed, screen the bed and close the ward to visitors.
The bed should be made free from crumbs and creases, so as to give maximum comfort to the patient.
Sheets have to be smooth and when tucking in, MITRE the corners.
Pillows and other bed accessories should be well arranged to give support and comfort where necessary.
When pillows are being shaken, the nurse should turn away from the patient and not over the patient.
The bed should be made in a way suitable for treating certain conditions such as shock and to prevent complications as a result of bad nursing.
Always use clean beddings and linen for each patient.
Always wash hands after making beds of infectious or septic patients before moving to the next bed.
Do not put any linen of another patient to the next patient’s bed.
If linen is dropped on the floor, it should not be used.
Always have a dirty linen container or hamper at hand in which to put dirty linen, never put it on the floor or carry the across the ward to prevent cross infection.
The patient’s face should not be covered with sheets or blankets.
The open end of a pillow case should face away from the main door or entrance of the ward.
Two nurses are required and they should work in harmony avoiding unnecessary movements of the bed and themselves.
Extra assistance should be available and if necessary, one should be called upon to help lift the patient.
Do not make a bed when a sterile procedure is in progress in the ward.
Beddings from the infectious patients should first be soaked in a disinfectant e.g. jik (3.5%=3.5/0.5-1=6) 1.6,(6%=6/0.5-1=11)1.11 for 24 hours before washing.
Use large mackintoshes for incontinent patients to protect the beddings.
Use small mackintoshes at the head of the bed for unconscious or post operative patients.
Use a bed cradle over leaking wounds e.g. in burns.
Beds should be made in such a way that the patient can be put in without difficulty.
Allow room for the patient’s feet for free movement or turning when placing the top sheet over the patient.
Always wash hands before and after bed making.

Types of Beds

Unoccupied bed/hospital bed
Occupied bed
Admission bed
Admission bed for burns
Operation/post-operative bed
Bed for complete rest
Cardiac bed
Divided bed
Plaster and fracture bed

Appliances Used in Bed Making

Mackintosh/plastic sheet: Protects the beddings during procedures. Protects the beddings in case of vomitus, urine, blood, faeces from soiling the bed sheets and the mattress.
Hot water bottles: To provide added warmth to the patient. The hot bottles must always be covered and the cover tight enough before use. Never place it directly on the patient’s skin to avoid burns.
Bed cradle: To keep the weight of the bed sheets away from the patient’s affected area e.g. in burns.
Bed blocks/bed elevators: To elevate the top or bottom of the bed e.g. in patients with shock, cardiac problems etc. To promote drainage in case of chest drainage.
Backrest/bed rest: To help the patient sit up-right for those with chest problems (breathing difficulties), cardiac problems etc. different degrees of elevation can be made with pillows placed on top of the backrest.
Sandbags: To prevent movement of limbs in the treatment of some conditions like fracture of the limbs.
Air rings: These are place under the buttocks to relieve pressure so as to prevent bed sores.
Foot rest: A small piece of wood or cloth rolled neatly at the foot of the bed for the patient to support his/her feet in-order to prevent slipping/falling down the bed.
A cardiac table: It is the table place in front of the patient over the bed for meals, medicine or any leisure activity e.g. a magazine newspaper or work etc. it is used in patients with cardiac conditions in cardiac bed.
Fracture boards: To make a firm surface for support and it is placed across the bed springs under the mattress.

Prepare and Make an Unoccupied Bed (PEX 1.4.1)

Is an empty bed and is fully covered with a counter pane to protect it from dust and dirt while waiting for the new patient for admission.

Purpose:

To protect the bed from dust and dirt
To keep a ready bed for the admission and emergency.
To give the room/ward a neat and tidy appearance.

Requirements: trolley

Items on the trolley:

Spring cover
2 bed sheets
1 mackintosh/draw mackintosh
1 ground mackintosh
1 draw sheet
1 pillow and pillow case
1 blanket
1 bed cover/counter pane

Items in the ward:

2 chairs/stools for stripping the bed
A dirty linen container/hamper
Hospital bed
Mattress and mattress cover

Appliances needed for the unoccupied bed:

Foot rest
Bed blocks
Bed cradle
Fracture board

Procedure:

Collect 1^st all the requirements needed.
Bring always the hamper with you.
Clear the room 1^st of unnecessary equipment e.g. kidney dishes, bed pans and the belongings of the patient or from the family.
Pull the bed from the wall.
Place the 2 chairs at the foot of the bed.
Wash hands.
Turn the mattress to see whether the spring cover is straight or complete springs (not broken.)
Replace the ground mackintosh then the bottom sheet and start to tuck in from the top (see that the right side is up). Mitre the corners, tuck in at the bottom and then the sides.
Replace the mackintosh/draw mackintosh, put at the height of the patient’s buttocks. Place the draw sheet covering the mackintosh completely.
Put on the top sheet, tuck in the bottom, mitre each corner and leave the top free.
Place the blanket on the bed then turn back the blanket and top sheet on top of the blanket.
Replace the pillow(s) to the bed (open ends away from the entrance) after shaking them.
Put the bed cover to the bed, tuck in the bottom only, mitre corners and leave the sides hanging down but make sure it is covering the whole bed.
Push back the patient’s bed to the original position.
Clear away and wash hands.
Document the procedure and replace the equipment to their place of storage.

Demonstrate Stripping and Changing of Patient Linen (PEX 1.4.2)

STRIPPING THE BED This means undressing the bed or removing the bed linen from the in preparation to lay/make afresh.

Requirements: trolley

As for the unoccupied bed (requirements list above).

Procedure:

Collect 1^st all the requirements needed.
Bring always the hamper with you.
Clear the room 1^st of unnecessary equipment e.g. kidney dishes, bed pans and the belongings of the patient or from the family.
Pull the bed from the wall.
Place the 2 chairs at the foot of the bed.
Wash hands.
Un-tuck all the beddings first.
Take away the pillows and undress.
Fold the bed cover, blanket, top sheet in three, the bottom part should be on top and put on the chairs provided one by one. Fold the draw sheet and mackintosh, put on the chairs. Bottom sheet is also folded in three, bottom part 1^st as the top will be tucked in first when putting it on again.
Remove the ground mackintosh by rolling if off the bed and put to the chairs.
Re make the bed as required (refer to procedures for occupied or unoccupied bed).

Prepare and Make an Occupied Bed (PEX 1.4.3)

OCCUPATION BED Is a suitable, comfortable and appropriate bed for hospitalized patients. It is made as usual and one corner of the linen is folded back at 90° to let the patient in.

Open bed: Patient is allowed out of bed.

Purpose:

To provide clean bed
To provide comfort to the patient.

Requirements: trolley

The requirements needed are as for the hospital bed/unoccupied bed
In addition: gloves

Procedure:

Collect all the equipment needed.
Explain the procedure to the patient.
The patient is allowed out of bed when able.
Pull the bed from the wall.
Wash hands thoroughly and put on gloves.
Strip the bed and replace with clean linen.
The bed is made in the same way as the unoccupied bed except for the bed cover. Fold 1^st the blanket, then put the bed cover over the blanket and fold the top sheet back over the bed cover.
Fold half of the beddings back in a corner of 90° at the side of the locker, so that it is easy for the patient to get into the bed.
Push back the patient’s bed to the original position.
Clear away and wash hands.
Document or record the procedure.

Prepare and Make a Closed Bed (with patient in bed)

With the patient in bed/closed bed The bed is made with the patient in, for a patient who is not able to get out of bed. It is usually done by two nurses.

Purpose:

To provide comfort to the patient
To change the soiled bed linen.

Requirements: trolley

As for the unoccupied bed
In addition: gloves

Procedure:

Collect the equipment needed.
Explain the procedure to the patient.
Screen the bed and close adjacent windows for privacy.
Pull the bed from the wall.
Wash hands thoroughly and put on gloves.
Place 2 chairs at the foot of the bed.
Remove all the pillows except one for the patient to rest his head.
Loosen the beddings on all sides and then strip the bed.
Turn the patient on his left, placing one pillow under his head. The nurse towards the side the patient is facing should support the patient so that he does not feel afraid of falling down.
Roll the draw sheet and mackintosh to the center of the bed near the patient’s back.
If the bottom sheet needs changing, roll it to the center of the bed near the back of the patient.
Place the clean bottom sheet to halfway the bed over the mattress. Make sure that the middle fold is in the middle of the bed. Tuck the head end first, mitre the corner at the top, bottom and then sides.
Bring back the mackintosh and draw sheet if clean, tuck them under the mattress.
Turn the patient on his right side, placing one pillow under his head, the nurse towards the side the patient is facing should support the patient.
The 2^nd nurse removes the soiled linen and puts the linen in the dirty linen container. Straightens out the bottom sheet, mackintosh, draw sheet and tuck them separately and firmly. Mitres the corners beginning from top then bottom and sides.
Turn the patient back to the center of the bed and support him whilst his pillows are plumped and arranged. Position the patient comfortably.
As soon as the top sheet has been replaced over the patient, the sheet or blanket covering him may be removed and replace the top bed clothes.
Ensure that the bed clothes are loose enough over the patient’s feet. A bed cradle may be used to support their weight if needed but in the absence of this, the patient is asked to cross one foot over the other whilst the bed is being made, ensuring plenty of room for his feet.
Push back the patient’s bed to the wall/original position.
Replace the patient’s locker and open the windows.
Clear away and wash hands.
Document the procedure.

Prepare and Make an Admission Bed (PEX 1.4.4)

ADMISSION BED FOR NEW PATIENTS The bed is made for the newly admitted patients. It contains the pack that can be lifted off the bed or fixed on one side.

Requirements: trolley

As for the hospital bed
Additional: 2 admission sheets

Procedure: Admitting the patient in a clean bed

Collect the equipment needed.
Pull the bed form the wall.
Wash hands thoroughly.
Place the 2 chairs at the foot of the bed.
Turn the mattress to check the springs and spring cover.
Place the bottom sheet, mitre corners from top to bottom.
Add the mackintosh and draw sheet, tuck in firmly the place the bottom admission sheet, mitre corners from top to bottom and tuck in the sides.
The top admission sheet is placed over the admission bottom sheet and left hanging. The other top sheet and blanket are added on top of the admission sheets and then the bed cover.
Turn back the bed cover, blanket and the two top sheets to make a pack. Tuck one side or don’t, roll the beddings to the other side while the top admission sheet is rolled together to the pack.
Push the bed back to its original position.
Place the chair at the top side of the bed and put the pillow whilst waiting for the patient.
On completion, clear away and wash hands.
Document the procedure.

N.B:

Admit the patient between the admission sheets.
Cover the whole bed with a bed cover if the patient is not yet admitted to prevent dust and dirt.
Remove the admission sheets after the bed bath has been given to the patient.

Prepare and Make Bed for Burns (PEX 1.4.6)

ADMISSION BED FOR BURNS It is the bed made for new patient with burns only.

Requirements: trolley

As for the unoccupied bed
Additional:
- 2 old sheets and if possible sterile sheets
- Mackintosh pillow cover
- A mosquito net
- Bed cradle
- Bed locks
At the bedside: Infusion stand.

Procedure:

Collect all the equipment needed.
Pull the bed from the wall.
Wash hands thoroughly.
Place the 2 chairs at the foot of the bed.
Make as an admission bed instead of admission sheets, use old or sterile sheets and make a pack.
Cover the pillows with the mackintosh covers before putting on the pillow cases.
Push back the bed to the original position.
Put/hang the mosquito net to protect the patient from flies.
Place the bed cradle over the affected area to relieve weight of the beddings over the affected part.
Bed blocks are used to elevate the foot of the bed if the patient is in shock.
If the patient is bathed on admission, the sheets are removed when it is completed. If patient is still in shock or the burns are extensive, then the sheet should be left until the patient has recovered from shock and the admission bath is then given.
Clear away and wash hands.
Document the procedure

Prepare and Make Post-Operative Bed (PEX 1.4.7)

POST-OPERATIVE BED This bed is prepared to receive the patients who have undergone surgical procedures, recovering from the effects of anesthesia.

Purpose:

To place the patient in bed with minimum discomfort.
To make a comfortable and safe bed for the patient who is recovering from the effects of anesthesia.
To prepare to meet any emergency.

Requirements: trolley

As for the unoccupied bed
Additional:
- A small mackintosh and towel.
- Be elevator
- Emergency tray (mouth gag, air way piece, tongue depressor, drugs (e.g. adrenaline), swabs)
- Hot water bottles
At the bedside: Infusion stand.
On the locker: Post-operative observation tray (BP machine, stethoscope/pulsometer or watch, thermometer and observation chart.)

Procedure:

Collect all the equipment required for the procedure.
Pull the bed from the wall.
Wash hands thoroughly.
Place the 2 chairs at the foot of the bed.
Strip the bed in the usual way.
Put all the dirty linen into the hamper.
Make a clean bed with clean linen, making it as the hospital bed but with a pack which can easily be removed when lifting the patient onto the bed.
Instead of the pillows, put the small mackintosh and towel across the top of the bed and tuck in at the top.
Push the bed back to the wall.
Put the pillow(s) on the chair/stools, which will be used later when the patient recovers.
Clear away and wash hands.
Document the procedure.

Prepare and Make a Cardiac Bed (PEX 1.4.5)

CARDIAC BED Is used to help the patient to assume a sitting up position; which can afford him great comfort with least strain. Cardiac bed is used for patients with heart diseases, those with dyspnoea to provide easy breathing.

Purpose:

To relieve dyspnoea
To assist recovery of the patient
To provide comfort and prevent complications

Requirements: trolley

As for the unoccupied bed
Additional:
- Back rest
- At least 4-6 pillows and pillow cases
- Air cushion/air ring and cover if required
- Bed blocks
- Sand bags and cover/foot support i.e. small board, a pillow, rolled cloth etc; may be necessary to support the feet
- Cardiac table
On the locker: Sputum mug, a bell: so that the patient can reach it easily.

Procedure:

Collect the equipment needed.
Wash hands thoroughly.
Place the 2 chairs at the foot of the bed.
Prepare the bed as the open bed with the patient but in a sitting up position.
When making the bed, take care to see that the patient’s shoulders are covered if possible. It is better to use a bed jacket or shawl or a small blanket - the bed clothes will be restricting.
Place the back rest and pillows so as to support the patient in upright position and use a bed elevator or bed blocks to prevent the patient from slipping down the bed.
Place sandbags/board/small pillow/rolled cloth against the feet where necessary as foot support.
Push the bed back to its original position.
Place the cardiac table over the bed for the patient to use whilst reading or performing any tolerable activity.
Clear away and wash hands.
Document the procedure.

Prepare and Make a Divided Bed (PEX 1.4.8)

DIVIDED/AMPUTATION/STUMP BED The bed is used for the patients who have had an amputation of the leg or have had a fractures lie in extension or for pelvic examination or treatment. It is commonly used for patients whose leg(s) has been amputated in order to keep the stump visible and elevated.

Purpose:

To keep the stump in a good position.
To help in the observation of the stump for bleeding constantly and apply tourniquet instantly if necessary.
To ensure safety and comfort to the patient by preventing soiling and staining of the linen.
To prevent jerking movements of the amputated leg, causing complications

Requirements: trolley

As for the unoccupied bed
Additional:
- 1 sheet
- 1 blanket
- 2 sandbags and covers
- Mackintosh and dressing towel
- Tourniquet and towel, only if ordered by the doctor in charge of the case.
- An emergency dressing trolley
- Bed cradle

Procedure:

Collect the equipment needed for the procedure.
Pull the bed from the wall.
Wash hands thoroughly.
Place the 2 chairs at the foot of the bed.
Make the bed in two halves; across the middle or for the amputation bed at the level of amputation. The top half having a sheet, blanket and counter pane and then the bottom half having a sheet and the blanket. This may be too hot for the patient at day time, so the top blanket may be omitted. At night, however it is much colder and both blankets may be needed.
On completion push back the bed to its original position.
Clear away and wash hands.
Document the procedure.

Prepare and Make a Fracture Bed (PEX 1.4.9)

PLASTER AND FRACTURE BEDS Is used for a patient with fracture of the trunk or extremities to provide firm support by use of a fracture board placed under the mattress. Fracture bed is a hard firm bed designed for the patient with a fracture particularly of the spine, pelvis or femur.

Purpose:

To make the patient comfortable.
To maintain the position and give support to the fracture.
To aid in immobilizing the fracture.
To prevent unnecessary pain.

Requirements: trolley

As for the unoccupied bed
Additional:
- Fracture board
- Bed cradle
- Sandbag with cover
- Extra pillows (at least 3)

Procedure:

Collect the equipment needed.
Pull the bed from the wall.
Wash hands thoroughly.
Place 2 chair at the foot of the bed.
This bed is made as the occupied bed.
The fracture boards are made the same width as the bed, and their purpose is to make a firm surface for placed support. They are place across the bed springs under the mattress.
Put the bed cradle over the affected part, so as to lift the weight of the beddings from the patient.
Push back the bed to the original position.
Clear away and wash hands.
Document the procedure.

TO CHANGE THE BOTTOM SHEET FROM SIDE TO SIDE

This method is used for changing the bottom sheet for most patients in the hospital especially those not able to move out of bed.

Requirements: trolley

1 air ring and cover
1 draw sheet
1 draw mackintosh
A tray for treating pressure areas may be required
1 sheet
Gloves

At the bedside:

2 stools/chairs
Hamper
Screen

Procedure:

Collect all the equipment needed.
Explain the procedure to the patient.
Bring the equipment needed to the bedside.
Close the windows if necessary. Screen the bed if the ward is not closed.
Pull the bed from the wall.
Place the stools/chairs at the foot of the bed.
Wash hands thoroughly and put gloves.
Place the clean linen on the stools/chairs at the foot of the bed and the hamper besides the chairs/stools.
Fold the clean sheets across the width in three or roll them for easy placement.
Strip the top bed clothes as usual, leaving the sheet covering the patient on a hot day or a blanket and sheet on a cold day. Back rest and air ring, foot support are also removed.
Both nurses lift the patient carefully down the bed off the draw sheet.
One nurse supports the patient, while the other removes the draw sheet and mackintosh, and then rolls the soiled bottom sheet down as far as the patient’s back and straightens the mattress cover and ground mackintosh.
The same nurse puts in the clean sheet, tucking it at the top and on her side as far as the dirty linen. She then puts in the draw mackintosh and draw sheet, tucks on her side. Replace the backrest, pillows and air ring. Treat pressure areas if necessary.
Both nurses lift the patient back up the bed and make sure that the pillows are comfortable. Then tuck in the mackintosh and draw sheet, top side of the bottom sheet on the second side.
Draw the soiled sheet to the bottom of the bed from under the patient’s legs and put it in the hamper.
With the hand, brush any crumbs and creases from the mackintosh if present and the mattress and straighten them both. Pull the clean sheet down to the bottom of the bed and tuck in, mitre corners.
Put on the top bed clothes as usual, make the patient comfortable.
Push back the bed to its original position.
Clear away, remove the gloves and wash hands.
Document the procedure.

NB. Some means should be used to prevent the patient in this position from slipping down the bed. This may be achieved by putting a sand bag or a pillow (with mackintosh cover) against the feet. This will also prevent foot drop or the foot of the bed may be raised on a bed elevator/bed blocks.

TO CHANGE THE BOTTOM SHEET FROM TOP TO BOTTOM

This method is used for changing the bottom sheet when the patient is nursed in an upright position and must not be flat e.g. chronic heart disease.

Requirement: trolley

1 air ring and cover
1 draw sheet
1 draw mackintosh
A tray for treating pressure areas may be required
1 sheet
Gloves

At the bedside:

2 stools/chairs
Hamper
Screen

Procedure:

Collect all the equipment needed.
Explain the procedure to the patient.
Bring the equipment needed to the bedside.
Close the windows if necessary. Screen the bed if the ward is not closed.
Pull the bed from the wall.
Place the stools/chairs at the foot of the bed.
Wash hands thoroughly and put gloves.
Place the clean linen on the stools/chairs at the foot of the bed and the hamper besides the chairs/stools.
Fold the clean sheets across the width in three or roll them for easy placement.
Strip the top bed clothes as usual, leaving the sheet covering the patient on a hot day or a blanket and sheet on a cold day. Back rest and air ring, foot support are also removed.
Both nurses lift the patient carefully down the bed off the draw sheet.
One nurse supports the patient, while the other removes the draw sheet and mackintosh, and then rolls the soiled bottom sheet down as far as the patient’s back and straightens the mattress cover and ground mackintosh.
The same nurse puts in the clean sheet, tucking it at the top and on her side as far as the dirty linen. She then puts in the draw mackintosh and draw sheet, tucks on her side. Replace the backrest, pillows and air ring. Treat pressure areas if necessary.
Both nurses lift the patient back up the bed and make sure that the pillows are comfortable. Then tuck in the mackintosh and draw sheet, top side of the bottom sheet on the second side.
Draw the soiled sheet to the bottom of the bed from under the patient’s legs and put it in the hamper.
With the hand, brush any crumbs and creases from the mackintosh if present and the mattress and straighten them both. Pull the clean sheet down to the bottom of the bed and tuck in, mitre corners.
Put on the top bed clothes as usual, make the patient comfortable.
Push back the bed to its original position.
Clear away, remove the gloves and wash hands.
Document the procedure.

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General Principles in Patient Care

Topic: Perform general nursing care

Demonstrate appropriate methods of lifting/positioning a patient (PEX 1.3.8)

Safe and effective patient lifting and positioning are crucial skills for nurses to prevent injury to both the patient and themselves, promote patient comfort, and facilitate various procedures and recovery.

This PEX focuses on demonstrating:

Using proper body mechanics when lifting and moving patients.
Selecting the appropriate method for lifting or moving based on the patient's condition and ability.
Positioning patients correctly in various therapeutic positions (as detailed in the 'Positions Used in Nursing' section).
Using assistive devices (if available) for lifting and transferring.
Communicating with the patient during the lifting/positioning process.
Ensuring patient safety and comfort throughout the procedure.

POSITIONS USED IN NURSING

Positioning is placing the person in a proper body alignment for the purpose of preventive, promotive, curative and rehabilitative aspect of health.

Purpose of position:

To provide comfort to the patient.
To relieve pressure on various parts of the body.
To improve circulation
To prevent formation of deformity
To carry out investigations (medical and surgical)
To prevent pressure sores
To provide proper body alignment
To conduct delivery
To carry out nursing interventions

Types of positions commonly used in nursing:

Recumbent/supine position
Dorsal recumbent position
Semi-recumbent position
Lithotomy position
Prone position
Lateral or sim’s position
Fowler’s/sitting up position
Knee-chest or genupectoral position
Trendelenburg’s position

Types of patients who need special care:

Unconscious patients
Infants and children
Hemiplegics and paraplegic patients
Immediate post-operative patients
Orthopedic patients
Cardiac patient etc

Specific Positions

Recumbent/supine position

One or two pillows may be used for this position. The patient lies on the pack with his head and shoulders are slightly elevated on the pillow(s). His legs should be slightly flexed and a small pillow under the knees or the legs are left straight.

One pillow: This is used to provide full relaxation for acutely ill patients and for patients on complete bed rest. It is also used when examining the trunk.

Two pillows: The patient lays in bed with 2 pillows under his head. This is commonly used both medical and surgical nursing.

Indications:

It is a common position used by most patients
used for examination of the trunk (chest and abdomen)

Contraindications:

Elderly patients
Patients with operation on abdomen, breast and thorax
Prone to hypostatic pneumonia
Patient’s with long standing illness and neurological conditions

Semi-recumbent position

The patient is half sitting up, supported by three or more pillows. This is a comfortable position for patients who are recovering from an illness and who wish to be able to read in bed.

Indications:

Recovering patients
To obtain good drainage in the pelvis
To prevent straining of abdominal muscles

Prone position

The patient lies on the front of the body and has his head turned to one side. A pillow is provided on which to rest the side of his face, a small soft pillow is placed under the abdomen and pelvis, the knees are flexed and the lower leg supported on a pillow, under the ankles. It is useful when there is danger of bed sores forming on the back or for change of position when the patient is in a plaster bed with a fractured supine.

Indications:

Post-operative patients
Prevention of bed sores
Relieve abdominal distension
Patients having injuries and burns of the back

Contraindications:

Not tolerated by the elderly
Patients with cardiovascular conditions
Patients with respiratory problems

Lateral/sim’s position

The patient lies on the right or left side of his body with legs flexed at the highs. The left lateral is the most commonly used and the patient lies on the left side. A pillow is kept in front of the abdomen, the back and one under the upper leg.

Indications:

Used for giving of an enema
Examination of the rectum
Inserting suppositories
Taking of rectal temperature
It is used as change of position from the semi-recumbent position
Colonic irrigation
Giving back care

Sitting up position

The patient is sitting nearly upright at least at an angle of 45° attained by means of a special bed or use of a back rest and pillows. Asorbo foam cushion/air ring to relieve weight at the sacrum and ileum is usually place under the buttocks and it is necessary to use some means to prevent the patient from slipping down the bed. This may be done by using a foot rest or elevating the bed on bed blocks. The position is used in cases where there is dyspnoea e.g. heart disease, pneumonia, bronchitis.

Indications:

Dyspnoea
Improve thrombosis
Post-operatively to assist drainage form abdominal or pelvic cavity
To relax the muscles of the abdomen and thighs
To relieve tension on abdominal sutures
To promote comfort
To relieve edema of the chest and abdomen

Semi-prone position

The position is similar to lateral except with the upper knee flexed and the upper part of the trunk turned so that the patient lies almost prone, one arm behind the back, the other arm flexed at the shoulder and elbow lying in front of the patient’s face. The head is turned on one side, no pillows are used. This position ensures the greatest safety for the unconscious patients because it prevents danger of the tongue falling and blocking air passage, and also allows any secretions run out of the mouth (drain).

Indications:

Unconscious patients,
Those returning from operating theatre,
Rectal examination
Relaxation in antenatal exercises

NB. The patients who have had an abdominal operation are placed in recumbent position but all other cases are put back into bed on the semi-prone position unless otherwise ordered.

Contraindications:

Patients with deformities of the hip or knee may be unable to assume this position.

Dorsal recumbent position

Patient lies on the back with the knees fully flexed, thighs flexed and externally rotated feet flat on the bed. The patient is placed on the back in bed with two or more pillows under the head and one pillow under the knees or the bed is elevated at the top to maintain the position.

Indications:

Catheterization
Vaginal douche
Vulva, vaginal and rectal examination
Vaginal operations
Insertion of tampons
Patients with abdominal or pelvic operations unless erect/sitting position is indicated.

Lithotomy position

The patient lies on her back, the legs are separated and supported on the stirrups, thighs are flexed on the abdomen and the patient’s buttocks are kept at the edge of bed or table. One pillow is placed under the patient’s head.

Indications:

Gynaecology examinations, treatments and operations on the genitourinary system
For delivery
Rectal examination and operations

Contraindications:

Patients with arthritis or joint deformity

Knee-chest position

The patient rests on the knees and the chest, the head is turned to one side with one cheek on a pillow and another pillow places under the chest. The weight is on the chest and knees.

Indications:

Used for sigmoidoscopy
Vaginal and rectal examination
First aid treatment in cord prolapsed or retroverted uterus.
As exercise for postpartum and gynaecology

Contraindications:

Patients with cardiovascular and respiratory problems

Trendelenburg’s position

The patient lies on his back, the head is lower than the trunk, the foot of the bed is elevated at 45° angle, the body is on an inclined angle and the legs hang downward over the end of the table.

Indications:

Used in emergency situations like shock and hemorrhage (arrest bleeding from lower limbs)
Used in vaginal surgeries
Used to displace intestines from the pelvic cavity the upper abdomen
Operations on the pelvic organs

Jack knife or Kroaske/Bozeman position

The patient is placed on a prone position with the hips directly over the band of the examining table. Tip the table with the head lower than the hips. Lower the foot part of the table so that the patient’s feet are below the level of his head. Place the pillow under the pelvis and abdomen to relieve the strain.

Indications:

Operation on the rectum and coccyx
Drainage

Walchers position

The patient is place flat on his back with the sacrum resting on the edge of the table. Lower the legs slowly towards the floor. Elevate the buttocks slightly if the table permits.

Indications:

To increase the diagonal conjugate of the pelvis in high forceps delivery and in breech presentation
To relax the perineum

Standing/erect position

The patient stands with the knees separated about ten inches with one foot on a low stool. Instruct her to place one hand on the back of the chair for support and the other hand on her hip.

Indications:

Vaginal examination for determining the degree of uterus prolapsed
Examination of hernia

LIFTING AND TURNING OF PATIENTS

A good nurse always knows how to lift and turn her patient gently. Great strength is not necessary to do this, it will need much practice.

To Lift a Patient Who Is in Sitting up Position in Bed

Procedure I: Orthodox lift

Two nurses are necessary
Move the patient forward from the pillows, each nurse placing a hand under the patient’s axilla.
Ask the patient to fold the arms across the chest and bend the head forward (chin on chest) and bend the knees a little.
Place the arm nearest the head of the head of the bed behind the buttocks at the patient’s back, grasping each other’s wrist firmly.
Slip the other hand under the patient’s high up at the junction of the thighs and buttocks, grasping each other’s wrist firmly
Each nurse should grip with one hand and be gripped on the other hand by the second nurse.
They then lift the patient down the bed and off the draw sheet.

Procedure II: Australian/shoulder lift

Both nurses face the head of the bed.
Bend down and place shoulder nearest to the patient under the axilla to act as a crutch.
Place the hand of the same arm under the thighs as in method I/procedure I.
The free hand is placed flat on the bed behind the patient’s back and is used to take the weight when doing the lifting.
Lift the patient down the bed and off the draw sheet.

To Turn a Patient onto the Side

See that the patient’s knees are flexed, and put arms and legs in position for turning.
Place one hand behind the shoulder furthest away and the other over the hips.
Then turn the patient onto the side towards you.

To Lift a Patient onto the Bed from the Stretcher

Three nurses are necessary.
Put the head of the stretcher to the foot of the bed.
Three nurses stand on the side nearest the bed, one lifts the head and shoulders, one the hips and the third at the legs.
All lift the patient together then move to the right and place the patient very carefully on the bed.
Make the patient comfortable in the bed.

To Lift a Patient onto the Bed from the Theatre Trolley

Wheel the trolley up beside the bed.
Then lift the patient onto the canvas stretcher and place him on the prepared bed.
Remove the poles and put them back on the trolley.
Remember the patient returning from theatre is usually unconscious; handle him very gently and carefully.
Place the arms and legs in position for turning and turn patient to the left side and roll the canvas and mackintosh up to the back.
Roll the patient back to the middle of the bed and then to the right side as above and take out the canvas and mackintosh, put on the theatre trolley.
Put the patient into the position which is used for the condition e.g. semi-prone or lateral.

NB. The patient should lie facing the locker side of the bed because the post-anesthetic tray should be ready on it and the nurse will remain by the bedside (on this side.)

To help a patient Out Of Bed Onto A chair

Requirements:

Patient’s gown
Slippers/sandals
Pillow from the bed
Arm chair
Blanket to put over the knees may be required
A bell

Procedure:

Help the patient into the gown and slippers.
Bring the chair to the side of the bed.
Place the patient’ legs over-side of the bed and help him to stand.
Support the patient while he turns to sit into the chair.
Place a pillow comfortably behind the back and fold a blanket over the knees if necessary.
Give the patient some activity to do e.g. a book or knitting material and if he is alone a bell to ring incase he feels faint.

Perform tepid sponging (PEX 1.3.9)

TEPID SPONGING Is the process of sponging with tepid water to cool the skin/reduce fever by evaporation and the temperature of the water used is 80-90°F (22-28°C)

Purpose:

To reduce the high temperature in a febrile state to normal
To stimulate circulation
To decrease toxicity
To relieve nervousness and delirium and hence soothe the nerves and promote sleep

Requirements:

Trolley:

Top shelf:

A large basin of Luke warm water
Jug of tepid water 6 sponge cloths/face towels in a bowl
Face towel in iced water in a bowl for a compress
Bath thermometer

Bottom shelf:

Clean linen/bed sheets
Patient’s gown
Mackintosh and draw sheet
2 bath towels
Temperature tray
Bucket for used water

At the bed side:

Screens
Hamper
Cold drink for the patient
Drugs with adrenaline

Procedure:

Collect all the equipment needed.
Explain the procedure to the patient.
Provide adequate privacy by screening and closing the adjacent windows.
Wash hands thoroughly.
Take the temperature of the patient and chart it.
Strip the bed up-to the top sheet and take off the patient’ gown.
Soak the face cloth in the ice cold water.
Apply the cold compress to the forehead of the patient.
Sponge the face and dry with a face towel (the face and back are the only parts to be dried to avoid chills)
Place the cold sponge in each axilla and groins, change if necessary.
Sponge the neck, expose the arms and sponge using long slow sweeping movements for 3 minute on each arm. Pour water over the hands and change the compress o the fore head.
Change the water if necessary and check the temperature again.
Cover the upper half of the body and expose the lower half of the body. Sponge the legs with long slow sweeping movements and pour water over the feet.
Remove the compress from the forehead and face cloths from the axillae and groins.
Turn the patient gently on the side, sponge the back using two face towels/cloths with long strokes/sweeping movements and dry.
Remake the bed using clean linen, give the patient a clean gown and leave him/her comfortable.
Give the patient a cold drink. The patient is left for 20 -30 minutes, then the temperature is taken again and charted in the TPR/BP chart. It should fall by 1°C.
Clear away and wash hands.
Report and record the procedure to the patient’ chart.

N.B:

If the patient shows any sign of collapse during the procedure, the procedure is stopped at once, dry the skin and report to the nurse in-charge. Remake the bed. Clear away. The procedure should be left for 20 minutes before commencing.
The patient must be observed carefully throughout the procedure for signs of chills or any abnormality.
The patient is moved as little as possible.

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Taking Vital Signs or Observations

Topic: Take vital observations (PEX 1.5.1 - 1.5.4)

Vital signs are measurements of the body's most basic functions. They should be looked at in total, to monitor the vital functions of the body. They help reflect changes in the body and determine the patient’s usual state of health.

There are four primary vital signs: body temperature, blood pressure, pulse (heart rate), and breathing rate (respiratory rate), often noted as BT, BP, HR, and RR.

Purpose of Taking Vital Observations

To assess the health status of an individual.
To plan and implement the nursing care.
To modify or change the mode of treatment.
Routine part of complete physical assessment.
It helps to understand the present problem; assists in diagnosis
To understand the effectiveness of the treatment.

Timing of Taking Vital Observations

On the patient’s admission to the hospital or health unit.
On routine schedule according to the physician’s order or hospital policy e.g. 6:00am to 6:00pm.
During patient’s visit to the clinic or physician’s office.
Before and after any invasive diagnostic procedure.
Before and after a surgical procedure e.g. 1^st 48hrs postoperatively or 4hrly with very ill patients or with fever.
Before and after administration of medication that affects the cardio vascular, respiratory and temperature control function.
When the patient’s general physical condition changes e.g. loss of consciousness, increase in intensity of pain.
Before and after nursing interventions influencing anyone of the vital signs e.g. before ambulating a patient who has been previously on bed rest or before the patient performs range of motion exercise, blood transfusion and tepid sponging.
Whenever the patient reports to the nurse about any non specific symptoms of physical distress e.g. “feeling funny or different”

Normal Values and Ranges of Vital Signs

Temperature:

Normal value: - 98.4°F or 37°C in adults.
Normal ranges: - 97°F-99°F or 36°C-37.2°C.

Pulse:

Normal value: - 72 b/m in adults
Normal ranges: -
- Adult: 60-90 b/m (18yrs +)
- Children: 90-120 b/m (1-18yrs)
- Infants: 120-140 b/m (1 month-1yr)
- Neonate (newborn): 140-160 b/m (0-28ays-1month)
- Old age - may be slower
- Extremely old age - may be more rapid

Respiration:

Normal value: 16 breaths/minute (adults)
Normal range:
- 16-20 breaths/minute (adults)
- 30-44 breaths/minute (neonates)
- 20-22 breaths/minute (children)
- Old age - 10 to 24 breaths per minute.

Blood pressure:

Normal value: 120/80 mmhg (in adults)
Normal range: 90/60 - 120/90 mmhg.
Newborn (neonates): - 30-50 / 10 mmhg
Infants: - 70-90 / 50 mmhg
Adult: - 90-120 / 60-90 mmhg (Note: This is the same as the general adult range, but listed again here).

Guidelines for Taking Vital Signs

The primary nurse caring for the patient is the best one to take vital signs, interpret their significance and make decisions about the care.
Equipment used to measure vital signs must be appropriate and working properly to ensure accurate findings.
Knowing the normal range for all vital signs helps the nurse to detect abnormalities.
A client’s normal range may differ from the standard range for that age or physical state.
A normal value for the client serve as a baseline for comparing in conditions over time.
Know the client’s medical history and therapies or medications, for vital sign changes.
Control or minimize environmental factors that may affect vital signs. For example measuring pulse after the patient experiencing pulse upset, will give unclear results for the client’s current state.
An organized, systemic approach when taking vital signs ensure accuracy of findings.

Take Patient's Temperature (PEX 1.5.1)

Temperature Is the degree of heat maintained by the body monitored/measured using a clinical thermometer.
Or
Is the degree of warmth or balance maintained between the heat produced (thermogenesis) and heat lost (thermolysis) in the body.
Or
Is the degree of heat of substance or body as measured by a thermometer.

Purpose:

To determine the body temperature
To assist in diagnosis
To evaluate the patient’s recovery from illness.
To plan immediate nursing interventions.
To evaluate the patient’s response.
To recognize any variation from the normal and its significance.

Normal body temperature from different sites (adult):

Oral: 37°C or 98.4°F (36°C-37°C)
Rectal: 37.6°C or 99.6°F or 1° higher than mouth temperature.
Axilla: 36.4°C or 97.6°F (36°C-37°C or 1° lower than mouth temperature.)
Groin: as for the axilla.

N.B:

Temperature varies at different times of the day, the evening temperature being about 1° (one degree) higher than that of the morning because of muscular and metabolic activity.
The temperature also varies according to the site used for taking it. E.g. the skin temperature i.e. axilla in a healthy person may be 36.1°C while the oral/mouth temperature is usually a degree higher and the rectal temperature may be 37.2°C or 99°F. The rectal temperature is the most accurate temperature.
When taking temperature, never be satisfied with anything but accurate result. Incorrect results do mislead diagnosis, prescription and treatment.

Factors that affect temperature:

Times of the day e.g. morning, evening.
Site used.
Gender, women normally have a higher temperature than men especially during ovulation.
Age, the temperature is highest in neonates and lowest in the elderly.
Emotional conditions.
Environment.

N.B: The mouth, axilla, groin, rectum and vagina are suitable places in taking temperature but as the reading varies according to the site, the same place must be used each time for the same patient.

Factors that influence heat production:

Metabolism, oxidation of food.
Muscle activity, exercise
Strong emotions, excitement, anxiety and nervousness.
Change in atmospheric temperature.
Diseases/conditions; bacterial invasions or infections.
Sympathetic stimulation; epinephrine and nor-epinephrine.

Factors that influence heat loss:

Sleep; body temperature is low
Fasting; leads to decreased heat production
Illness and lower vitality; due to depressed nervous system, the heat production is lowered.
Prolonged exposure to cold
Use of narcotic drugs; suppress the temperature centre.

The body heat is lost through the following;

Conduction- Transfer of heat from body to substance (air, water and cloths) directly in contact.
Radiation- Transfer of heat from the body to heat waves which travel through the space.
Evaporation-Transfer of heat from the body in form of vapor (liquid is converted into vapor)
Convection-It is transfer of heat from the surface of one subject to the surface of the other; such as skin by movement of heated air or fluid particles.

General rules for taking temperature:

The mouth is the usual place to take temperature but it must not be used for the following;
- A child under 5 years
- If there is difficulty in breathing or much coughing
- Unconscious or mentally confused patients.
- If there is disease of the mouth or nose.
- It should not be taken immediately after hot or cold fluids, because the factors affect the temperature recorded on the thermometer.
Wait for 10 minutes after the patient has eaten or drunk.
Grasp the thermometer securely by the upper end of the stem; never hold it by the bulb as it will easily be broken or contaminated.
If the patient bites or breaks a thermometer in the mouth, quickly give cold water to rinse and inform the in charge for further management.
If taking temperature by rectum, always hold the thermometer for the patient in place (children)
Report to the supervisor the temperature below 35°C or above 38°C
Always wash the used thermometer with cold water and soap or disinfect with a disinfectant.
Never take oral and rectal temperature at the same time.
Shake it by quick movement of the wrist below 35°C or 94°F.
Care should be taken when shaking the thermometer near an object or articles to avoid breakages.
Patients are never told what the vital sign reading is but simply explain to the patient i.e. “you are fine, okay, don’t worry.”

Types of thermometer:

Clinical thermometer: It is an instrument used for recording body temperature. It is made of glass with a hollow tube running through the centre. At one end is bulb containing mercury which rises into the center tube when heated. The mercury remains stationary at registration point until shaken down due to a constriction in the tube which prevents this. Degrees of temperature are marked on the clinical thermometer from 35°C-43°C or 94°F-110°F.

Electronic or digital thermometer: It consists of battery powered display unit, a thin wire cord and a temperature sensitive probe covered by a disposal plastic sheath to prevent transmission of infection. Separate probe are available for oral and rectal insertion.

Disposable thermometer: It is a single use thermometer, made of thin plastic strips with chemically impregnated paper, they are used for children to take oral and axillary temperature only. 45 seconds are needed to record the temperature, it is less accurate.
Tympanic membrane thermometer: These are small held devices similar to hodoscopes with disposable speculum. Infrared-sensing electronic and liquid crystal displays. Results are displayed 1-2 seconds after placing their speculum in the outer third of the ear canal, it is accurate.

Oral Temperature

Temperature checked by the oral cavity.

Requirement: Temperature tray containing the following;

Oral clinical thermometer in a jar containing a disinfectant solution e.g. hibitane cetrimide 1-20.
Galipot of swabs
Galipot of water
A receiver for used swabs
Watch with second hand ticker
Temperature chart
A pen

Procedure:

Collect the equipment needed.
Explain the procedure to the patient.
Position the patient and give privacy.
Wash hands.
Hold the colour coded end or system glass thermometer with finger tips.
If the thermometer is stored in disinfectant solution, rinse in cold plain water and dry before use. Inspect for cracks and if broken do not use.
Read mercury level while holding thermometer horizontally and gently rotating at the eye level. If the mercury is above a desired level, grasp at the tip of thermometer securely and sharply flick the wrist downward, continue shaking until reading is below 35°C or 94°F.
Ask the patient/client to open the mouth and gently place the thermometer under the tongue in posterior sublingual, lateral to center of the lower jaw.
Ask the patient to hold thermometer with lips closed. Caution against biting the thermometer and talking whilst the thermometer is in place.
Leave the thermometer for 3 minutes in place or according to agency policy. Carefully remove the thermometer, read at eye level while holding horizontally.
Wipe the thermometer in rotating movements with a wet swab, place it back in its jar and chart the readings and report any unusual variations to the in charge nurse.
Clear away, make the patient comfortable and wash hands.

N.B:

If the ward temperatures are taken orally, individual thermometers should be used.
When taking the temperature the patient should be sitting or lying down.

Contraindications (Oral Temperature):

Disease, injuries, inflammation and surgeries of the oral cavity.
Infants, children below 5 years, mentally disturbed patients; delirious, no-cooperative and unconscious- cannot retain the thermometer in place.
Patients with breathing problem/difficulty in breathing, convulsions, patients with oxygen masks, frequent and severe cough.
Should not be taken immediately after hot bath, after smoking, taking hot or cold drinks - because these factors affect the temperature recorded on the thermometer.

Axillary Temperature

The temperature is sometimes taken by axilla when it cannot be taken by mouth or contra indicated to oral temperature.

Requirements: As for oral temperature.

Procedure:

Collect the equipment needed for the procedure.
Explain the procedure to the patient.
Position the patient and provide privacy.
Wash hands.
Inspect the axilla and dry it thoroughly with a dry swab.
The thermometer is dried on swabs and shaken with a flick of wrist until the mercury falls below 35°C or 94°F mark. Inspect for cracks.
Insert the thermometer into the center of the axilla with the bulb in contact with the skin folds, care should be taken in that clothing should not interfere. The elbow is kept at the side and place arm across client’s/patient’s chest to retain the thermometer in position.
Leave the thermometer in place for 3 min.
Remove the thermometer from the axilla, read it at the eye level. Wipe the thermometer using a swab soaked is a disinfectant or plain water from stem to bulb using a firm twisting motion. Place it back in its jar and chart the findings and report any variations to the in charge nurse.
Clear away, make the patient comfortable and wash hands

Contraindications (Axillary Temperature):

If there are sores or burns at the site
Emaciated or thin patients

NB. The patient should be in sitting or lying position.

Groin Temperature

The rules apply as for the axilla, but one leg is flexed over the other.

Requirements: As for the oral temperature.

Procedure:

Collect the equipment needed for the procedure.
Explain the procedure to the patient.
Position the patient and provide privacy.
Wash hands.
Inspect the groin and dry it thoroughly with a dry swab.
The thermometer is dried on a swab and shaken with a flick of the wrist until the mercury falls below 35°C or 94°F mark. Inspect for cracks.
Insert the thermometer in the center of the groin by asking the patient to abduct the thigh and flex the upper leg over the other.
Leave the thermometer for 3 minutes.
Grasp the end of the thermometer and remove it from the groin, read it at the eye level.
Wipe the thermometer using a swab soaked in a disinfectant or plain water from the stem to bulb using affirm twisting motion.
Place it back in its jar and chart the findings and report any variations to the nurse in-charge.
Clear away, make the patient comfortable and wash hands.

Contraindications (Groin Temperature):

Sores or burns at the site.
Emaciated or thin patients.

Rectal Temperature

Rectal temperature measurement is a technique used to measure body temperature by placing a thermometer in the rectum.

This method is used for head injuries, head operations and for children under 5 years. The rectum thermometer has a blunt end colored blue, to prevent inadvertent use in other situations. The thermometer must be kept in a jar containing a disinfectant solution.

Requirements:

Rectal thermometer
Galipot of swabs
Galipot of water (2); Lukewarm and cool water
Receiver for used swabs.
A watch with a second hand ticker
Temperature chart
A pen
Vasciline or other lubricant
Gloves

Procedure:

Collect all the equipment needed.
Explain the procedure to the patient.
Screen the bed to provide privacy.
Position the patient in sim’s position with the upper leg flexed to expose only the anal area.
Wash hands and put on gloves.
Swab the area.
Remove the thermometer from the jar, clean it/dry it, check for cracks and shake below 35°C.
Squeeze liberal portion of a lubricant on a swab and dip the thermometer’s bulb end into the lubricant covering 2.5-3.5 cm (1-1.5 inches) for adult or 1.2-2.5cm (0.5-1 inch) for infant.
With a non-dominant hand, separate the patient’s buttocks to expose the anus and ask the patient to breathe in slowly and relax.
Gently insert the thermometer into anus along the rectal wall towards the umbilicus so as to register the hemorrhoid artery temperature instead of the faecal temperature. Insert it about 1.2-2.5cm for infants and 2.5-3.5 for adults. Do not force the thermometer to prevent perforation of anus or rectum and breakage of the thermometer.
If resistance is felt during insertion withdraw the thermometer immediately and report.
Hold or leave the thermometer in place for 3 minutes.
Carefully remove the thermometer and wipe off secretions with a swab, wiping in rotating movements towards the bulb.
Read the thermometer at eye level and chart the findings in the patient’s chart.
Wash the thermometer in Lukewarm water or disinfectant, rinse in cool water, dry and replace it in its container or jar.
Clear away, remove the gloves and wash hands.
Report any unusual variations to the nurse in-charge

Contraindications (Rectal Temperature):

Injuries, disease, inflammation and surgeries of the rectum
Patients with faecal impaction
Patients with chronic diarrhea
Patients requiring bowel wash/enema.

Conversions (Temperature)

The Fahrenheit scale ranges from 32°F to 212°F whereas centigrade scale ranges from 0°C to 100°C.

When converting Fahrenheit to centigrade, the formula is (F-32) * 5/9 = C
And in converting centigrade to Fahrenheit, the formula is (C * 9/5) + 32 = F.

Rigors

Is a sudden attack of intense shivering when the heat regulating center in the brain is disturbed. It is seen in certain infections like malaria, allergic reactions i.e. after intravenous infusion.

Stages of rigors:

Cold stage: The patient feels chill, extreme shivering and hyperpyrexia.

Management:

Provide rest and supplementary oxygen.
Offer hot drinks and use hot water bottle to provide warmth.
Provide with an extra blanket.
Give more fluids to take.

Hot stage: The patient feels extremely hot.

Management:

Remove extra blankets and hot water bottles.
Cold sponge/tepid sponge and give ice pack compresses.

Sweating stage: Here the patient is sweating profusely.

Management:

Wipe the patient with a wet towel and cover with a sheet.

N.B: During all the three stages, take temperature and record in the patient’s chart.

Take Patient's Pulse Rate (PEX 1.5.3)

PULSE Is the wave of expansion and recoil of an artery in response to the pumping action of the heart. This can be felt by the examining fingers.

Purpose:

To determine the number of heartbeats acquiring per minutes created.
To evaluate amplitude (strength) of the pulse.
To assess the vascular status of the limbs.
To assess the response of the heart to cardiac medication, activity, blood volume and gas exchange.
To assess the heart’s ability to deliver blood to distant areas of the body.
To obtain information about the heart rhythm and patterns of beats.

Normal pulse rates:

Newborn - 140 b/m
Infant - 120 b/m
2-3 years - 100 b/m
4-10 years - 90 b/m
11 years and above - 70-80 b/m (average - 72 b/m)
Old age - may be slower
Extremely old age - may be more rapid

Normal ranges of pulse rate:

Neonate (newborn) - 140 to 160 b/m (0-1 month)
Infant - 120 to 140 b/m (28 days/1 month - 1 year)
Children - 90 to 120 b/m (1 year - 18 years)
Adults - 60 to -90 b/m (18 years and above)

Common Sites of Taking Pulse:

Site	Location
Radial artery	In front of the wrist at the thumb side.
Brachial artery	Medially above the elbow.
Carotid artery	At the side of the neck where the carotid artery runs between the trachea.
Temporal artery	Over the temporal bone.
Facial artery	Above the lower jaw.
Femoral artery	In the groin.
Tibial artery	Behind the medial malleolus.
Dorsal pedis	On the foot.
Apical	At the left side of the chest in the 4^th 5^th and 6^th intercostals’ space.
Popliteal	Medial or lateral to the popliteal fossa with the knees flexed.
Ulnar pulse	Outer aspect of the wrist along the little finger side.
Fontanelles of infants	Head.

Observations made on taking pulse:

When taking the pulse the following should be noted;

Rate: Is the number of beats per minute. Corresponds with the age, average for adults is 72 b/m.
Rhythm: It is the regularity of beats. The distance between beats is equally spaced (regular)
Volume: It is the fullness of an artery. It is the force of blood felt at each beat (full/large/small/weak). Amount of blood distending the artery with each beat.
Tension: It is the degree of compressibility (high/low). The pulse should be felt soft under the nurse’s fingers, it should not feel hard. If it is difficult to compress or stop the tension, it is high and if it is easy to compress or stop, then it is low.

Factors that affect the pulse:

Age - children have faster beats and very old persons have a slow pulse rate.
Sex - it is slower in men than women.
Stature - It is slower in tall people than in short people.
Position - The pulse rate is slower at rest and sleep than in a standing position.
Emotions - Anger or excitement increases the pulse rate temporarily.
Exercise - It is much faster during exercise.
Fever increases the pulse
Extreme heat and cold - increase
Drugs - may increase the pulse rate e.g. morphine, digitalis.
Shock and hemorrhage (cerebral vascular accident)
Diseases e.g. thyrotoxicosis, myocardial failure (increase)
Fasting (increases)
Head tumors (increase)

Abnormal pulse:

Tachycardia: Is the rapid heart action indicated by a rapid pulse rate. The pulse rate is more than 100 b/m. It is commonly found in patients with fevers, thyrotoxicosis, organic heart disease, nervous disorders and intake drugs like morphine, caffeine and alcohol.
Bradycardia: It is an abnormally slow heart rate indicated by a slow pulse rate of less than 60 b/m. Commonly caused by opium poisoning heart muscle disorder, cerebral tumors and myxedema.
Dicrotic pulse (abnormal volume): There is a one heartbeat and two arterial pulsations giving the sensation of a double beat due to flabby weak arterial pulse.
Abnormal rhythm: There is intermittent pulse and extra systoles e.g. cardiac irritability, hypoxia, digitalis overdose, potassium imbalance, arrhythmias.
Water hammer or Corrigan’s pulse: It is a full volume pulse. This type of pulse is found in aortic regurgitation, when blood is forced into the artery then leaks back into the ventricle due to non closure of the aortic valve.

General rule for taking pulse:

Count the pulse for one full minute especially when there is irregularity.
Observe the rate, rhythm, volume and tension of the pulse.
Pulse should not be taken immediately after the exercise, in emotional stress or after a painful treatment. Check 10-15 minutes of exercise.
Record the pulse immediately.
Choose a suitable site for taking the pulse.
Be aware or take note if the patient is on any medication that can interfere with the heart rate e.g. morphine, digitalis.
Notify the physician when the pulse rate is below 60 b/m or above 100 b/m, abnormal patterns (missing beats).
Assess the pulse again by having another nurse to conduct measurement, if the pulse is abnormal or irregular.

Requirements (Radial Pulse - most common):

In a small tray;
Watch with a second hand ticker
A pen
TPR chart

Procedure (Radial Pulse):

Collect the equipment needed.
Explain the procedure to the patient
Position the patient either sitting or lying down position. Bend the patient’s elbow at 90° and support lower arm on a chair or table or nurse’s arm and slightly extend the wrist with palm downwards.
Wash hands and dry thoroughly.
Place the tips of the 1^st two or middle three fingers of the dominant hand over the groove along radial or thumb side of the patient’s wrist applying slight and steady pressure.
When the pulse is easily palpable, look at the watch’s second hand ticker and begin to count the rate.
If the pulse is regular count the rate for 30 seconds and multiply by 2 and if irregular count for a full minute.
Assess the regularity, the strength (volume), rate and the tension of the pulse.
Assist the patient to return to a comfortable position.
Record the findings to the patient’s chart.
Clear away and wash hands.
Report abnormal findings immediately to the nurse in-charge or physician.

N.B. Record immediately the pulse at the same time the thermometer is placed into the patient’s mouth or any site when the patient is unaware of the counting.

Take Patient's Respiratory Rate (PEX 1.5.4)

RESPIRATIONS Is the act of breathing in /taking in oxygen (inspiration/inhalation) and breathing out/ expelling out of carbon dioxide (expiration/exhalation). The exchange of gases between the blood and lungs is called external or pulmonary respiration and the exchange of gases between the blood and cells is known as internal respiration.

Purpose:

To determine the respiratory status of the patient.
To determine the number of respirations occurring per minute.
To gather information about the rhythm and depth.
To assess response of a patient to any related therapy/medication.

Normal respiration rates:

At birth (neonate) - 30 to 44 breaths per minute.
1 year (infant) - 26 to 30 breaths per minute.
2 to 5 years - 20 to 26 breaths per minute.
Adolescent - 20 to 22 breaths per minute (average 20 breaths per minute.)
Adults - 16 to 20 breaths per minute.
Old age - 10 to 24 breaths per minute.

Factors that influence respiration:

Sex - female have slightly rapid respiration than the male.
Exercise - exertion of any type increases the metabolic rate and stimulates respiration.
Rest and sleep - during rest and sleep metabolism is decreased, so respiration rate is normal or decreased.
Emotions - sudden stressful condition such as fear and anxiety, excitement influence the respiratory rate (rapid)
Change in atmospheric pressure.
In high altitudes the content of oxygen in the atmosphere is very low, the rate of respiration in increased and the increased demand of oxygen is fulfilled.
Disease - in some heart diseases, respiration increases and it is decreased when there is pressure on the brain due to tumors.

Characteristics of a normal respiration:

Normal breathing is effortless.
It is painless, quiet and automatic
It consists of rhythmical rising and falling of the chest wall.
Respiratory rate in a resting adult is 16 to 18 b/m.
Eupnoea; it is regular, even and produces no noise.

Abnormal respirations:

Stridor respiration: It is a noisy shrill and vibrating inspiration occurring in obstruction of the upper airway or may be whistling sound. It is commonly seen in laryngitis and foreign body in the respiratory tract.
Wheezing: It is a difficult and louder/noisy expiration due to partial obstruction of the smaller bronchi and bronchioles and this is seen in asthma and emphysema.
Apnoea: This is a temporary cessation of breathing due to excessive oxygen and lack of carbon dioxide e.g. very ill patients, CNS disorders.
Dyspnoea: It is forced, painful, difficult or labored breathing and it may be accompanied by cyanosis, it is seen in heart diseases, respiratory diseases, obstruction of the airway due to infection, new growth and foreign body, convulsions.
Orthopnoea: Is inability to breathe except when sitting up or in upright position. It is found in congestive heart failure.
Cheyne-strokes breathing: Is the breathing which starts with slow and shallow respirations and gradually increases in rate and depth (volume) until it reaches the maximum (climax) and then a slowly pause occurs and breathing stops/ceases for 5- 30 seconds and the cycle begins again. It is a periodic breathing usually common in patients who are near death, this should be reported at once.
Asphyxia: It is a state of suffocation when the lungs fail to get sufficient supply of oxygen to supply the vital organs.
Rale: An abnormal rattling or bubbling sound caused by the mucus obstructing the airway, which is seen in bronchitis due to pneumonia.
Hyperpnoea/kussumauls breathing/hyperventilation: Is the abnormal forced breathing in which the respiration are deep though regular but rapid or with increased rate and it is seen in diabetic ketoacidosis.
Croup: Is a difficult, noisy breathing due to laryngeal spasms.
Stertorous breathing: Is a noisy breathing which occurs in the unconscious patients.
Biot’s respiration: It is a shallow breathing interrupted by irregular periods of apnoea, usually seen in central nervous system disorders.
Cyanosis: It is the blueness or discoloration of the skin and mucous membranes due to lack of oxygen supply to the tissues.
Bradypnoea: Is slowness of breathing or respirations.
Tachypnoea: Rapid breathing or respiration rate

General rules in counting respirations:

The patient should be placed in a comfortable position (sitting up position)
Respirations should be counted when the patient is unaware of the counting, immediately after counting the pulse before the nurse removes her fingers from the patient’s wrist. The patient may involuntarily increase or decrease the respirations.
Look at the chest wall. The respiratory cycle consists if inspiration, expiration and a pause.
Children’s respiration rate should be counted before disturbing the child to take the temperature.
Inform the physician in case of bradypnoea, tachypnoea or other abnormal respiratory patterns.
Maintain half ½ hourly checking of respiration when indicated.
Make sure the patient’s chest movements are visible, if necessary remove bed linen or gown.
If the patient or client has been active, wait for 5-10 minutes before assessing respirations.

Observations made on respiration counting.

The following should be observed when counting the respiration;

Rate - the number of times the patient breathes in and out per minute. The rate may change in health.
Depth - the nurse should notice whether the respiration are shallow or deep. When they are shallow, the patient is only taking little breaths perhaps because it hurts to breathe as is seen in infections of the respiratory tract or fractured ribs. When the respirations are deep, the patient is taking big breaths and the respirations are usually slow and noisy.
Discomfort - the nurse should notice any discomfort that the patient may have when breathing e.g. pain as in fractured ribs or respiratory diseases or heart diseases.
Movements - it is important to note the muscular movements that take place during breathing. Normally there should be some movements in the abdominal wall as well as in the thoracic muscles.

Requirements:

Wrist with second hand ticker
A pen
TPR chart/patient chart

Procedure:

Collect the equipment needed.
Explain the procedure to the patient.
Position the patient, place the patient’s arm in relaxed position across the abdomen or lower chest.
Observe complete respiratory cycle (one inspiration, one expiration and pause.)
After the cycle is observed, look at the watch’s second hand ticker and begin to count the rate. Count one with a first full respiration cycle.
If the rhythm is regular in adults, count number of respirations in 30 seconds and multiply by 2.
In infants or young children count respirations for a full minute.
If adult has irregular rhythm or abnormally slow or fast rate, count for one full minute.
Note the depth of respirations. This can be assessed by observing the degree of chest wall movement while counting the rate.
Note the rhythm of ventilatory cycle. Normal breathing is regular and uninterrupted. Infants breathe less regularly. Young children breathe slowly and then suddenly the breathe fastens.
On completion replace the patient’s clothes /gown and cover with bed linen to make him/her comfortable.
Record the findings to the patient’s chart and any accompanying signs and symptoms of respiratory alterations. Compare with the previous findings.
Clear away and wash hands.
Report any abnormal findings to the physician or a nurse in charge.

Take Patient's Blood Pressure (PEX 1.5.2)

Blood pressure Is the force or pressure that the blood exerts on the walls of the blood vessels (artery) in which it is contained.

Purpose:

To obtain the baseline rate for diagnosis and treatment
To compare with subsequent changes that may occur during care of the patient.
To assist in evaluating status of the patient’s blood volume.
To evaluate patients’ response to change in physical condition as a result of treatment with fluids or medications.

Types of pressure:

Systolic pressure: Is the highest degree of pressure exerted by the blood against the arterial wall as the left ventricle contracts and forces the blood from it into the aorta.
Diastolic pressure: Is the lowest degree of pressure when the heart is in its resting period just before contraction of the left ventricle.

Factors that influence blood pressure:

Exercise - this will increase blood pressure.
Age - adults’ blood pressure tends to increase with advancing age. The older adults’ blood pressure is 140/80 to 160/90 mmhg.
Stress - anxiety, fear, pain; emotional stress increases blood pressure.
Medication - narcotic and analgesics lower the blood pressure.
Diurnal variation - it is lowest in early morning and higher in late evening.
Sex - in men it is higher than in female.
Bleeding - it causes low blood pressure.

General rules of taking blood pressure:

Assess the arm on which the blood pressure is to be taken. Do not take blood pressure reading on a patient’s arm if;
- The arm has an intravenous infusion line.
- The arm is injured or diseased.
- The arm has a shunt or fistula for renal dialysis.
- On the same side of the body where a female patient had a radial mastectomy.
Postpone blood pressure taking on the patient who is anxious, angry or in pain or crying child.
Check the diagnosis, reason for taking blood pressure, schedule and frequency of obtaining the blood pressure.
Find out the patient’s current emotional status before taking blood pressure; since exercise, emotions, anxiety, fear, tension and worry cause temporary rise in blood pressure. Allow the patient to rest at least 5-10 minute prior to taking blood pressure.

Requirements:

Sphygmomanometer
Stethoscope
Observation/patient’s chart
A pen

Procedure:

Collect the equipment needed.
Explain the procedure to the patient in order to gain co-operation of the patient and to alley anxiety.
Place the patient in a comfortable position either lying down with the arm resting on the bed or sitting up with arm resting /supported on the table/chair arm at the heart level to ensure accurate reading.
Wash hands.
Bring the equipment to the bedside or near the patient.
Apply deflated cuff evenly with rubber ladder over the brachial artery, the lower edge being 2 inches above the antecubital fossa. The two tubes turning towards the palm.
Palpate the brachial artery with the finger tips. Place the bell/diaphragm of the stethoscope on the brachial pulse. The stethoscope must hang freely from the ears.
Close the valve on the pump by turning the knob clockwise. Pump up air in the cuff until the sphygmomanometer registers 20mm above the point at which the radial pulsation disappears.
Open the valve slowly by turning the knob anti-clockwise. Permit the air to escape very slowly. Note the number on the manometer where the 1^st louder sound begins, this is the systolic pressure. Continue to release the pressure slowly and also note the point on the manometer where the 2^nd (last) sound ceases, this is the diastolic pressure.
Allow the air to escape and the mercury to fall to zero. Wait for one minute with the cuff to deflate.
Repeat the procedure if there is any doubts about the reading.
Do not take blood pressure more than 3 times in succession on reading on the same arm.
Make the patient comfortable.
Record the findings immediately with the date and time on the patient’s chart; as systolic/diastolic e.g. 60/90 mmhg.
Clear away, wash hands and report any abnormalities to the physician or nurse in-charge.

Nurses Revision

Taking Vital Signs or Observations Read More »

General Principles and Rules of All Nursing Procedure

Topic: General principles and rules of all nursing procedures

These are guidelines that should be observed as a nurse carries out all nursing procedures:

Show interest and devotion to duty and be alert and prompt in all your assignments.
Make the patient the focus of attention, as she/he is the sole reason for the existence of the nursing profession.
Be clean in appearance and behave with an apparent ease and assurance in all-nursing procedures.
Demonstrate and inspire confidence, knowledge of and efficiency in techniques at all times.
Use the available equipment and nursing appliances, which should be collected quickly, quietly and methodically.
Trays and trolleys must be neat and complete to give an adequate nursing procedure.
Thoroughly test all equipment to make sure it is in good condition, before preparing the tray or trolley.
Display a high sense of responsibility in administration and custody of drugs and in the dispensation of any kind of treatment.
Keep up to date with new methods, techniques, drugs and lotions; know exactly their use, dosage, toxic effects and calculation of the dosage.

Patient's Comfort (Principles related to Procedures)

Ensuring maximum comfort for the patient during any procedure is essential and reflects respect for their privacy. Key aspects include:

Ensure maximum comfort to the patient and respect his/her privacy by:
- Telling him/her what is to take place, explaining the procedure as simple as possible.
- Protect the patient from draught and avoid undue exposure, make sure that windows are closed and screens appropriately placed.
- Establish a good nurse/patient relationship to secure the patient’s confidence and to induce their tranquility of mind.
- Observe any change in the patient’s general condition during the procedure.
Always prepare everything that will be required and have it by the patient’s bedside before beginning the procedure.
Lift and handle the patient as gently as possible exhibiting courtesy, efficiency, and skill.

General Rules for Carrying out Nursing Procedures (Detailed Steps)

Collect the equipment needed and prepare the tray /trolley.
Explain the procedure to the patient.
Screen the bed and close adjacent windows.
Bring the tray / trolley to the bed side.
Position the patient.
Wash hands.
Carry out the procedure.
On completion of the procedure leave the patient comfortable.
Leave the surroundings dry and tidy.
Clean and replace the equipment.
Wash hands.
Report and record procedure.
Send any specimens obtained to the Laboratory as soon as possible.

Topic: Hospital Economy

Understanding how resources are managed efficiently in the hospital setting is part of the introductory aspects of the nursing profession.

Note: Detailed information specifically titled "Hospital Economy" or elaborating on its principles and rules was not present in the provided lecture notes document beyond the initial curriculum outline. However, understanding the responsible use of resources, such as equipment and supplies, as mentioned in other sections (e.g., equipment maintenance, preparation for procedures), is a practical aspect of hospital economy.

Topic: Cleaning Methods

WARD MAINTENANCE PRACTICES

Daily Cleaning

A. Ward Maintenance

Collect all equipment necessary on the trolley.
Make the patient’s beds and pull bed and lockers away from the wall.
Collect and put away all the equipment not necessary on the ward for immediate use.
The floor is swept and mopped.
Carry out dump and dry dusting of all ward furniture and equipment, using the ward cleaning trolley.
Return beds and lockers to their position.
Replace sputum mugs with clean ones empty the used ones, rinse well in the sluice room, leave soaked in the disinfectant.
Give out clean drinking mugs and feeding cups. Refill bottles for drinking water if required.
Clean used equipment and keep in the proper place.

In dressing and treatment rooms:

Shelves - Wash daily and whenever necessary
Sinks and wash basins - wash daily and after use with vim or hebitane.
Sterilizers - empty, clean inside with hebitane when necessary, refill with clean water.
Trolleys - wash daily and after with soap and water, dry thoroughly. Do not use gumption or vim on food trolleys.
Lifting forceps - boiled daily and whenever contaminated forceps jars cleaned, boiled and lotion changed daily. Lotion jar inspected daily and more lotion added if required. Or boiled or autoclaved daily and kept in a dry sterile container.
Soiled dressing buckets - keep lid on at all times, keep the outside clean. And they should be thoroughly cleansed after emptying.

Hygiene in Special Areas (Operating theatre, Intensive care unit (ICU), Pre-mature unit and Labour suit.)

Operating theatre:

Operating tables, trolleys and shelves - dump dust daily using water and detergent.
Walls - dump cleaning 2.5-3m downward daily with water and detergent.
Floors - scrub with water and detergent daily and whenever soiled and leave to dry.
Floors where there are spillages of body fluids - apply 1% hydrochloride for 15min and spot clean. Clean after every operation. Do weekly cleaning of all equipment and areas.

Note: The same method of cleaning applies to all the rest of the special areas mentioned above (intensive care unit, pr-mature unit and labour suit.)

B. Equipment Maintenance (Detailed Procedures - extracted from your notes):

It is the responsibility of every health worker in the hospital to see that all equipment is very well looked after, serviced regularly and given immediate attention when there is any defect.

Equipment should be handled with care and breakages reported immediately, this will definitely keep the hospital expenditure very low.

1. Electric machine

Have regular servicing of the machines and as soon as they are out of order, make a requisition to the maintenance department, have them inspected and repaired.

Refrigerators: These are regulated in order to be effective, regulators should be regularly checked and temperatures recorded every day. Defrosting should be carried out weekly, and then the interior is thoroughly washed with hot soapy water, rinsed and the shelves replaced. Ice trays are taken out and washed with cold water.
Suction machines: Wash with soap and water daily and whenever used. Replace the lotion in the bottles.
Autoclaves: Dump dust them daily, check the functionality of the water and pressure gauges. Always unplug from the mains when not in use.
Boilers and sterilizers: Empty, clean inside with gumption/hebitane. When necessary refill with clean water and always unplug from the mains when not in use.
Hot plates: Any substance spilt on it should be wiped off immediately using a dump cloth. Always unplug from the mains when not in use.
Oxygen concentrators: Dump dust daily; make sure there is water in the wolf’s bottles and check the regulator daily. Always unplug from the mains when not in use and clean the filter.
Lamps: Dump then dry and dust shades and bulbs daily.

2. Oxygen cylinders

Dump dust them daily. Check whether the flow meters are working; check whether there is oxygen in the cylinder and the far the water level in the wolf’s bottles. Label the empty cylinders boldly with the word ‘Empty.’

3. Drainage under water seal gadgets

Disinfect, clean and sterilize.

4. Beds

Make them and dump dust the rails daily. On discharge of the patient; wash with soap and water.

5. Bed rests/backrests

Dump dust daily, wash with soap and water, rinse and dry when necessary and on discharge on an infectious patient disinfect.

6. Bed blocks/elevators

Dump dust daily. On discharge of the patients, scrub with soap and water.

7. Bed cradles

Wash with soap and water, rinse and dry when necessary and in discharge of the patient, scrub with soap and water.

8. Fracture boards

On discharge of the patients, scrub with soap and water.

9. Drip stands

Dump dust daily, wash with soap and water whenever necessary and keep them dry.

10. Trolleys

Wash daily and after use with soap and water, dry thoroughly. Do not use vim on food trolleys.

11. Enamel ware

Wash with soap and water after use, if stained use vim or hebitane/gumption, rinse and dry.

12. Stainless steel ware

Wash with soap or detergent and water, rinse and dry. Do not use vim.

13. Plastic ware

Wash with soap or detergent and water, rinse and dry. Use vim if necessary.

14. Shelves

Wash daily and whenever necessary.

15. Sinks and hand washing basins

Wash daily and after use with vim.

16. Crockery and glass ware

Wash daily with soap or detergent and water, rinse and dry.

17. Cutlery

Wash with soap or detergent and water, rinse and dry.

18. Soiled dressing buckets

Keep the lid on at all times, keep the outside clean. And they should be thoroughly cleansed after emptying.

N.B: Use large basins for dusting; do not use receivers and bowls.

19. Infusion stands

Dump and dust daily, wash with soap and water, dry when necessary.

Weekly Cleaning

In the ward:

Move the beds from one side of the ward to the other
Put lockers outside the ward

Proceed on the empty side as follows;

Brush walls and ceiling and wire gauze of ventilators with long handled brush.
Wash painted walls with soap and water, cleaning any edges and corners carefully.
Wash lamp shades.
The sweeper then sweeps and scrubs the floor.
Clean windows.
Replace beds

Repeat the same procedure on the other side.

Scrub lockers and return to the ward when dry.
Turn out and scrub all cupboards.
Polish furniture if necessary.

In the ward annexes (kitchen, bathroom, linen room etc)

Turn out and clean both the room and equipment.

Refrigerators:

Defrosting should be carried weekly, when the interior is washed thoroughly with hot soapy water, rinsed and the shelves replaced. The ice trays are taken out and washed with cold water.

Bedding and linen:

Care of mattress foam-rubber with cotton and plastic:

Do not remove the plastic mattress cover, wash with soap and water, rinse and dry whenever necessary.

Pillows:

May be protected by plastic cover under cotton cover, to avoid soiling. The cover is removed for laundry whenever dirty, do not remove the plastic cover, wash with and soap, dry and put on the cover.

Rubber goods:

Use only soap and cold water. Before hanging to dry wipe off excess water, do not fold if they are to be out of use for a long time, powder them before storing away.

Do not hang on hot pipes or boiling sterilizers or in the sun.

All linen from the infectious patients should be soaked in disinfectant and soiled linen should be sluiced before sending to laundry.

If linen has been stained with blood soak in cold water for 2-3 hours then rinse.

On discharge of patients all linen should be removed and sent to laundry.

Rubber sheets:

Mackintoshes are washed in soapy water and rinsed, hang out to dry, but never folded.

Rubber tubing:

Rubber tubing-catheters and long tubing; these should be washed in soapy water, and under running water, rolled in the hands immediately after use. Rinse and roll and hang to dry.

Woolen blankets:

Bed blankets; avoid frequent washing, but they should be sent to laundry whenever soiled.

Ward linen:

To avoid cross infection in hospitals great care should be taken in handling of soiled linen contain discharges from patients.

During bed making soiled linen should be separated and be put in a special dirty container/hamper.

A trolley should be used for clean linen.

DAMP DUSTING

Is the cleaning/brushing off, of the dust from a surface using a slightly wet cloth e.g. as of a table, chair, floor or wall etc.

Requirement (prepare a trolley):

Top shelf:

Basin of clean water
Soap and vim
2 Clean dusters in bowl
A jar of clean water

Bottom shelf:

Container for rubbish
Bucket for dirty water
Gloves
Apron
Gumboots

Procedure:

Wash hands and put on gloves. Put on apron and gumboots.
Always start to dust from the highest points or things first and work downward so you do not dirtied surfaces already cleaned.
Remove items from the surface to be cleaned.
Dampen or rinse the cloth in cleaning water.
Wipe away the dust with the damp cloth/duster.
Flat surfaces, wipe in straight lines beginning with the edges once each time.
Turn the cloth on each side 2^nd pass and rinse regularly in clean water.
Take care to damp dust the edges and undersides of the surfaces after the tops.
Where there are extendable items, such as bedside tables, are to be damp dusted extend the before beginning to work.
Polish with the dry duster to clean and dry.
Change the cleaning water when it becomes soiled (dirty)
Greasy or stubborn deposits may require repeated passes.
Replace any items moved on the clean surface when it is dry.
On completion, clean and dry all equipment and store safely and tidily in a secure storage area.
Remove gloves and wash hands.
Document the procedure

N.B: The basin used for dusting should be large one, receivers and dressing bowls are not to be used.

RULES ON CARE OF ALL TYPES OF LINEN

Linen should be used only for the purpose it is intended for.
Avoid frequent laundering of woolen articles.
All linen should be marked, checked before and on retuning from laundry.
Check all linen after laundry for any repairs
Lending and borrowing is avoided, lending book may be necessary
Removal of stains;
- Blood- soak immediately in cold water, if it fails to come off, use hydrogen peroxide or ammonia and rinse it well with cold water afterwards.
- Ink- put immediately in cold water or milk, until the stain fades, later use methylated spirit.
- Coffee and tea stains- wash in cold water, then put in hot water.
- Iodine stains- use hot water or ammonia the rinse.
- Stains caused by drugs- use hot water or ammonia the rinse.

Nurses Revision

General Principles and Rules of All Nursing Procedure Read More »

Infection Prevention and Control

Topic: Carry out infection Prevention and control

Infection

Infection is the successful invasion and multiplication of micro-organism in the body to cause disease. There are many different species of micro-organisms that affect the human body as a host and cause a disease.

Some of the factors involved in transmission of infection are as follows;

Reservoir of infection:

Men
Animals

Mode of escape of micro-organisms:

Nose - exhalation, sneezing (expired air).
Mouth - coughing.
Urinary system - urine.
Gastrointestinal tract - faeces.
Wounds and ulcers - discharge, pus.
Skin - sweat e.g. Ebola, Hep.B.

Vehicle for transmission:

Contaminated hands.
Air
Water
Food
Linen
Crockery and cutlery

Mode of entry:

Nose - inhalation
Mouth - ingestion
Urethra - direct contact
Trans - placental
Genital tract - direct contact with fluids
Mucous membranes and unhealthy skin - direct contact i.e. gonorrhea can be got through kissing.

Susceptible host:

People with low immunity.

Causes of infection

Infection happens when tiny living things called **micro-organisms** successfully enter the body and multiply, causing disease. There are many different types of micro-organisms that can affect the human body and cause illness.

For an infection to happen, there needs to be a chain of events. Breaking any link in this chain can prevent infection. The chain involves:

Reservoir: Where the micro-organisms live and multiply (e.g., people, animals, environment).
Mode of escape: How micro-organisms leave the reservoir (e.g., nose/mouth when coughing or sneezing, urine, feces, wounds, skin).
Vehicle for transmission: How micro-organisms travel from the reservoir to another person (e.g., contaminated hands, air, water, food, linen).
Mode of entry: How micro-organisms enter a new person's body (e.g., nose/mouth through breathing or eating, urethra, cuts in the skin).
Susceptible host: A person who is at risk of getting the infection, usually because they have low immunity or are already weak.

Ways in which infection can be prevented (breaking the chain of infection)

Breaking the chain of infection is crucial in nursing. Key methods include:

Isolation or barrier nursing:

Is the separation of the patient and his unit from others to prevent the direct or indirect contact of infectious agents to a susceptible person e.g. droplet infection, clothing etc.

Hand washing:

Is the single most important means of preventing the transmission of infection. Careful washing of hands using soap, water and nail brush reduces the number of bacteria.

Use of protective gears:

Gears such as gloves, gowns, masks, gargles, gumboots; help protect the nurse from pathogen. They serve as a barrier when handling articles which are contaminated.

Principles of Infection Control

There are five basic universal principles of infection control;

Hand washing

Routing hand washing
Antiseptic hand washing
Alcohol hand rub
Surgical hand scrub

Adequate protective gears

Gloves; - sterile surgical single use gloves, examination disposable gloves, heavy-duty utility gloves
Plastic aprons; - Wear these for all procedures where there is a potential of contamination from splashing of blood and body fluids, handling of soiled dressings and used linen from all patients.
Gowns; - Worn in operating theatres and other areas where a patient may bleed heavily.
Eye/face protection; - Protective eye wear and face masks be made fully available and worn where applicable.
Boots; - Worn in places where spillage of blood, body fluids, secretion and excretions are anticipated. NB. Clean bots with soap and water immediately after use. In case of contamination with blood or body fluids; disinfect.
Surgical masks; - Wear a mask to protect the mucous membranes of the nose and mouth from splashes of body fluids.

Proper sterilization

Sterilization policy is a code of practice, which if correctly followed will ensure a clean and safe health unit, where multiplication and spread of harmful microbes is kept under control.

Proper sharp disposal

Sharps should be handled with extreme caution to avoid injuries during use, disposal or reprocessing. Where possible, all sharps should be disposable.

Safe waste management

It is essential that every health care worker without exception, who handles and disposes the waste, understands the nature of waste and risks, the color code of waste bins, uses personal protective equipment, is conversant with emergency procedures, and is aware they are liable to discipline for non-compliance.

Principles of infection prevention and control

Infection prevention and control are very important in nursing to protect patients, healthcare workers, and the community. The main goal is to break the chain of infection. There are five basic universal principles of infection control:

Hand washing: This is the single most important way to prevent the spread of infection. Proper hand washing with soap and water or using alcohol hand rub reduces the number of bacteria.
Use of personal protective equipment (PPE): Wearing gloves, gowns, masks, and other protective gear creates a barrier to protect nurses from pathogens and prevents the spread of micro-organisms.
Cleaning, disinfection, and sterilization: Cleaning removes visible dirt and most micro-organisms. Disinfection destroys most pathogenic micro-organisms. Sterilization destroys all micro-organisms, including tough spores and viruses. These processes are essential for making instruments and surfaces safe to handle.
Safe waste management and disposal: Handling and disposing of medical waste correctly prevents the spread of infection. Waste should be segregated (sorted) at the point of generation.
Isolation of infectious patients: Separating patients with infectious diseases from others helps prevent direct or indirect contact and stops the spread of pathogens.

Other important measures include maintaining a clean environment, ensuring proper ventilation, safe handling of food and water, safe disposal of waste, controlling rodents and insects, immunization, and promoting personal hygiene.

Use of personal protective equipment (PPE)

Using PPE correctly is a crucial part of infection control. PPE creates a barrier to protect you from contact with infectious materials.

Adequate protective gears:
- Gloves: Wear sterile surgical gloves for procedures and examination disposable gloves for general tasks. Heavy-duty utility gloves are used for cleaning.
- Plastic aprons: Wear these for all procedures where there is a risk of splashing blood or body fluids, or when handling soiled linen from patients.
- Gowns: Wear gowns in areas like operating theatres or other areas where there is a risk of bleeding heavily.
- Eye/face protection: Protective eyewear (goggles or face shields) and face masks should be available and worn when there is a risk of splashes or sprays reaching your eyes, nose, or mouth.
- Boots: Wear boots in areas where there is a risk of spillage of blood, body fluids, or waste. Clean boots immediately after use and disinfect if there is contamination.
- Surgical masks: Wear a mask to protect your nose and mouth from splashes of body fluids.

Routine and weekly cleaning of the ward

Keeping the ward clean is essential for preventing infections. This involves daily and weekly cleaning tasks.

Daily Cleaning (Ward Maintenance):

Collect all necessary equipment on the trolley.
Make the patient’s beds and pull bed and lockers away from the wall.
Collect and put away all the equipment not necessary on the ward for immediate use.
The floor is swept and mopped.
Carry out dump and dry dusting of all ward furniture and equipment, using the ward cleaning trolley.
Return bed and lockers to their position.
Replace sputum mugs with clean ones, empty the used ones, rinse well in the sluice room, leave soaked in the disinfectant.
Give out clean drinking mugs and feeding cups. Refill bottles for drinking water if required.
Clean used equipment and keep in the proper place.

In dressing and treatment rooms (Daily):

Shelves: Wash daily and whenever necessary.
Sinks and wash basins: Wash daily and after use with cleaning agent like vim or hebitane.
Sterilizers: Empty, clean inside with hebitane when necessary, refill with clean water.

Equipment (Daily):

Trolleys: Wash daily and thoroughly with soap and water. Do not use rough cleaners like gumption or vim on food trolleys.
Trolley mop and jar: Boil daily, change or refill fresh lotion daily.
Lifting forceps: Boil daily and whenever contaminated, clean forceps jars, boil forceps, and change lotion daily. Store boiled or autoclaved forceps in a dry sterile container.
Soiled dressing buckets: Keep lid on at all times, keep the outside clean. Thoroughly clean after emptying.

Hygiene in Special Areas (Daily):

Operating theatre, Intensive Care Unit (ICU), Pre-mature unit, and Labour suit have stricter cleaning routines:

Operating tables, trolleys and shelves: Damp dust daily using water and detergent.
Walls: Damp cleaning 2.5-3m downward daily with water and detergent.
Floors: Scrub with water and detergent daily and leave to dry when soiled.
Floors with body fluid spills: Apply 1% hydrochloride for 15 minutes, then spot clean. Clean after every operation. Do weekly cleaning of all equipment and areas.

Note: The same method of cleaning applies to all other special areas.

Weekly Cleaning (In the ward):

Move the beds from one side of the ward to the other.
Put lockers outside the ward.
Proceed on the empty side as follows:
Brush walls and ceiling and wire gauze of ventilators with long handled brush.
Wash painted walls with soap and water, cleaning any edges and corners carefully.
Wash lamp shades.
The sweeper then sweeps and scrubs the floor.
Clean windows.
Replace beds.
Repeat the same procedure on the other side.
Scrub lockers and return to the ward when dry.
Turn out and scrub all cupboards.
Polish furniture if necessary.

In the ward annexes (kitchen, bathroom, linen room etc) (Weekly):

Turn out and clean both the room and equipment.

Refrigerators (Weekly): Defrost weekly, wash interior with hot soapy water, rinse, and replace shelves. Clean ice trays with cold water.

Suction machines (Daily/Whenever Used): Wash with soap and water daily and whenever used. Replace the lotion in the bottles.

Autoclaves (Daily): Dump dust daily, check functionality of water and pressure gauges. Unplug from the mains when not in use.

Boilers and sterilizers (Daily): Empty, clean inside with gumption/hebitane. Refill with clean water and always unplug from the mains when not in use.

Hot plates (Daily/When Spilled): Wipe any spills immediately with a dump cloth. Unplug from the mains when not in use.

Oxygen concentrators (Daily): Dump dust daily, check water in wolf's bottles and check the regulator. Unplug from mains and clean the filter.

Lamps (Daily): Dump dust shades and bulbs daily.

Oxygen cylinders (Daily): Dump dust daily, check flow meters, check oxygen level. Label empty cylinders "Empty."

Drainage under water seal gadgets (After Use): Disinfect, clean, and sterilize.

Beds (Daily/On Discharge): Make beds and dump dust rails daily. On discharge, wash beds with soap and water.

Bed rests/backrests (Daily): Dump dust daily, wash with soap and water, rinse, and dry when necessary.

Bed blocks/elevators (Daily/On Discharge): Dump dust daily. On discharge, scrub with soap and water.

Bed cradles (Daily/On Discharge): Wash with soap and water, rinse, and dry when necessary and on discharge.

Fracture boards (On Discharge): Scrub with soap and water.

Drip stands (Daily): Dump dust daily, wash with soap and water whenever necessary and keep dry.

Trolleys (Daily): Wash daily and after use with soap and water, dry thoroughly. Do not use rough cleaners on food trolleys.

Enamel ware (After Use): Wash with soap and water after use. If stained, use vim or hebitane/gumption, rinse, and dry.

Stainless steel ware (After Use): Wash with soap or detergent and water, rinse, and dry. Do not use vim.

Plastic ware (After Use): Wash with soap or detergent and water, rinse, and dry. Use vim if necessary.

Shelves (Daily/Whenever Necessary): Wash daily and whenever necessary.

Sinks and hand washing basins (Daily/After Use): Wash daily and after use with vim.

Crockery and glass ware (Daily): Wash daily with soap or detergent and water, rinse, and dry.

Cutlery (Daily): Wash with soap or detergent and water, rinse, and dry.

Soiled dressing buckets (Keep lid on at all times): Keep outside clean. Thoroughly clean after emptying. Use large basins for dusting; do not use receivers and bowls for this.

Infusion stands (Daily): Dump and dust daily, wash with soap and water, dry when necessary.

Isolation of infectious patients

Isolation is a key measure in infection control. It means separating a patient who has an infectious disease from other patients, visitors, and staff to prevent the spread of the infection.

The goal is to prevent direct contact (like touching) or indirect contact (like through contaminated objects or air) between the infectious patient and others who might be at risk.

Examples of infections that might require isolation include droplet infections or infections spread through contaminated clothing.

Perform Hand Washing (PEX 1.2.1)

Hand washing is the single most important means of preventing the transmission of infectious agents.

Rules for hand washing:

Wash hands;

On starting and completion of duty shifts.
Before performing any invasive or non-invasive procedures.
Between handling of patients and between the procedures on the same patient.
After handling of patients and procedures.
After handling contaminated articles like urinals, bed pans etc.
Nails should be short to avoid the dirt and micro-organisms.
Remove the watch and jewelry from the hands and wrist before starting to wash the hands.
Fold back sleeves above the elbow if necessary.
Stand away from the wash basin.
Avoid splashing water onto the uniform.

Requirements:

Soap/antiseptic lotion/detol
Bowl
Nail brush
Hand towel
Running water/tap water

Procedure:

Turn on the tap using the elbow and regulate the flow of water.
Wet the hands and lower arms under the running water. Keep the hands, fore arms lower than the elbows during washing.
Apply soap to the hands, replace soap in the dish.
Scrub the hands, area between the fingers and wrist in rotatory movements for 15-30 seconds.
Clean finger nails with a brush or use finger nails of the other hand.
Rinse hands and wrist, fore arm and elbow in running water. Ensure that the hand and fore arm are lower than the elbow during washing.
Close the tap using the elbow.
Dry the hands from fingers to wrist and fore arm, now hold hands above the elbows ready to put on gloves for the procedure.

Surgical Hand Washing (Detailed Procedure)

The hands should be thoroughly cleaned for about 3-5 minutes (in operation room, hands are scrubbed up to 10 minutes.)

Procedure:

Wet the hands and fore arms.
Apply soap (containing 3% hexachlorophene) to make a good lather/foam e.g. Detol, Protex etc.
Clean under the nails for 30 seconds. Nails should be kept very short.
Rinse thoroughly
Apply soap to the arms again
Scrub with the brush so that every area receives 15-30 strokes.
Add little amount of water frequently and use just enough detergent to maintain the lather.
Rinse the arms and hands
In rinsing keep palms higher than the elbow so that the water does not run over them from the arms.
Dry on a sterile towel moving from the palms to the arms. Hold hands above the elbow ready to put on gloves for the procedure.

Demonstrate Appropriate Use of Protective Equipment (PEX 1.2.2)

Understanding and demonstrating the correct use of protective equipment is a crucial practical skill for nurses.

This PEX focuses on the practical demonstration of:

Proper hand washing technique.
Proper donning (putting on) of various protective gears like gloves, gowns, masks, and eye protection.
Proper doffing (taking off) of protective gears to prevent self-contamination.
Selecting the appropriate PPE based on the type of procedure and potential exposure.

Perform Routine and Weekly Cleaning of the Ward (PEX 1.2.3)

Maintaining a clean ward environment is crucial for infection prevention and patient well-being. This PEX involves demonstrating the practical skills of ward cleaning.

This PEX focuses on demonstrating:

Following the established procedures for daily ward cleaning (as described in the 'Ward Maintenance Practices' section).
Following the established procedures for weekly ward cleaning.
Using appropriate cleaning agents and equipment.
Maintaining a clean and tidy environment effectively.
Performing damp dusting correctly.

WARD MAINTENANCE PRACTICES:

Daily Cleaning:

A. Ward Maintenance

Collect all equipment necessary on the trolley.
Make the patient’s beds and pull bed and lockers away from the wall.
Collect and put away all the equipment not necessary on the ward for immediate use.
The floor is swept and mopped.
Carry out dump and dry dusting of all ward furniture and equipment, using the ward cleaning trolley.
Return beds and lockers to their position.
Replace sputum mugs with clean ones empty the used ones, rinse well in the sluice room, leave soaked in the disinfectant.
Give out clean drinking mugs and feeding cups. Refill bottles for drinking water if required.
Clean used equipment and keep in the proper place.

In dressing and treatment rooms:

Shelves - Wash daily and whenever necessary
Sinks and wash basins - wash daily and after use with vim or hebitane.
Sterilizers - empty, clean inside with hebitane when necessary, refill with clean water.
Trolleys - wash daily and after with soap and water, dry thoroughly. Do not use gumption or vim on food trolleys.
Lifting forceps - boiled daily and whenever contaminated forceps jars cleaned, boiled and lotion changed daily. Lotion jar inspected daily and more lotion added if required. Or boiled or autoclaved daily and kept in a dry sterile container.
Soiled dressing buckets - keep lid on at all times, keep the outside clean. And they should be thoroughly cleansed after emptying.

Hygiene in Special Areas (Operating theatre, Intensive care unit (ICU), Pre-mature unit and Labour suit.)

Operating theatre:

Operating tables, trolleys and shelves - dump dust daily using water and detergent.
Walls - dump cleaning 2.5-3m downward daily with water and detergent.
Floors - scrub with water and detergent daily and whenever soiled and leave to dry.
Floors where there are spillages of body fluids - apply 1% hydrochloride for 15min and spot clean. Clean after every operation. Do weekly cleaning of all equipment and areas.

Note: The same method of cleaning applies to all the rest of the special areas mentioned above (intensive care unit, pr-mature unit and labour suit.)

B. Equipment Maintenance (Detailed Procedures - extracted from your notes):

It is the responsibility of every health worker in the hospital to see that all equipment is very well looked after, serviced regularly and given immediate attention when there is any defect.

Equipment should be handled with care and breakages reported immediately, this will definitely keep the hospital expenditure very low.

1. Electric machine

Have regular servicing of the machines and as soon as they are out of order, make a requisition to the maintenance department, have them inspected and repaired.

Refrigerators: These are regulated in order to be effective, regulators should be regularly checked and temperatures recorded every day. Defrosting should be carried out weekly, and then the interior is thoroughly washed with hot soapy water, rinsed and the shelves replaced. Ice trays are taken out and washed with cold water.
Suction machines: Wash with soap and water daily and whenever used. Replace the lotion in the bottles.
Autoclaves: Dump dust them daily, check the functionality of the water and pressure gauges. Always unplug from the mains when not in use.
Boilers and sterilizers: Empty, clean inside with gumption/hebitane. When necessary refill with clean water and always unplug from the mains when not in use.
Hot plates: Any substance spilt on it should be wiped off immediately using a dump cloth. Always unplug from the mains when not in use.
Oxygen concentrators: Dump dust daily; make sure there is water in the wolf’s bottles and check the regulator daily. Always unplug from the mains when not in use and clean the filter.
Lamps: Dump then dry and dust shades and bulbs daily.

2. Oxygen cylinders

3. Drainage under water seal gadgets

Disinfect, clean and sterilize.

4. Beds

Make them and dump dust the rails daily. On discharge of the patient; wash with soap and water.

5. Bed rests/backrests

Dump dust daily, wash with soap and water, rinse and dry when necessary and on discharge on an infectious patient disinfect.

6. Bed blocks/elevators

Dump dust daily. On discharge of the patients, scrub with soap and water.

7. Bed cradles

Wash with soap and water, rinse and dry when necessary and in discharge of the patient, scrub with soap and water.

8. Fracture boards

On discharge of the patients, scrub with soap and water.

9. Drip stands

Dump dust daily, wash with soap and water whenever necessary and keep them dry.

10. Trolleys

Wash daily and after use with soap and water, dry thoroughly. Do not use vim on food trolleys.

11. Enamel ware

Wash with soap and water after use, if stained use vim or hebitane/gumption, rinse and dry.

12. Stainless steel ware

Wash with soap or detergent and water, rinse and dry. Do not use vim.

13. Plastic ware

Wash with soap or detergent and water, rinse and dry. Use vim if necessary.

14. Shelves

Wash daily and whenever necessary.

15. Sinks and hand washing basins

Wash daily and after use with vim.

16. Crockery and glass ware

Wash daily with soap or detergent and water, rinse and dry.

17. Cutlery

Wash with soap or detergent and water, rinse and dry.

18. Soiled dressing buckets

Keep the lid on at all times, keep the outside clean. They should be thoroughly cleaned after emptying.

N.B: Use large basins for dusting; do not use receivers and bowls.

19. Infusion stands

Dump and dust daily, wash with soap and water, dry when necessary.

Weekly Cleaning:

In the ward:

Move the beds from one side of the ward to the other
Put lockers outside the ward

Proceed on the empty side as follows;

Brush walls and ceiling and wire gauze of ventilators with long handled brush.
Wash painted walls with soap and water, cleaning any edges and corners carefully.
Wash lamp shades.
The sweeper then sweeps and scrubs the floor.
Clean windows.
Replace beds

Repeat the same procedure on the other side.

Scrub lockers and return to the ward when dry.
Turn out and scrub all cupboards.
Polish furniture if necessary.

In the ward annexes (kitchen, bathroom, linen room etc)

Turn out and clean both the room and equipment.

Refrigerators:

Defrosting should be carried weekly, when the interior is washed thoroughly with hot soapy water, rinsed and the shelves replaced. The ice trays are taken out and washed with cold water.

Bedding and linen:

Care of mattress foam-rubber with cotton and plastic:

Do not remove the plastic mattress cover, wash with soap and water, rinse and dry whenever necessary.

Pillows:

May be protected by plastic cover under cotton cover, to avoid soiling. The cover is removed for laundry whenever dirty, do not remove the plastic cover, wash with and soap, dry and put on the cover.

Rubber goods:

Use only soap and cold water. Before hanging to dry wipe off excess water, do not fold if they are to be out of use for a long time, powder them before storing away.

Do not hang on hot pipes or boiling sterilizers or in the sun.

All linen from the infectious patients should be soaked in disinfectant and soiled linen should be sluiced before sending to laundry.

If linen has been stained with blood soak in cold water for 2-3 hours then rinse.

On discharge of patients all linen should be removed and sent to laundry.

Rubber sheets:

Mackintoshes are washed in soapy water and rinsed, hang out to dry, but never folded.

Rubber tubing:

Rubber tubing-catheters and long tubing; these should be washed in soapy water, and under running water, rolled in the hands immediately after use. Rinse and roll and hang to dry.

Woolen blankets:

Bed blankets; avoid frequent washing, but they should be sent to laundry whenever soiled.

Ward linen:

To avoid cross infection in hospitals great care should be taken in handling of soiled linen contain discharges from patients.

During bed making soiled linen should be separated and be put in a special dirty container/hamper.

A trolley should be used for clean linen.

DAMP DUSTING:

Is the cleaning/brushing off, of the dust from a surface using a slightly wet cloth e.g. as of a table, chair, floor or wall etc.

Requirement (prepare a trolley):

Top shelf:

Basin of clean water
Soap and vim
2 Clean dusters in bowl
A jar of clean water

Bottom shelf:

Container for rubbish
Bucket for dirty water
Gloves
Apron
Gumboots

Procedure:

Wash hands and put on gloves. Put on apron and gumboots.
Always start to dust from the highest points or things first and work downward so you do not dirtied surfaces already cleaned.
Remove items from the surface to be cleaned.
Dampen or rinse the cloth in cleaning water.
Wipe away the dust with the damp cloth/duster.
Flat surfaces, wipe in straight lines beginning with the edges once each time.
Turn the cloth on each side 2^nd pass and rinse regularly in clean water.
Take care to damp dust the edges and undersides of the surfaces after the tops.
Where there are extendable items, such as bedside tables, are to be damp dusted extend the before beginning to work.
Polish with the dry duster to clean and dry.
Change the cleaning water when it becomes soiled (dirty)
Greasy or stubborn deposits may require repeated passes.
Replace any items moved on the clean surface when it is dry.
On completion, clean and dry all equipment and store safely and tidily in a secure storage area.
Remove gloves and wash hands.
Document the procedure

N.B: The basin used for dusting should be large one, receivers and dressing bowls are not to be used.

Carry out Appropriate Waste Management and Disposal (PEX 1.2.4)

Effective waste management is essential for preventing the spread of infection in a healthcare setting. This PEX involves demonstrating the practical skills of waste segregation and disposal.

This PEX focuses on demonstrating:

Segregating waste correctly at the point of generation using the established color codes.
Using appropriate containers for different types of waste.
Handling and disposing of waste safely to minimize risks.
Properly disposing of sharps.
Understanding and implementing emergency procedures related to waste handling.

MEDICAL WASTE SEGREGATION:

Segregate waste at the point of generation according to the type. Place each type in a separate bin/container that is color coded according to the type of waste. The bins should be well covered and the waste handlers should wear protective gears.

Type of waste	Category	Type of bin
-Discarded paper, packing material, empty bottles or cans, food peelings.	Non-infectious waste	✓ Wet waste ✓ Dry waste Two black bins
-used gauze or dressing, used I.V fluid lines, used giving sets.	Infectious waste	Yellow bin
-sputum containers, used test tubes, extracted teeth, all anatomical waste e.g. placenta. -pathological wastes.	Highly infectious waste	Red bin
-pharmaceutical waste e.g. expired drugs. -laboratory waste e.g. expired reagents	Toxic waste	Brown bin
-used syringe needles, needle cuts, cut from used infusion sets, used scalpels, blades and broken glass.	Sharp waste	Safety box.

Proper sharp disposal:

Sharps should be handled with extreme caution to avoid injuries during use, disposal or reprocessing. Where possible, all sharps should be disposable.

Carry out Isolation of Infectious Patients (PEX 1.2.5)

Isolating patients with infectious diseases is a critical measure to prevent transmission. This PEX focuses on the practical application of isolation procedures.

This PEX focuses on demonstrating:

Identifying patients who require isolation.
Placing the patient in the appropriate isolation room or area.
Implementing specific isolation protocols based on the mode of transmission (e.g., airborne, droplet, contact).
Ensuring appropriate use of PPE when entering and leaving the isolation area.
Educating the patient, family, and other staff about the isolation protocols.
Maintaining necessary supplies within the isolation area.

Definition of Isolation:

Is the separation of the patient and his unit from others to prevent the direct or indirect contact of infectious agents to a susceptible person e.g. droplet infection, clothing etc.

Underpinning knowledge/ theory for Infection Prevention and Control:

(This is covered within the sections above, pulling from the curriculum outline and your notes.)

Infection prevention and control principles
Definition of infection
Chain of infection
Modes of transmission (Causes of Infection)
Types of microorganisms (relevant to causing infection)
Sterilization and disinfection techniques
Medical waste management
Hand hygiene
Isolation procedures
Use of Personal Protective Equipment (PPE)
Routine and terminal cleaning

Learning-Working Assignments (LWAs) and related Practical Exercises (PEXs) for this topic:

Topic: Carry out infection Prevention and control
PEX 1.2.1: Perform hand washing
PEX 1.2.2: Demonstrate appropriate use of protective equipment
PEX 1.2.3: Perform routine and weekly cleaning of the ward
PEX 1.2.4: Carry out appropriate waste management and disposal
PEX 1.2.5: Carry out isolation of infectious patients

Revision Questions for Infection Prevention and Control:

1. Define infection and list three modes of escape for microorganisms from a reservoir.

2. What is the single most important means of preventing the transmission of infection?

3. List at least four types of protective gear used in nursing practice.

4. Explain the purpose of isolating a patient with an infectious disease.

5. Describe the correct procedure for routine daily cleaning of a patient ward.

6. Outline the color coding system for medical waste segregation and give an example of waste for each color.

7. What is the difference between sterilization and disinfection?

8. Explain the importance of proper handling and disposal of sharps.

9. Describe the key steps in performing surgical hand washing.

10. When should medical gloves be worn, and how do they help prevent infection?

Nurses Revision

References (from Curriculum for CN-1111):

Below are the core and other references listed in the curriculum for Module CN-1111. Refer to the original document for full details.

Uganda Catholic Medical Bureau (2015) Nursing and Midwifery procedure manual 2nd Edition Print Innovations and Publishers Ltd. Uganda
Nettina .S,M (2014) Lippincott Manual of Nursing Practice 10th Edition, Wolters Kluwer, Philadelphia, Newyork
Gupta, L.C., Sahu,U.C. and Gupta P.(2007):Practical Nursing Procedures. 3rd edition. JAYPEE brothers, New Delhi.
Craveni, R. Hirnle, C. and Henshaw, M.C. (2017). Fundamentals of Nursing Human Health and Function. 8th Edition. Wolters Kluwer
Hill, R., Hall, H and Glew, P. (2017). Fundamentals of Nursing and Midwifery, A person-Centered Approach to care. Wolters Kluwer
Rosdah I, BC and Kowalkski, TM (2017) Text book for Basic Nursing 11th Edition Wolters Kluwer.
Samson .R. (2009) Leadership and Management in Nursing Practice and Education 1st Edition Jaypee Brothers Medical Publishers India.
Taylor.C.R (2015) Fundamentals of Nursing, The Art and Science of person – centred nursing care, 8th Edition Wolters Kluwer, Health/Lippincott Williams and Wilkins.
Timby, K.B (2017) Fundamental Nursing Skills and concept 11th Edition Wolters Kluwers, Lippincotts Williams and Wilkins.
Lynn, P. (2015) Tyler's Clinical nursing skills, A Nursing Process Approach 4th Edition Wolters Kluwers, China
Gupta, D.S. (2005) Nursing Interventions for the critically ill 1st Edition Jaypee Brothers Medical Publishers Ltd. India.
Uganda Catholic Medical Buraeu (2010) Nursing and Midwifery Procedure Manual. 1st Ed. Print Innovations and Publishers Ltd., Uganda.
Carter, J. P. (2012) Lippincott's Textbook for nursing Assistant. 3rd Edition. Walters Kluwers. Lippingcotts Williams and Wilkins
Jensen, S. (2015) Nursing Health Assessment; A host Practice Approach. 2nd Edition. Wlaters Kluwer,
Gupta, D.S. (2005) Nursing Interventions for the Critically Ill. 1st Edition. Jaypee Brothers Medical Publishers Ltd. India.
UCMB. (2015) Nursing and Midwifery Procedure Manual. 2nd Edition. Print Innovation and Publishers Ltd. Kampala. Uganda.
Karesh, P. (2012) First Aid for Nurses. 1st Edition. Jaypee Brothers Publishers Ltd. India.
Molley, S. (2007) Nursing Process; A Clinical Guide. 2nd Edition. Jaypee Brothers Medical Publishers Ltd. India.
Carter, J.P. (2016) Lippincott's Textbook for Nursing Assistants. 4th Edition. Wolters Kluwer, Lippincotts Williams and Wilkins.
Rahim,A. (2017). Principles and practices of community medicine. 2nd Edition. JAYPEE Brothers Medical Publishers Ltd. New Delhi
Cherie Rector, (2017),Community & Public Health Nursing: Promoting The Public's Health 9e Lippincott Williams and Wilkins
Gail A. Harkness, Rosanna Demarco (2016) Community and Public Health Nursing 2nd edition, Lippincott Williams and Wilkins
Basavanthapp, B.T and Vasundhra, M.K (2008), Community Health Nursing, 2nd edition. JAYPEE Brothers Medical Publishers Ltd. New Delhi
Kamalam, S. (2017), Essentails in Community Health Nursing Practice 3rd edition. JAYPEE Brothers Publishers Ltd. New Delhi
James F. McKenzie, PhD, MPH, MCHES, MEd,and Robert R. Pinger, PhD, (2018) An Introduction to Community & Public Health, 9th edition, Jones and Bartlett Publishers. Sandburg, Massachusetts.
Maurer, F.A, Smith, C.M (2005), Community /Public health Nursing Practice, 3rd edition ELSEVIER SAUNDERS, USA
МОН, (2013) Occupational Safety and Health Training Manual, 1st Edition
МОН, (2008), Policy for Mainstreaming Occupational Health & Safety In The Health Service Sector.
Wooding, N. Teddy, N. Florence, N. (2012) Primary Health Care in East Africa. 1st Edition. Fountain Publishers. Kampala. Uganda.

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Skin Anatomy and Physiology

BNS 111: Anatomy & Physiology - Skin Notes

BNS 111: Anatomy & Physiology

SEMESTER I - Skin

Skin Structure, Appendages, and Adaptations

The skin, also known as the integument or cutaneous membrane, is the largest organ of the body. It's a complex organ system that covers the entire external surface of the body, acting as a vital protective barrier between our internal environment and the outside world. Think of it as our body's first line of defense and its outer suit!

The skin is composed of two main layers:

Epidermis: This is the outer, thinner layer of the skin. It's made of stratified squamous epithelium, which we discussed earlier. This epithelial layer is avascular (no blood vessels), so it gets its nutrients by diffusion from the layer below. The epidermis is constantly renewing itself as cells from the deeper layers divide and push older cells towards the surface, where they flatten, fill with a tough protein called keratin, and eventually shed off. This process, called keratinization, makes the outer layer (stratum corneum) tough and waterproof. The epidermis contains different cell types:
- Keratinocytes: The most abundant cells, producing keratin.
- Melanocytes: Produce the pigment melanin, which gives skin its color and protects against UV radiation.
- Langerhans cells (Dendritic cells): Immune cells that help activate the immune system.
- Merkel cells (Tactile epithelial cells): Touch receptors, associated with nerve endings.
Dermis: This is the inner, thicker layer of the skin, located beneath the epidermis. It's made of connective tissue proper (specifically areolar and dense irregular connective tissue). The dermis is well vascularized (rich in blood vessels), innervated (contains nerve fibers for touch, pain, temperature), and contains various structures like hair follicles, sweat glands, oil glands, and sensory receptors. It has two layers:
- Papillary Layer: The upper layer, made of loose areolar connective tissue. It forms projections called dermal papillae that indent the epidermis, containing capillaries (for nutrient supply to epidermis) and nerve endings (for touch and pain).
- Reticular Layer: The deeper, thicker layer, made of dense irregular connective tissue with bundles of collagen and elastic fibers. It provides the skin's strength, elasticity, and extensibility.

Just below the dermis is the Hypodermis (Superficial Fascia). While not technically part of the skin, it's closely associated. It's made of loose connective tissue (areolar and adipose tissue) and anchors the skin to underlying muscles and bones, stores fat, insulates the body, and absorbs shock.

[Diagram showing a cross-section of the skin, labeling the epidermis, dermis (papillary and reticular layers), and hypodermis. Show the different cell types in the epidermis.]

Skin Appendages (Accessory Structures): These structures develop from the epidermis but extend into the dermis. They include:

Hair and Hair Follicles: Hairs are flexible strands of keratinized cells that grow from hair follicles rooted in the dermis. Functions include protection (from sun, heat loss, physical trauma), sensory reception (hairs detect light touch), and signaling (e.g., eyebrows).
Nails: Hard plates of keratinized cells located on the dorsal surface of the fingers and toes. Protect the fingertips and toes and aid in grasping small objects.
Sweat Glands (Sudoriferous Glands): Produce sweat, primarily for thermoregulation (cooling the body) and excretion of some waste products. There are different types, mainly eccrine sweat glands (most numerous, found almost everywhere, watery sweat for cooling) and apocrine sweat glands (found mainly in axillary and genital areas, thicker sweat, associated with body odor).
Sebaceous Glands (Oil Glands): Secrete sebum (oil) into hair follicles or directly onto the skin surface. Sebum lubricates and softens the skin and hair, prevents water loss, and has some antibacterial properties.

[Diagram showing skin appendages: hair follicle with sebaceous gland, sweat glands (eccrine and apocrine), and nail structure.]

Functions of the Skin (Adaptations): The structure of the skin makes it perfectly adapted to perform many essential functions:

Protection:
- Chemical Barrier: Sebum and sweat create an acidic surface that inhibits bacterial growth. Melanin protects against UV damage.
- Physical Barrier: The keratinized layers of the epidermis and the tight junctions between cells prevent entry of pathogens, water loss, and damage from abrasion.
- Biological Barrier: Langerhans cells in the epidermis and macrophages in the dermis activate the immune system to fight invaders.
Body Temperature Regulation (Thermoregulation):
- Sweating: Evaporation of sweat cools the body.
- Blood Vessel Control: Dermal blood vessels can dilate (widen) to radiate heat away from the body surface when hot, or constrict (narrow) to conserve heat when cold.
Cutaneous Sensation: Contains numerous sensory receptors in the dermis that detect touch, pressure, vibration, pain, and temperature, allowing us to interact with our environment and avoid injury.
Metabolic Functions: The skin plays a role in synthesizing Vitamin D when exposed to UV radiation. Vitamin D is crucial for calcium absorption. Keratinocytes can also disarm some carcinogens and activate some hormones.
Blood Reservoir: The extensive blood supply in the dermis can hold about 5% of the body's entire blood volume, which can be diverted to other organs if needed.
Excretion: Sweat eliminates small amounts of nitrogenous wastes (like urea), salts, and water.

Common Developmental Abnormalities of Skin

Skin development in the embryo is a complex process, and sometimes errors can occur, leading to birthmarks or other congenital skin conditions. Some common developmental abnormalities include:

Congenital Melanocytic Nevi (Birthmarks): These are moles that are present at birth. They vary in size and appearance and are caused by a proliferation of melanocytes. Large congenital nevi can have a slightly increased risk of developing into melanoma (skin cancer) later in life.
Vascular Birthmarks: Caused by abnormalities in blood vessels. Examples include:
- Hemangiomas: Raised, red or bluish marks caused by a dense collection of small blood vessels. They often appear in the first few weeks or months of life and may grow for a while before typically shrinking and disappearing on their own by childhood.
- Port-wine Stains: Flat, pink, red, or purple marks caused by dilated capillaries. They are present at birth, do not typically disappear on their own, and can sometimes be associated with other medical conditions (e.g., Sturge-Weber syndrome).
Epidermal Nevi: Birthmarks caused by an overgrowth of cells in the epidermis. They often appear as raised, warty, or linear lesions.
Accessory Nipples (Supernumerary Nipples): Extra nipples that can appear anywhere along the "milk line," a ridge of tissue that develops during embryonic development. They are usually small and harmless but can sometimes be associated with kidney abnormalities.
Ichthyosis: A group of genetic disorders that affect keratinization, leading to dry, scaly, or thickened skin. Severity varies greatly.

Understanding these developmental abnormalities helps healthcare professionals identify and manage them appropriately, including providing reassurance to parents or referring for specialist care if needed.

[Images showing examples of common developmental skin abnormalities like a congenital melanocytic nevus, hemangioma, or port-wine stain.]

Common Conditions Affecting the Skin and Appendages

The skin is constantly exposed to the environment, making it susceptible to a wide range of conditions, from infections and allergic reactions to chronic diseases and cancers. Here are some common conditions you will encounter in nursing:

Infections:
- Bacterial Infections: Impetigo (contagious, often around nose and mouth, causes red sores that crust over), Folliculitis (inflammation/infection of hair follicles), Cellulitis (bacterial infection of the dermis and subcutaneous tissue, causing redness, swelling, pain).
- Fungal Infections: Commonly called tinea or ringworm, affecting skin, hair, or nails (e.g., Tinea corporis - body ringworm, Tinea pedis - athlete's foot). Candidiasis (yeast infection), often in moist areas.
- Viral Infections: Warts (caused by Human Papillomavirus - HPV), Herpes simplex (cold sores, genital herpes), Varicella-zoster (chickenpox and shingles).
- Parasitic Infestations: Scabies (itchy rash caused by mites burrowing in the skin), Lice (infestation of head, body, or pubic hair).
Inflammatory and Allergic Conditions:
- Dermatitis/Eczema: General terms for skin inflammation, often causing red, itchy, dry skin. Atopic dermatitis is a common chronic form, often linked to allergies. Contact dermatitis is an allergic reaction to something touching the skin (e.g., poison ivy, certain metals).
- Urticaria (Hives): Itchy, raised welts on the skin, often an allergic reaction.
- Psoriasis: A chronic autoimmune disease causing rapid turnover of skin cells, leading to thick, red, scaly patches (plaques).
- Acne Vulgaris: A common condition affecting hair follicles and sebaceous glands, leading to pimples, blackheads, and whiteheads, often on the face, chest, and back. Influenced by hormones, bacteria, and genetics.
Chronic Conditions:
- Pressure Ulcers (Bedsores): Injuries to the skin and underlying tissue resulting from prolonged pressure, usually over a bony prominence. Common in immobile patients.
- Diabetic Foot Ulcers: Non-healing sores on the feet of people with diabetes, often due to poor circulation and nerve damage.
- Varicose Veins and Chronic Venous Insufficiency: Affects veins in the legs, leading to swelling, skin changes, and sometimes ulcers.
Pigmentation Disorders:
- Vitiligo: Loss of melanocytes, causing patches of depigmented (white) skin.
- Melasma: Patches of darker skin pigmentation, often on the face, linked to hormonal changes (e.g., pregnancy, birth control) and sun exposure.
Skin Cancers: Abnormal growth of skin cells, the most common type of cancer.
- Basal Cell Carcinoma (BCC): The most common type, slow-growing, rarely metastasizes. Often looks like a pearly or waxy bump.
- Squamous Cell Carcinoma (SCC): The second most common type, can metastasize if not treated. Often looks like a firm, red nodule or a scaly, crusted lesion.
- Melanoma: Less common but the most dangerous type due to its high potential for metastasis. Arises from melanocytes. Often appears as a new mole or a change in an existing mole (look for asymmetry, irregular border, varied color, diameter >6mm, evolving size/shape/color - ABCDEs of melanoma).
Burns: Damage to the skin caused by heat, chemicals, electricity, or radiation. Classified by depth (first, second, third, fourth degree). Affects the skin's barrier and regulatory functions.

As nurses, you will be heavily involved in assessing skin conditions, providing wound care, administering topical and systemic medications, educating patients on skin health, preventing pressure ulcers, and recognizing signs of infection or potential skin cancers. Knowing the normal structure and function of the skin is essential for identifying abnormalities and providing appropriate care.

[Images showing the appearance of common skin conditions: impetigo, ringworm, acne, psoriasis, pressure ulcer, different types of skin cancer.]

Revision Questions: Skin

Test your understanding of the key concepts covered in this section:

Describe the two main layers of the skin (Epidermis and Dermis), including the type of tissue found in each layer and their key characteristics. Explain how the epidermis receives nutrients.
Name and briefly describe the four main cell types found in the epidermis and their primary functions.
Explain the structure and function of the hypodermis, noting why it is closely associated with but not considered part of the skin.
List and briefly describe the structure and function of three different skin appendages (e.g., hair, nails, sweat glands, sebaceous glands).
Describe in detail three essential functions of the skin and explain how the skin's structure is adapted to perform these functions (e.g., protection, thermoregulation, sensation, metabolic function).
Identify and briefly describe two common developmental abnormalities of the skin that may be present at birth.
Name and briefly describe a common bacterial skin infection, a common fungal skin infection, and a common viral skin infection.
Compare and contrast eczema (dermatitis) and psoriasis, including their general appearance and nature (inflammatory, autoimmune).
Explain what a pressure ulcer is and why nurses are heavily involved in their prevention and management.
Name and describe the three main types of skin cancer, noting which is the most common and which is the most dangerous. What are the ABCDEs of melanoma?
Why is comprehensive skin assessment a vital part of nursing care?

References for BNS 111: Anatomy & Physiology

Tortora, G.J. & Derickson N.,P. (2006) Principles of Anatomy and Physiology; Harper and Row
Drake, R, et al. (2007). Gray's Anatomy for Students. London: Churchill Publishers
Snell, SR. (2004) Clinical Anatomy by Regions. Philadelphia: Lippincott Publishers
Marieb, E.N. (2004). Human Anatomy and physiology. London: Daryl Fox Publishers.
Young, B, et al. (2006). Wheater's Functional Histology: A Text and Colour Atlas: Churchill
Sadler, TW. (2009). Langman's Medical Embryology. Philadelphia: Lippincott Publishers

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Cells and Tissues

BNS 111: Anatomy & Physiology - Cell and Tissues Notes (Part 1)

BNS 111: Anatomy & Physiology

SEMESTER I - Cell and Tissues

Cell Theory

Alright, let's dive into the microscopic world that makes up our bodies, starting with the fundamental concept of theCell Theory. This theory is one of the cornerstones of biology and medicine, giving us the basic understanding of life. It essentially has three main parts, like three key rules about cells:

All living organisms are made up of one or more cells.This means whether it's a tiny bacterium, a plant, or a human being, the basic unit of structure is the cell. Some organisms are single-celled (like amoeba), while complex organisms like us are made of trillions of cells working together.
The cell is the basic unit of structure and organization in organisms.This means that the cell is the smallest level at which life functions can be carried out. Just like a single brick is the basic unit of a wall, a cell is the basic unit of a tissue, an organ, and ultimately, an organism. All the complex processes of life happen within cells.
Cells arise from pre-existing cells.This means cells don't just appear out of nowhere. New cells are produced through cell division (like mitosis or meiosis) from cells that already exist. This explains growth, repair, and reproduction in living things.

Understanding the cell theory is crucial because it tells us that to understand how the body works in health and disease, we must understand how cells work, what they are made of, and how they interact. Diseases often occur when cells are damaged, malfunction, or grow uncontrollably.

Cell Structure and Organelles

Now that we know cells are the basic units, let's peek inside and see what they are made of! Think of a cell like a tiny factory, with different departments and machines (calledorganelles) each doing a specific job to keep the factory running. Human cells, being eukaryotic (having a true nucleus), have several key parts:

The cell is generally divided into two main regions:

Plasma Membrane (Cell Membrane):This is the outer boundary of the cell, like the factory wall. It's a flexible but sturdy barrier that controls what enters and leaves the cell. It's made mainly of a double layer of lipids (fats) with proteins embedded in it. These proteins act like gates, channels, or pumps, allowing specific substances to pass through. The plasma membrane is crucial for maintaining the cell's internal environment and communicating with other cells.
Cytoplasm:This is everything inside the plasma membrane but outside the nucleus. It's like the factory floor and all the machinery on it. The cytoplasm consists of two main parts:
- Cytosol:This is the jelly-like fluid portion of the cytoplasm. It's mostly water, but contains dissolved substances like salts, sugars, proteins, and waste products. Many chemical reactions of the cell happen here.
- Organelles:These are the "little organs" or specialized structures suspended in the cytosol, each with its own shape and specific function. They are like the different machines and departments in our factory.

Let's look at the key organelles found in a typical human cell:

Nucleus:This is the "control center" or "brain" of the cell, usually the largest organelle. It contains the cell's genetic material (DNA) organized intochromosomes. The nucleus controls the cell's activities by directing protein synthesis. It is surrounded by a double membrane called thenuclear envelope, which has pores allowing materials to pass in and out.
Mitochondria:These are the "powerhouses" of the cell. They are responsible for generating most of the cell's supply ofATP(adenosine triphosphate), which is the cell's main energy currency, through a process calledcellular respiration. Cells that need a lot of energy, like muscle cells, have many mitochondria.
Endoplasmic Reticulum (ER):This is a network of interconnected membranes extending throughout the cytoplasm. It's involved in producing, processing, and transporting proteins and lipids. There are two types:
- Rough ER (RER):Studded with ribosomes, it's involved in the synthesis and modification of proteins that are destined for secretion or insertion into membranes.
- Smooth ER (SER):Lacks ribosomes and is involved in synthesizing lipids (like steroids), detoxifying harmful substances (especially in liver cells), and storing calcium ions (especially in muscle cells).
Ribosomes:These are tiny structures responsible forprotein synthesis. They can be free in the cytoplasm (making proteins used within the cell) or attached to the RER (making proteins for export or membranes). They are like the assembly lines for building proteins.
Golgi Apparatus (Golgi Complex or Golgi Body):This is like the cell's "packaging and shipping center." It modifies, sorts, and packages proteins and lipids received from the ER into vesicles for transport to their final destinations, either inside or outside the cell.
Lysosomes:These are like the cell's "recycling centers" or "garbage disposal." They contain powerful digestive enzymes that break down waste materials, cellular debris, and foreign invaders like bacteria.
Peroxisomes:These are small vesicles that contain enzymes that help detoxify harmful substances (like alcohol) and break down fatty acids. They produce hydrogen peroxide as a byproduct, but also contain enzymes to break down hydrogen peroxide into water and oxygen, protecting the cell.
Cytoskeleton:This is a network of protein filaments and tubules that extends throughout the cytoplasm. It's like the cell's "skeleton" and "road system," providing structural support, maintaining cell shape, and allowing for movement of organelles and the cell itself (in some cases). It includesmicrofilaments,intermediate filaments, andmicrotubules.
Centrosomes and Centrioles:Located near the nucleus, the centrosome is the main organizing center for microtubules. Within the centrosome are two cylindrical structures called centrioles, which are important for cell division, forming the spindle fibers that separate chromosomes.
Cilia and Flagella:These are whip-like or hair-like projections extending from the surface of some cells.Ciliaare usually short and numerous, and their coordinated beating moves substances along the cell surface (e.g., in the airways to move mucus).Flagellaare usually long and single, and their movement propels the cell itself (e.g., the tail of a sperm cell).

Cell Functions and Functional Specialization

Even though all cells share basic structures and carry out essential life processes, different types of cells in our body are highly specialized to perform specific functions. Thisfunctional specializationis what allows us to have complex tissues, organs, and organ systems. Think of the different workers in our factory – some are builders, some are packers, some are security guards, each with a unique role.

Some fundamental functions that most cells perform to stay alive and maintain the organism include:

Metabolism:The sum of all chemical processes that occur in the body. Cells carry out metabolic reactions to obtain energy (like cellular respiration in mitochondria) and to synthesize or break down molecules needed for their structure and function.
Responsiveness:The ability to detect and respond to changes in their environment. This can be sensing chemical signals, physical touch, or electrical impulses. For example, nerve cells respond to stimuli by generating electrical signals.
Movement:Can refer to movement of the entire cell (like white blood cells moving to an infection site) or movement of structures within the cell (like organelles being transported) or movement produced by the cell (like muscle cells contracting).
Growth:An increase in cell size or an increase in the number of cells through cell division.
Differentiation:The process by which a less specialized cell becomes a more specialized cell type. This is how a single fertilized egg develops into all the different cell types in the body (nerve cells, muscle cells, skin cells, etc.).
Reproduction:Can refer to the formation of new cells for growth, repair, or replacement (through mitosis) or the production of a new organism (through meiosis and fertilization).

Now, let's look at how different cells are specialized for particular jobs, often by having more of certain organelles or unique structures:

Muscle Cells:Specialized for contraction. They are packed with protein filaments (actin and myosin) that slide past each other to shorten the cell, producing force and movement. They also have abundant mitochondria for energy and specialized smooth ER (sarcoplasmic reticulum) for calcium storage, which is crucial for contraction.
Nerve Cells (Neurons):Specialized for transmitting electrical and chemical signals over long distances. They have long extensions called axons and dendrites. Their plasma membrane is excitable, meaning it can generate and conduct electrical impulses. They have many ribosomes and ER for synthesizing neurotransmitters.
Red Blood Cells:Specialized for transporting oxygen. They lack a nucleus and most organelles (like mitochondria) in their mature state, which maximizes the space available for hemoglobin, the protein that binds oxygen. Their biconcave shape also increases surface area for gas exchange and allows them to squeeze through narrow blood vessels.
Epithelial Cells:Specialized for covering surfaces, lining cavities, protection, absorption, and secretion. They are often tightly packed together and may have specialized structures like microvilli (to increase surface area for absorption, like in the intestines) or cilia (to move substances, like in the airways).
Gland Cells:Specialized for secretion (producing and releasing substances like hormones, enzymes, or mucus). They have abundant ribosomes, ER, and Golgi apparatus to synthesize, process, and package their secretory products into vesicles.
Bone Cells (Osteocytes):Specialized for maintaining bone tissue. They are embedded in a hard extracellular matrix they helped produce, providing structural support to the body.
White Blood Cells (e.g., Macrophages):Part of the immune system, specialized for defense. Some can move actively (amoeboid movement) and engulf foreign particles or debris (phagocytosis), acting like the body's cleanup crew and security. They have abundant lysosomes to break down ingested material.

Understanding cell specialization helps us appreciate how the different parts of the body perform their unique roles and how disruptions at the cellular level can impact the function of entire tissues and organs.

Cell Cycle Regulation and Disorders

Cells don't live forever. For growth, repair, and replacement, cells need to divide. TheCell Cycleis the ordered sequence of events that a cell goes through from the time it is formed until it divides into two new daughter cells. It's a tightly regulated process, like a carefully planned schedule. The main phases of the cell cycle are:

Interphase:This is the longest phase where the cell grows, copies its DNA, and prepares for division. It includes three sub-phases:
- G1 Phase (First Gap):Cell grows and carries out normal metabolic functions.
- S Phase (Synthesis):DNA is replicated (copied).
- G2 Phase (Second Gap):Cell continues to grow and synthesizes proteins needed for division.
Mitotic (M) Phase:This is when the cell actually divides. It includes:
- Mitosis:The nucleus divides, and the copied chromosomes are separated into two identical sets. Mitosis itself has stages: Prophase, Metaphase, Anaphase, Telophase.
- Cytokinesis:The cytoplasm divides, splitting the original cell into two separate daughter cells.

The cell cycle is controlled by a complex system of internal and external signals and checkpoints, like quality control points in the factory.Cell cycle regulationensures that cells divide only when necessary, that DNA replication is completed accurately, and that chromosomes are correctly distributed to the daughter cells. Key regulators include proteins calledcyclinsand enzymes calledcyclin-dependent kinases (CDKs). There are also checkpoints (e.g., G1 checkpoint, G2 checkpoint, M checkpoint) that pause the cycle if something is wrong, allowing time for repair or signaling the cell to undergo programmed cell death (apoptosis) if the damage is too severe.

Disorders of Cell Cycle Regulation:What happens when this careful regulation goes wrong? This is where we see serious problems, most notablycancer. Cancer is fundamentally a disease of uncontrolled cell division. It occurs when genetic mutations damage the genes that regulate the cell cycle (like genes for cyclins, CDKs, or checkpoint proteins). Damaged cells ignore the checkpoints, divide continuously without proper signals, and can invade other tissues (metastasis). Other disorders can involve too little cell division, leading to tissue degeneration or poor wound healing. Understanding cell cycle regulation is vital for developing treatments for cancer and other related conditions.

Epithelial Tissue and Glands

Epithelial tissue, also calledepithelium(plural: epithelia), is one of the four basic tissue types in the body. Think of it as the "covering" or "lining" tissue. It forms sheets of cells that cover body surfaces, line body cavities and hollow organs, and are the main tissue in glands.

Key characteristics of epithelial tissue:

Polarity:Epithelial cells have an apical surface (free surface, exposed to the body exterior or the cavity of an internal organ) and a basal surface (attached to underlying tissue). The apical surface often has specialized structures like microvilli or cilia.
Specialized Contacts:Epithelial cells fit closely together to form continuous sheets, bound by specialized junctions like tight junctions (prevent leakage) and desmosomes (provide strong adhesion). This creates a barrier function.
Supported by Connective Tissue:The basal surface is attached to a thin layer of connective tissue by abasement membrane(also called the basal lamina). This membrane provides structural support and acts as a selective filter.
Avascular but Innervated:Epithelial tissue itself does not have blood vessels (avascular), so it receives nutrients by diffusion from the underlying connective tissue. However, it does have nerve endings (innervated).
Regeneration:Epithelial tissue has a high regenerative capacity, meaning it can reproduce rapidly to replace damaged or lost cells (important for tissues exposed to friction or damage, like the skin).

Epithelial tissues are classified based on two main criteria: thenumber of cell layersand theshape of the cells.

Based on the number of layers:

Simple Epithelium:Consists of a single layer of cells. These are typically found where absorption, secretion, and filtration occur, as the single layer allows for easy passage of substances.
Stratified Epithelium:Consists of two or more layers of cells. These are found in areas subject to wear and tear, where protection is important (e.g., skin surface). The layers provide durability.
Pseudostratified Epithelium:Appears to be stratified because the cell nuclei are at different levels, but it is actually a single layer of cells of varying heights. Often ciliated, found in the respiratory tract.

Based on the shape of the cells (named according to the shape of the cells in the apical layer for stratified epithelia):

Squamous Cells:Flat, scale-like cells.
Cuboidal Cells:Cube-shaped cells, about as tall as they are wide.
Columnar Cells:Tall, column-shaped cells, taller than they are wide.

Combining the number of layers and cell shape gives us the main types of epithelial tissue:

Simple Squamous Epithelium:Single layer of flat cells. Found in air sacs of lungs, lining of blood vessels. Allows for rapid diffusion and filtration.
Simple Cuboidal Epithelium:Single layer of cube-shaped cells. Found in kidney tubules, small glands. Involved in secretion and absorption.
Simple Columnar Epithelium:Single layer of tall cells. Found in the lining of the digestive tract (often with microvilli for absorption) and gallbladder. Involved in absorption and secretion (including mucus).
Pseudostratified Columnar Epithelium:Single layer, but appears layered; cells are columnar. Found in the trachea and upper respiratory tract (usually ciliated, moving mucus). Involved in secretion and movement of mucus.
Stratified Squamous Epithelium:Multiple layers, apical cells are flat. Found in the skin surface (keratinized, tough) and lining of the mouth, esophagus, vagina (non-keratinized, moist). Provides protection against abrasion.
Stratified Cuboidal Epithelium:Multiple layers, apical cells are cube-shaped. Rare, found in ducts of some large glands (e.g., sweat glands).
Stratified Columnar Epithelium:Multiple layers, apical cells are columnar. Very rare, found in small amounts in the pharynx, male urethra, and some gland ducts.
Transitional Epithelium:Modified stratified epithelium where the apical cells change shape depending on stretching. Found in the lining of the urinary bladder, ureters, and part of the urethra. Allows these organs to stretch and recoil.

Main functions of epithelial tissue:

Protection:Forms barriers against physical injury, chemicals, bacteria, and water loss (e.g., skin epidermis).
Absorption:Takes in substances from a free surface (e.g., nutrients in the digestive tract lining).
Secretion:Produces and releases substances like mucus, hormones, enzymes, and sweat (done by glandular epithelium).
Filtration:Allows passage of small molecules while blocking larger ones (e.g., in the kidneys and capillaries).
Excretion:Removes waste products from the body (e.g., in sweat).
Sensory Reception:Contains nerve endings for touch, pain, temperature, etc. (e.g., in the skin).

Disorders affecting Epithelial Tissue:Many common diseases involve epithelial tissue. Since they form coverings and linings and regenerate quickly, they are often sites of injury and uncontrolled growth.

Carcinomas:The most common type of cancer, arising from epithelial tissue. Examples include skin cancer, lung cancer, breast cancer, colon cancer. Because epithelial cells divide rapidly, they are prone to mutations leading to uncontrolled growth.
Inflammation:Epithelial linings are often the first point of contact for pathogens, leading to inflammation (e.g., bronchitis - inflammation of bronchial lining).
Genetic Disorders:Some genetic conditions affect epithelial cell function, like Cystic Fibrosis, which affects epithelial cells in the lungs, pancreas, and other organs, leading to thick mucus secretions.
Physical Damage:Abrasions, burns, and cuts damage epithelial tissue (skin).

Glands:Glands are organs or tissues that produce and secrete specific substances. They are primarily made up of epithelial tissue. Glands can be unicellular (single-celled) or multicellular (made of many cells). They are classified based on where they secrete their products:

Endocrine Glands:These are "ductless" glands. They secrete hormones directly into the bloodstream or interstitial fluid, which then travel to target cells elsewhere in the body to regulate various functions. Examples include the pituitary gland, thyroid gland, adrenal glands, pancreas (parts of it), ovaries, and testes. Hormones are chemical messengers.
Exocrine Glands:These glands secrete their products into ducts, which then carry the secretions to a body surface (either external, like the skin) or into a body cavity (like the digestive tract or airways). Exocrine secretions include mucus, sweat, saliva, tears, digestive enzymes, and oil. Examples include sweat glands, salivary glands, mammary glands, liver (secretes bile into ducts), and the pancreas (secretes digestive enzymes into ducts).

Classification of Exocrine Glands based on structure:

Unicellular:Simple, single-celled glands scattered within an epithelial sheet (e.g., goblet cells that secrete mucus in the lining of the intestines and respiratory tract).
Multicellular:Composed of many cells forming a more complex structure with a duct and a secretory unit (acinus or tubule). They can be simple (single unbranched duct) or compound (branched duct), and tubular (tube-shaped secretory part), alveolar/acinar (sac-like secretory part), or tubuloalveolar.

Classification of Exocrine Glands based on mode of secretion:

Merocrine Glands:Secrete their products by exocytosis (vesicles releasing contents outside the cell). The cell is not damaged. Most common type (e.g., sweat glands, salivary glands, pancreas).
Apocrine Glands:Secrete by budding off portions of the cell membrane containing the product. Part of the cell apex is pinched off (e.g., mammary glands secrete fat droplets).
Holocrine Glands:Secrete by accumulating products within the cell until it ruptures and dies, releasing its contents. The entire cell becomes the secretion (e.g., sebaceous glands that secrete oil onto hair and skin).

Common Disorders of Glands:

Endocrine Disorders:Result from too much or too little hormone secretion (e.g., Diabetes Mellitus - problem with insulin from the pancreas; Hypothyroidism - too little thyroid hormone).
Exocrine Disorders:Can involve blockage of ducts (e.g., gallstones blocking bile ducts from the liver/gallbladder, kidney stones blocking ureters from the kidney), infection of glands (e.g., mastitis - infection of mammary gland), or over/undersecretion (e.g., excessive sweating, dry mouth due to salivary gland problems).
Cancers:Glandular epithelial tissue (adenocarcinoma) is a common site for cancer development.

Connective Tissue

Connective tissue is the most abundant and widely distributed of the primary tissues in the body. As the name suggests, its main function is toconnect, support, bind, and separate other tissues. Think of it as the body's "glue," packaging material, and structural support system. Unlike epithelial tissue, which is mainly cells, connective tissue is characterized by having a lot ofextracellular matrix– the stuff outside the cells.

Key characteristics of connective tissue:

Common Origin:All connective tissues arise frommesenchyme, an embryonic tissue.
Varying Degrees of Vascularity:Connective tissues have different amounts of blood supply. Some, like cartilage, are avascular (no blood vessels). Others, like bone, are well vascularized. Dense connective tissue (like ligaments) has poor vascularity.
Extracellular Matrix:This is the non-living material found between the cells, and it's what gives connective tissue its unique properties. The matrix is made up of aground substance(an unstructured gel-like material that fills the space between cells) andfibers(protein fibers that provide support – collagen, elastic, reticular). The type and amount of ground substance and fibers vary greatly depending on the specific type of connective tissue, determining its strength, elasticity, or rigidity.
Cells:Connective tissues have various cell types. Immature cells (ending in "-blast", e.g., fibroblasts, chondroblasts, osteoblasts) are actively secreting the matrix. Mature cells (ending in "-cyte", e.g., fibroblasts, chondrocytes, osteocytes) maintain the matrix. Other cells like fat cells (adipocytes), mast cells (involved in inflammation), and defense cells (macrophages, plasma cells) can also be found in some connective tissues.

Connective tissue is a broad category with several major classes and subclasses, each specialized for specific functions. Based on your outline, we'll focus on:

Connective Tissue Proper (Fibrous Tissue):This is the most widespread type, with varying amounts of fibers and ground substance.
Cartilage:A flexible but tough supporting tissue.
Bone (Osseous Tissue):A hard, rigid supporting tissue.
Blood:A fluid connective tissue involved in transport.

Connective Tissue Proper (Fibrous Tissue)

Connective tissue proper has two broad categories based on the density and arrangement of its fibers: Loose Connective Tissue and Dense Connective Tissue. The primary cell type in connective tissue proper is thefibroblast(or fibrocyte in its mature form), which produces the fibers and ground substance.

Loose Connective Tissue:In this type, the fibers are loosely arranged, leaving a lot of space filled with ground substance. This provides cushioning and support for other tissues and organs. It's well vascularized.

Areolar Connective Tissue:The most common loose connective tissue. It has a gel-like matrix with all three fiber types (collagen, elastic, reticular) and various cell types (fibroblasts, macrophages, mast cells, some white blood cells). It acts as a packing material between organs, surrounds blood vessels and nerves, and underlies epithelia, providing support and holding tissue fluid. It's involved in inflammation and immunity.
Adipose Tissue (Fat):Primarily made up ofadipocytes(fat cells) which store triglycerides (fats). It has a sparse matrix. Functions include energy storage, insulation against heat loss, and cushioning/protection of organs (e.g., around kidneys and eyeballs).
Reticular Connective Tissue:Contains delicate networks of reticular fibers in a loose ground substance. Forms the stroma (framework) of lymphoid organs like the spleen, lymph nodes, and bone marrow, supporting blood cells.

Dense Connective Tissue:In this type, the fibers (mainly collagen) are packed more densely, providing greater strength and resistance to tension. It's less vascularized than loose connective tissue.

Dense Regular Connective Tissue:Collagen fibers are arranged in parallel bundles, running in the same direction. This provides great tensile strength in one direction. Found intendons(connect muscle to bone) andligaments(connect bone to bone).
Dense Irregular Connective Tissue:Collagen fibers are thicker and arranged irregularly, running in various directions. This provides tensile strength in multiple directions. Found in the dermis of the skin, fibrous capsules of organs and joints, and the perichondrium and periosteum (coverings of cartilage and bone).
Elastic Connective Tissue:Contains a high proportion of elastic fibers, allowing the tissue to stretch and recoil. Found in the walls of large arteries, some ligaments (e.g., ligaments connecting vertebrae), and the bronchial tubes.

Disorders of Fibrous Connective Tissue:Problems with connective tissue proper can lead to various conditions:

Injuries:Sprains (ligaments stretched/torn) and strains (tendons/muscles stretched/torn) are common injuries involving dense regular connective tissue.
Inflammation:Tendinitis (inflammation of a tendon) or fasciitis (inflammation of fascia, a type of dense irregular connective tissue).
Adipose Tissue Disorders:Obesity (excessive fat storage), or lipedema (abnormal fat distribution).
Genetic Disorders:Some genetic conditions affect collagen or elastic fiber synthesis, leading to disorders like Ehlers-Danlos syndromes (affecting connective tissue strength and elasticity throughout the body) or Marfan syndrome (affecting elastic tissue, particularly in the cardiovascular system and skeleton).

[Placeholder for a diagram illustrating the different types of connective tissue proper (Areolar, Adipose, Reticular, Dense Regular, Dense Irregular, Elastic) with examples of their location and appearance under a microscope.]

[Placeholder for diagrams showing the structure of tendons and ligaments.]

Cartilage

Cartilageis a flexible but tough supporting connective tissue. It's found in many areas of the body, including joints, the nose, ears, trachea, and intervertebral discs. Unlike most connective tissues, mature cartilage isavascular(no blood vessels) and lacks nerve fibers, which means it heals very slowly if damaged.

Key features of cartilage:

Cells:The primary cells arechondroblasts(immature, produce matrix) andchondrocytes(mature, maintain matrix). Chondrocytes are located in small cavities within the matrix calledlacunae.
Matrix:Firm, gel-like ground substance containing varying amounts of collagen and/or elastic fibers. This matrix is what gives cartilage its resilient and supportive properties.
Perichondrium:A layer of dense irregular connective tissue that surrounds most cartilage (except articular cartilage in joints). It contains blood vessels that supply nutrients to the cartilage cells by diffusion, and it's involved in cartilage growth and repair.

There are three types of cartilage, differing in the composition of their matrix and fibers, which affects their properties and location:

Hyaline Cartilage:The most abundant type. It has a smooth, glassy appearance with fine collagen fibers. Provides support and flexibility, reduces friction. Found at the ends of long bones in joints (articular cartilage), in the nose, trachea, larynx, and rib cage (costal cartilage).
Elastic Cartilage:Similar to hyaline cartilage but contains abundant elastic fibers. This makes it more flexible and able to tolerate repeated bending. Found in the external ear and the epiglottis (flap of cartilage in the throat).
Fibrocartilage:The strongest type of cartilage, containing thick bundles of collagen fibers and less ground substance. It's compressible and resists tension, acting as a shock absorber. Found in structures subjected to heavy pressure, such as the intervertebral discs (between vertebrae), the menisci of the knee, and the pubic symphysis (joint between pelvic bones).

Disorders of Cartilage:

Osteoarthritis:A very common degenerative joint disease where the articular cartilage at the ends of bones wears away, leading to pain, stiffness, and reduced movement.
Cartilage Tears:Can occur in fibrocartilage structures like the menisci of the knee due to injury. Healing is slow due to avascularity.
Inflammation:Chondritis is inflammation of cartilage.

[Placeholder for diagrams illustrating the three types of cartilage (Hyaline, Elastic, Fibrocartilage) showing their microscopic appearance and examples of their location in the body.]

[Placeholder for a diagram showing a joint and highlighting the articular cartilage.]

Bone (Osseous Tissue)

Bone, or osseous tissue, is a hard, dense connective tissue that forms the skeletal framework of the body. It's one of the hardest tissues in the body due to the presence of inorganic calcium salts in its matrix. Bone is well vascularized and innervated, meaning it has a good blood supply and nerve endings, which is why bone fractures hurt and heal (though healing time varies).

Key features of bone:

Cells:Bone tissue contains several cell types involved in its formation, maintenance, and breakdown:
- Osteoblasts:Bone-forming cells that secrete the organic part of the bone matrix (collagen fibers and ground substance).
- Osteocytes:Mature bone cells located in lacunae within the matrix. They are connected to each other and the blood supply through tiny channels calledcanaliculi. Osteocytes maintain the bone tissue.
- Osteoclasts:Large multinucleated cells that break down (resorb) bone tissue. This process is important for bone remodeling, growth, and repair, and for releasing calcium into the blood.
Matrix:Bone matrix is unique because it ismineralized. It has both organic components (mainly collagen fibers, which provide flexibility and tensile strength) and inorganic components (mainly calcium phosphate salts, calledhydroxyapatite, which provide hardness and compressional strength). The combination makes bone strong and resistant to both pulling and pushing forces.
Periosteum:A tough, fibrous membrane that covers the outer surface of most bones. It contains blood vessels, nerves, and bone-forming cells (osteoblasts), playing a crucial role in bone nourishment, growth in thickness, and repair.
Endosteum:A delicate membrane lining the internal surfaces of bone, including the cavities within spongy bone and the canals within compact bone. It also contains osteoblasts and osteoclasts.

There are two main types of bone tissue found in most bones:

Compact Bone:Dense, solid bone tissue that forms the outer layer of all bones and the shaft (diaphysis) of long bones. Its structural unit is theosteon (Haversian system)– concentric rings of bone matrix (lamellae) around a central canal containing blood vessels and nerves. This structure provides strength and resistance to stress.
Spongy Bone (Trabecular Bone):Located inside compact bone, especially at the ends (epiphyses) of long bones and in flat bones. It consists of a network of bony struts and plates calledtrabeculaewith spaces in between. These spaces are often filled withred bone marrow, where blood cells are produced (hematopoiesis). Spongy bone is lighter than compact bone and helps bones resist stress from different directions.

Functions of Bone:

Support:Provides a framework for the body and supports soft tissues.
Protection:Protects vital organs (e.g., skull protects the brain, rib cage protects heart and lungs).
Movement:Serves as attachment points for muscles, acting as levers for movement at joints.
Mineral Storage:Stores calcium and phosphate, releasing them into the bloodstream when needed to maintain blood mineral levels (crucial for nerve and muscle function).
Blood Cell Formation (Hematopoiesis):Occurs in the red bone marrow found within the spaces of spongy bone.
Triglyceride (Fat) Storage:Yellow bone marrow, found in the medullary cavity of long bones, stores fat.

Disorders of Bone Tissue:

Fractures:Breaks in bone tissue, common due to trauma. Bone's good blood supply allows it to heal, but the process takes time.
Osteoporosis:A condition where bone resorption (breakdown) outpaces bone formation, leading to decreased bone density and increased risk of fractures, especially in older adults.
Osteomalacia/Rickets:Softening of bones due to insufficient mineralization, often caused by vitamin D or calcium deficiency. Rickets occurs in children, osteomalacia in adults.
Osteomyelitis:Inflammation of bone tissue, often caused by infection.
Bone Cancers:Primary bone cancers (like osteosarcoma) or metastatic cancers that spread to bone.

[Placeholder for a diagram showing the microscopic structure of Compact Bone (Osteons) and Spongy Bone (Trabeculae) with cell types labeled.]

[Placeholder for a diagram showing a long bone and labeling its parts (diaphysis, epiphysis, periosteum, endosteum, medullary cavity, compact bone, spongy bone, red/yellow marrow).]

[Placeholder for images showing different types of bone fractures.]

Blood

Bloodis considered a connective tissue because it originates from mesenchyme and consists of cells suspended in an extensive fluid matrix calledplasma. Unlike other connective tissues, the fibers in blood are soluble protein molecules visible only during blood clotting. Blood is vital for transportation and maintaining homeostasis throughout the body.

Key components of blood:

Plasma:The fluid extracellular matrix, making up about 55% of blood volume. It's mostly water (about 90%), but contains a vast array of dissolved substances, including plasma proteins (like albumin, globulins, fibrinogen), hormones, nutrients (glucose, amino acids), electrolytes (ions like sodium, potassium), respiratory gases (oxygen, carbon dioxide), and waste products. Plasma transports these substances throughout the body.
Formed Elements:The cellular and cell fragment components suspended in plasma, making up about 45% of blood volume. They are produced in the red bone marrow. The main types are:
- Erythrocytes (Red Blood Cells - RBCs):The most numerous formed elements. Small, biconcave discs that lack a nucleus and most organelles in mammals. They are specialized for transporting oxygen from the lungs to the tissues and a small amount of carbon dioxide from the tissues to the lungs, thanks to the proteinhemoglobin.
- Leukocytes (White Blood Cells - WBCs):Part of the immune system, involved in defending the body against infection and disease. They are complete cells with nuclei and organelles. There are different types of WBCs (neutrophils, lymphocytes, monocytes, eosinophils, basophils), each with specific roles in immunity. They can leave the bloodstream and enter tissues to fight infection.
- Thrombocytes (Platelets):Not true cells, but small, irregular-shaped fragments of larger cells called megakaryocytes found in bone marrow. They are essential forblood clotting (hemostasis), plugging damaged blood vessels and releasing factors that promote clotting.

Functions of Blood:

Transportation:Transports oxygen from lungs to tissues, carbon dioxide from tissues to lungs, nutrients from the digestive tract to cells, hormones from endocrine glands to target organs, metabolic wastes from cells to kidneys and liver for excretion, and heat throughout the body.
Regulation:Helps maintain body temperature (by distributing heat), maintains normal pH in body tissues (using buffer systems), and maintains adequate fluid volume in the circulatory system.
Protection:Prevents blood loss through clotting (hemostasis) and prevents infection using antibodies, complement proteins, and white blood cells.

Disorders of Blood:Problems with blood components or function are very common:

Anemia:A condition characterized by a reduced number of red blood cells or insufficient hemoglobin, leading to decreased oxygen-carrying capacity (e.g., iron-deficiency anemia, sickle cell anemia).
Leukemia:Cancers of the white blood cells, leading to an overproduction of abnormal or immature white blood cells that don't function properly.
Clotting Disorders:Conditions affecting the blood's ability to clot, either excessively (e.g., thrombosis, leading to blood clots) or insufficiently (e.g., hemophilia, excessive bleeding). Problems with platelets or clotting factors.
Infections:Many infections are transported by blood, and white blood cell counts are a key indicator of infection. Sepsis is a life-threatening condition caused by the body's overwhelming response to an infection in the bloodstream.

[Placeholder for a diagram illustrating the components of blood: Plasma and Formed Elements (RBCs, WBCs - showing different types, Platelets) with approximate percentages.]

[Placeholder for microscopic images of a blood smear showing red blood cells, different types of white blood cells, and platelets.]

Muscle Tissue (Propulsion Tissue)

Muscle tissueis specialized tissue that is responsible for movement. It does this by contracting, which means its cells can shorten and generate force. This force is used for body movements (like walking or lifting), moving substances within the body (like blood, food, or urine), and generating heat. Muscle tissue is often referred to as "propulsion tissue" because of its role in moving things.

Key characteristics that all muscle tissues share:

Excitability (Responsiveness):The ability to receive and respond to stimuli (like nerve signals or hormones) by changing its electrical state and contracting.
Contractility:The ability to shorten forcibly when stimulated. This is the defining property of muscle tissue.
Extensibility:The ability to be stretched or extended. Muscles can be stretched beyond their resting length.
Elasticity:The ability of a muscle cell to recoil and resume its resting length after being stretched.

There are three main types of muscle tissue in the body, classified based on their structure, location, and how they are controlled:

Skeletal Muscle Tissue:
- Structure:Made up of long, cylindrical cells calledmuscle fibers. These fibers are multinucleated (have many nuclei) and appearstriated(have visible bands or stripes) under a microscope due to the arrangement of the contractile proteins (actin and myosin).
- Control:Voluntarycontrol, meaning we consciously control its contraction (e.g., moving your arm or leg).
- Distribution:Primarily attached to bones (via tendons), forming the muscles that move the skeleton. Also found in some areas like the diaphragm and the external anal sphincter.
- Functions:Body movement, maintaining posture, stabilizing joints, and generating heat.
- Regeneration:Has limited regenerative capacity. Damage is often repaired by fibrosis (formation of scar tissue).
Smooth Muscle Tissue:
- Structure:Made up of spindle-shaped cells (tapered at both ends) with a single central nucleus. It isnon-striated, meaning it does not have the visible banding seen in skeletal or cardiac muscle.
- Control:Involuntarycontrol, meaning we do not consciously control its contraction. It is regulated by the autonomic nervous system, hormones, and local factors.
- Distribution:Found in the walls of hollow internal organs (viscera) like the stomach, intestines, bladder, uterus, blood vessels, airways, and arrector pili muscles in the skin.
- Functions:Propels substances through internal passageways (peristalsis in the digestive tract), regulates blood flow (by constricting/dilating blood vessels), moves substances through airways, empties the bladder and uterus.
- Regeneration:Has a moderate capacity for regeneration.
Cardiac Muscle Tissue:
- Structure:Found only in the wall of the heart. Made up of branched cells that are connected to each other by specialized junctions calledintercalated discs. These discs allow electrical signals to pass rapidly from one cell to another, enabling the heart to contract as a coordinated unit. Cardiac muscle cells are usually uninucleated (one nucleus, sometimes two) and arestriated.
- Control:Involuntarycontrol. The heart has its own pacemaker cells that initiate contractions, but the rate and force can be influenced by the autonomic nervous system and hormones.
- Distribution:Exclusively found in the wall of the heart (myocardium).
- Functions:Propels blood throughout the body as the heart contracts.
- Regeneration:Has very limited regenerative capacity. Damage (like from a heart attack) is primarily repaired by scar tissue formation.

Disorders of Muscle Tissue:

Muscle Strains/Tears:Common injuries, especially in skeletal muscle, where muscle fibers are overstretched or torn.
Muscle Spasms/Cramps:Involuntary, painful contractions of muscles.
Muscular Dystrophy:A group of genetic diseases that cause progressive weakness and degeneration of skeletal muscles.
Myasthenia Gravis:An autoimmune disorder that affects the neuromuscular junction, leading to skeletal muscle weakness and fatigue.
Cardiomyopathy:Diseases of the heart muscle, affecting its ability to pump blood effectively.
Smooth Muscle Disorders:Can affect the function of organs containing smooth muscle, e.g., asthma (constriction of smooth muscle in airways), Irritable Bowel Syndrome (abnormal smooth muscle contraction in the intestines).

[Placeholder for diagrams illustrating the three types of muscle tissue (Skeletal, Smooth, Cardiac) showing their microscopic appearance side-by-side (striations, shape, nuclei, intercalated discs).]

[Placeholder for a diagram showing the organization of skeletal muscle, from the whole muscle down to the muscle fiber and sarcomere.]

[Placeholder for a diagram showing an intercalated disc in cardiac muscle.]

Nervous Tissue

Nervous tissueis the main tissue that makes up the nervous system – your body's control and communication network. It's responsible for receiving stimuli, processing information, and transmitting signals to other parts of the body to coordinate actions and responses. Think of it as the body's electrical wiring and processing unit.

Nervous tissue is composed of two main types of cells: highly specialized nerve cells called neurons, and several types of supporting cells collectively called neuroglia (or glial cells).

Structural Features of Neurons and Neuroglial Cells

Neurons (Nerve Cells):These are the excitable cells of the nervous system that are specialized for transmitting information via electrical and chemical signals. They are the functional units of the nervous system. While neurons vary in shape and size, they generally have the following structural components:

Cell Body (Soma):This is the central part of the neuron containing the nucleus and most of the cell's organelles (like abundant ribosomes, Rough ER, and Golgi apparatus, reflecting high protein synthesis for neurotransmitters). The cell body is the metabolic center of the neuron.
Dendrites:These are typically short, branched extensions that extend from the cell body. They act like antennae, receiving signals (neurotransmitters) from other neurons and transmitting these signals *towards* the cell body. A neuron usually has many dendrites to receive input from multiple sources.
Axon:This is a single, typically long projection that extends from the cell body. The axon transmits electrical signals (action potentials) *away* from the cell body towards other neurons, muscles, or glands. Axons can be very long, extending up to a meter in length (e.g., from the spinal cord to the muscles in your foot).
- Axon Hillock:The cone-shaped region where the axon arises from the cell body. This is typically where the action potential is generated.
- Axon Terminals (Synaptic Terminals):The branched endings of the axon. These are where the neuron communicates with other cells at junctions calledsynapses. They contain vesicles filled withneurotransmitters, chemical messengers that transmit the signal across the synapse.
Myelin Sheath:Many axons, especially long ones, are covered by a fatty layer called the myelin sheath. In the peripheral nervous system, this sheath is formed bySchwann cells; in the central nervous system, it's formed byoligodendrocytes(types of neuroglia). The myelin sheath acts as an insulator, greatly speeding up the conduction of electrical signals along the axon by allowing the signal to jump between gaps in the sheath calledNodes of Ranvier(this is calledsaltatory conduction). Not all axons are myelinated (unmyelinated axons conduct signals more slowly).

Neurons communicate with each other and with target cells (muscles, glands) at synapses. Asynapseis the junction between an axon terminal of one neuron (the presynaptic neuron) and a dendrite or cell body of another neuron (the postsynaptic neuron), or a target cell. Signal transmission at most synapses is chemical, involving the release of neurotransmitters.

Neuroglial Cells (Glial Cells):These are non-excitable supporting cells found in nervous tissue. They do not transmit nerve impulses themselves, but they play crucial roles in supporting, nourishing, insulating, and protecting neurons. They are often more numerous than neurons. Different types exist in the central and peripheral nervous systems:

Neuroglia in the Central Nervous System (CNS - Brain and Spinal Cord):
- Astrocytes:Star-shaped cells that are the most abundant neuroglia in the CNS. They form a supportive framework, help regulate the chemical environment around neurons (mopping up excess neurotransmitters), help form theblood-brain barrier(which protects the brain from harmful substances in the blood), and assist in guiding neuron development.
- Microglia:Small, mobile cells that act as the CNS's immune cells. They are phagocytic, meaning they engulf and remove cellular debris, dead neurons, and pathogens. They are like the cleanup crew and defense system of the brain and spinal cord.
- Ependymal Cells:Epithelial-like cells that line the cavities within the brain (ventricles) and spinal cord (central canal). They help produce and circulatecerebrospinal fluid (CSF), which cushions the CNS.
- Oligodendrocytes:Cells that form themyelin sheatharound axons in the CNS. Each oligodendrocyte can myelinate multiple axon segments.
Neuroglia in the Peripheral Nervous System (PNS - Nerves outside the Brain and Spinal Cord):
- Schwann Cells:These cells form themyelin sheatharound axons in the PNS. Unlike oligodendrocytes, each Schwann cell typically myelinates only a single axon segment. They are crucial for regeneration of damaged peripheral nerve fibers.
- Satellite Cells:Flattened cells that surround neuron cell bodies in ganglia (collections of neuron cell bodies in the PNS). They provide support and regulate the chemical environment around the neurons.

Neuroglia are essential for the proper functioning and survival of neurons. Damage to neuroglia can contribute to neurological disorders.

[Placeholder for a detailed diagram of a motor neuron showing the cell body, dendrites, axon, axon hillock, myelin sheath (with Schwann cells/oligodendrocytes and Nodes of Ranvier), and axon terminals/synapses.]

[Placeholder for diagrams illustrating the different types of neuroglial cells in the CNS (Astrocytes, Microglia, Ependymal cells, Oligodendrocytes) and PNS (Schwann cells, Satellite cells) showing their shapes and relationship to neurons.]

[Placeholder for a diagram showing a synapse, illustrating the presynaptic terminal, synaptic cleft, neurotransmitters, and postsynaptic membrane.]

Organization of Peripheral Nerves and Ganglia

While the brain and spinal cord make up the central nervous system (CNS), thePeripheral Nervous System (PNS)consists of all the nerves that extend outside the CNS, connecting it to the rest of the body, and collections of neuron cell bodies outside the CNS called ganglia.

Peripheral Nerves:A nerve is essentially a bundle of many axons (nerve fibers) wrapped in connective tissue. Think of it like a communication cable containing many individual wires. The structure of a peripheral nerve from the inside out includes:

Axon (Nerve Fiber):The core of the structure, carrying the electrical signal. May or may not be covered by a myelin sheath formed by Schwann cells.
Endoneurium:A delicate layer of loose connective tissue that surrounds each individual axon (nerve fiber), including its myelin sheath if present.
Fascicle:A bundle of several axons wrapped together by a coarser connective tissue layer.
Perineurium:A layer of dense irregular connective tissue that surrounds a fascicle. It forms a protective barrier around the axon bundles.
Epineurium:The outermost, tough fibrous sheath of dense irregular connective tissue that surrounds the entire nerve, enclosing all the fascicles, blood vessels, and lymphatic vessels supplying the nerve.

Peripheral nerves can contain axons of sensory neurons (carrying signals towards the CNS), motor neurons (carrying signals away from the CNS to muscles/glands), or both (mixed nerves). This organized structure protects the delicate axons and allows nerves to transmit signals reliably across the body.

Ganglia (Singular: Ganglion):A ganglion is a collection or cluster of neuroncell bodieslocated in the peripheral nervous system. They are like "relay stations" or "switching centers" where nerve impulses are processed or relayed.

Sensory Ganglia:Contain the cell bodies of sensory neurons (e.g., dorsal root ganglia near the spinal cord).
Autonomic Ganglia:Contain the cell bodies of autonomic motor neurons, which regulate involuntary functions (e.g., sympathetic and parasympathetic ganglia).

In the central nervous system, a collection of neuron cell bodies is called anucleus(plural: nuclei). So, ganglion is the PNS equivalent of a nucleus in the CNS.

Disorders affecting Nervous Tissue:

Neuropathy:Damage to peripheral nerves, leading to pain, numbness, tingling, and weakness (e.g., diabetic neuropathy, carpal tunnel syndrome).
Neurodegenerative Diseases:Conditions involving progressive loss of neurons (e.g., Alzheimer's disease, Parkinson's disease).
Stroke:Damage to brain tissue due to interruption of blood supply, causing neuronal death.
Spinal Cord Injury:Damage to the spinal cord, disrupting communication between the brain and the body.
Tumors:Cancers can arise from neuroglial cells (gliomas) or neurons (less common).

[Placeholder for a cross-section diagram of a peripheral nerve showing the Epineurium, Perineurium surrounding fascicles, and Endoneurium surrounding individual axons (myelinated and unmyelinated).]

[Placeholder for a diagram illustrating the structure of a ganglion, showing neuron cell bodies surrounded by satellite cells.]

[Placeholder for a diagram showing a sensory neuron with its cell body located in a dorsal root ganglion.]

Revision Questions: Cell and Tissues

Test your understanding of the key concepts covered in this section:

State the three main tenets of the Cell Theory and explain their significance in understanding living organisms.
Describe the main structural components of a typical eukaryotic (human) cell, including the plasma membrane, cytoplasm (cytosol and organelles), and nucleus. Briefly explain the primary function of at least five different organelles.
Explain the concept of functional specialization in cells and provide three specific examples of how different cell types in the body are specialized for unique functions, relating their structure to their job (e.g., muscle cells, neurons, red blood cells).
Outline the main phases of the cell cycle (Interphase and Mitotic Phase) and briefly describe what happens in each phase. Why is the regulation of the cell cycle crucial for health? What happens when this regulation fails?
Compare and contrast the structure, location, control, and regenerative capacity of the three types of muscle tissue (Skeletal, Smooth, and Cardiac).
Describe the key characteristics of connective tissue that distinguish it from epithelial tissue. Explain the role of the extracellular matrix in connective tissue.
Name and describe the main components of blood. Explain why blood is considered a connective tissue despite its fluid nature. List three major functions of blood.
Compare and contrast the three types of cartilage (Hyaline, Elastic, Fibrocartilage) in terms of their fiber composition, properties, and locations in the body. Why does cartilage heal slowly?
Describe the structural features of bone tissue, including the different cell types (osteoblasts, osteocytes, osteoclasts) and the composition of the bone matrix. Explain the difference between compact bone and spongy bone.
Explain the main structural components of a neuron (cell body, dendrites, axon, axon terminals) and their respective functions in transmitting nerve impulses. Describe the role of the myelin sheath.
Identify the different types of neuroglial cells found in the Central Nervous System (CNS) and Peripheral Nervous System (PNS). Briefly explain the function of at least three types of neuroglia.
Describe the organization of a peripheral nerve, including the Epineurium, Perineurium, and Endoneurium. What is a ganglion, and how does it differ structurally from a peripheral nerve?
Discuss one common disorder for each of the four main tissue types (Epithelial, Connective, Muscle, Nervous) and briefly explain how the tissue is affected in each disorder.

References for BNS 111: Anatomy & Physiology

Tortora, G.J. & Derickson N.,P. (2006) Principles of Anatomy and Physiology; Harper and Row
Drake, R, et al. (2007). Gray's Anatomy for Students. London: Churchill Publishers
Snell, SR. (2004) Clinical Anatomy by Regions. Philadelphia: Lippincott Publishers
Marieb, E.N. (2004). Human Anatomy and physiology. London: Daryl Fox Publishers.
Young, B, et al. (2006). Wheater's Functional Histology: A Text and Colour Atlas: Churchill
Sadler, TW. (2009). Langman's Medical Embryology. Philadelphia: Lippincott Publishers

Cells and Tissues Read More »

Anatomy Introduction

BNS 111: Anatomy & Physiology - Introduction Notes

BNS 111: Anatomy & Physiology

SEMESTER I - Introduction

Key definitions and Levels of Organization

Alright, let's start with the very basics of studying the body. When we talk about Anatomy, we are talking about the **structure** of the body. Think of it like building a house – anatomy is looking at the bricks, the cement, how they are put together to form the walls, the roof, and all the rooms. It's about the physical parts and where they are located, their shape, size, and how they relate to each other. When we study anatomy, we can do it in different ways: Gross Anatomy is looking at structures you can see with your naked eye, like organs and muscles during dissection or on imaging scans. Microscopic Anatomy (also called Histology) is when we use a microscope to see the tiny details, like cells and tissues. Understanding the structure is the foundation for understanding how things work.

Now, Physiology is different. This is about how those parts *work*. So, if anatomy is the house structure, physiology is about how the plumbing system moves water, how the electrical wires carry power, or how the ventilation system brings in fresh air. It's the study of the **functions** of the body and its parts, explaining *how* they carry out their life-sustaining activities. Physiology often involves looking at complex chemical and physical processes happening at the cellular and organ system levels. Anatomy and physiology are always studied together because you can't really understand how something works if you don't know its structure, and knowing the structure gives you clues about the function. They are deeply interconnected, like two sides of the same coin.

To understand the complexity of the body better, we break it down into different levels of organization, starting from the smallest parts working together to form bigger, more complex ones. It's like looking at a city, then zooming into a neighborhood, then a specific building, then a room, and finally a single brick:

Chemical Level: This is the most basic level, involving atoms (like carbon, hydrogen, oxygen) and molecules (like water, proteins, carbohydrates, fats) that are essential for life. All the building blocks of the body are found here.
Cellular Level: These are the basic structural and functional units of all living organisms. Cells are made up of various molecules organized into structures called organelles within a cell membrane. They are like the single bricks in our house analogy – the smallest independent units that can carry out the basic processes of life, such as metabolism, growth, and reproduction. Examples include muscle cells, nerve cells (neurons), and blood cells. Each type of cell is specialized for a particular function that contributes to the body's overall activities.
Tissue Level: A group of similar cells (and their surrounding extracellular matrix) that work together to perform a specific function. Think of a wall made of many similar bricks joined by cement, providing structure or a barrier. There are four main types of tissues in the body, each with distinct roles:
- Epithelial Tissue: Covers body surfaces (like the epidermis of the skin), lines body cavities and hollow organs (like the lining of the stomach), and forms glands (like sweat glands). Its main functions are protection, absorption, secretion, and filtration.
- Connective Tissue: Provides support, connects different tissues and organs, stores energy (fat), and transports substances (blood). It's the most abundant tissue type in the body. Examples include bone, cartilage, blood, adipose tissue (fat), and ligaments.
- Muscle Tissue: Specialized for contraction, which produces movement. There are three types: Skeletal muscle (attached to bones, voluntary movement), Smooth muscle (in walls of internal organs like the stomach and blood vessels, involuntary movement), and Cardiac muscle (forms the heart, involuntary pumping).
- Nervous Tissue: The primary component of the nervous system (brain, spinal cord, nerves). It's composed of specialized cells called neurons that transmit electrical and chemical signals rapidly, and supporting cells called neuroglia. Nervous tissue allows for communication, coordination, and control of body activities.
Organ Level: Different types of tissues that are organized and work together to perform a more complex, specific function that none of the tissues could do alone. Like a whole room in our house analogy, combining walls (epithelial/connective tissue), floor (muscle tissue), and ceiling (nervous tissue) to create a functional space for living. The heart is a classic example of an organ, made of cardiac muscle tissue (for pumping), connective tissue (forming valves and covering), epithelial tissue (lining the chambers), and nervous tissue (regulating heart rate). The stomach, lungs, brain, and kidneys are other examples of organs.
Organ System Level: A group of organs that cooperate closely to perform a major, life-sustaining function for the body. The organs within a system often have related functions and work in a coordinated manner. For instance, the Digestive System includes the mouth, esophagus, stomach, intestines, liver, pancreas, and gallbladder – all working together to break down food, absorb nutrients, and eliminate waste. Other examples are the Respiratory System (breathing), Cardiovascular System (blood circulation), Nervous System (control and communication), and Musculoskeletal System (support, movement). The human body has 11 major organ systems that interact extensively with each other to maintain life.
Organismal Level: This is the highest level of organization – the complete living being (you or me!), made up of all the organ systems working together in a coordinated manner to maintain life, interact with the environment, grow, and reproduce. All the systems must communicate and cooperate effectively for the organism to survive and function as a healthy whole.

Another absolutely critical concept in physiology is Homeostasis. This is the body's incredible ability to maintain a stable internal environment despite external changes. Think of it as the body's "steady state" or balance. Factors like body temperature (around 37°C), blood sugar levels, blood pressure, blood pH (around 7.35-7.45), oxygen levels, and fluid balance need to stay within a narrow, healthy range for our cells and systems to function properly. The body constantly monitors these factors using sensory receptors and uses feedback mechanisms (primarily negative feedback loops) to detect deviations from the set point and initiate responses (like sweating when you're hot or shivering when you're cold, or releasing insulin to lower high blood sugar) to correct them and bring things back to balance. Maintaining homeostasis is fundamental for the normal functioning of every cell, tissue, and organ system, and ultimately, for survival. When homeostasis is significantly disrupted, either by internal or external factors, it can overwhelm the body's control systems and lead to illness and disease.

[Placeholder for a diagram showing the levels of structural organization: Chemical -> Cellular -> Tissue -> Organ -> Organ System -> Organism, with brief descriptions and maybe icons for each level. Show how each level builds upon the previous one.]

[Placeholder for a simple diagram illustrating the concept of homeostasis using a negative feedback loop example (e.g., regulation of body temperature or blood glucose). Show the sensor, control center, and effector.]

Branches and Approaches to Studying Anatomy

Anatomy is a huge field, and people study it in different ways depending on their focus. Think of it like studying Kampala – you could study the entire city from above (gross), or focus on the small details of specific buildings (microscopic), or how the city changes over time (developmental), or how pollution affects specific areas (pathological/environmental). Here are some important branches and approaches:

Gross Anatomy (or Macroscopic Anatomy): This is the study of body structures that are large enough to be seen with the naked eye, without using a microscope. When you look at organs like the heart, lungs, or bones during a dissection or on an X-ray, you are studying gross anatomy. It provides a big-picture understanding of the body's organization.
Within gross anatomy, there are common approaches to studying it:
- Regional Anatomy: Studying the body region by region. In this approach, all the structures in a specific area (like the upper limb, the head and neck, or the abdomen) are examined together – including bones, muscles, nerves, blood vessels, and organs – before moving on to the next region. This is how many anatomy courses are taught, as it's useful for clinical practice where problems often occur in specific regions.
- Systemic Anatomy: Studying the body system by system. Here, you focus on one organ system (like the skeletal system, the muscular system, or the cardiovascular system) and trace it throughout the entire body before studying the next system. This approach is good for understanding the overall function and distribution of a system.
- Surface Anatomy: The study of internal structures as they relate to the overlying skin surface. This is incredibly important for nurses and clinicians. It involves identifying anatomical landmarks on the body surface that correspond to underlying organs or structures. For example, feeling for a pulse in a specific spot helps you locate an underlying artery, or identifying bony prominences helps you know where to give an injection safely.
Microscopic Anatomy: This is the study of structures that are too small to be seen with the naked eye, requiring the use of a microscope.
Its main subdivisions are:
- Cytology: The study of cells. This involves examining the structure and function of individual cells and their components (organelles). Electron microscopes are often used for very high magnification to see ultrastructure.
- Histology: The study of tissues. This involves examining the organization and detailed structure of the four main tissue types (epithelial, connective, muscle, nervous) and how they form organs. Light microscopes are commonly used for this.
Developmental Anatomy: This branch studies the structural changes that occur in the body throughout the entire life span, from the fertilized egg to old age. It helps us understand how body structures form and develop.
Key periods within developmental anatomy include:
- Embryology: The study of the development of an individual from fertilization through the eighth week of gestation (the embryonic period). This is a period of rapid and significant structural formation.
- Ontogeny (or Ontogenesis): Refers to the origin and development of an organism from the fertilized egg all the way to its mature form, and even through aging (senescence). It's a broader term than embryology, covering the entire lifespan's structural changes.
Pathological Anatomy: Also known as Pathology, this is the study of structural changes (at the gross or microscopic level) caused by disease. Pathologists examine tissues and organs to diagnose illnesses.
Radiographic Anatomy: This involves studying the internal structure of the body using medical imaging techniques such as X-rays, CT (Computed Tomography) scans, MRI (Magnetic Resonance Imaging) scans, and ultrasound. This is essential for diagnosis in modern medicine.

[Placeholder for images illustrating different branches: e.g., a dissection image (Gross), a stained tissue slide under a microscope (Histology), an electron microscope image (Cytology/Ultrastructure), a fetal ultrasound image (Developmental/Embryology), a normal chest X-ray (Radiographic), a CT scan image]

[Placeholder for simple diagrams showing Regional vs. Systemic approaches to studying anatomy]

[Placeholder for an image illustrating surface anatomy, pointing out landmarks like bony prominences]

Concepts, Landmarks, and Body Divisions

When we study anatomy, especially when we need to describe the location of a structure, a wound, or a procedure, we need a standard starting point and a set of precise directions. Imagine trying to tell someone where a building is in Kampala without mentioning any roads or famous spots! In the body, we use a standard reference position called the Anatomical Position. This is the universally accepted posture used to describe locations and directions in the body. The person is standing upright, facing directly forward, feet flat on the floor and slightly apart, and arms hanging comfortably at the sides with the palms facing forward. The thumbs are pointing away from the body. This position is the baseline; even if a patient is lying down, sitting, or in a different posture, we still describe anatomical locations *as if* they were in the anatomical position. This consistency avoids confusion and ensures everyone is on the same page when communicating about a patient.

To precisely describe the position of one body part relative to another from the anatomical position, we use specific directional terms. These are like our anatomical compass and map, giving us clear ways to indicate relative locations:

Superior (or Cranial): Means towards the head end of the body or towards the upper part of a structure. Your head is superior to your neck. The brain is superior to the spinal cord.
Inferior (or Caudal): Means away from the head end or towards the lower part of a structure. Your feet are inferior to your knees. The stomach is inferior to the heart. ("Caudal" is sometimes used, meaning towards the tail, though less common for adult humans).
Anterior (or Ventral): Means towards the front of the body. Your breastbone (sternum) is anterior to your spine. Your tummy is anterior to your back. ("Ventral" refers to the belly side).
Posterior (or Dorsal): Means towards the back of the body. Your spine is posterior to your breastbone. Your shoulder blades are posterior to your chest. ("Dorsal" refers to the back side).
Medial: Means towards the midline of the body (an imaginary vertical line running down the exact center of the body). Your nose is medial to your eyes. The heart is medial to the lungs.
Lateral: Means away from the midline of the body, towards the sides. Your ears are lateral to your nose. Your arms are lateral to your chest.
Intermediate: Means between a more medial and a more lateral structure. For example, your collarbone (clavicle) is intermediate to your breastbone (sternum) and your shoulder joint.
Proximal: Used primarily for limbs or structures attached to the main body trunk; means closer to the point of attachment of the limb to the trunk or closer to the origin of a structure. Your elbow is proximal to your wrist. The knee is proximal to the ankle. The part of a blood vessel nearer to the heart is proximal to the part further away.
Distal: Used primarily for limbs or structures attached to the main body trunk; means further away from the point of attachment of the limb to the trunk or further from the origin of a structure. Your fingers are distal to your wrist. Your toes are distal to your ankle. The part of a blood vessel further from the heart is distal to the part nearer to it.
Superficial (or External): Means towards or at the body surface. Your skin is superficial to your muscles. A scratch affects superficial tissues.
Deep (or Internal): Means away from the body surface, more internal. Your bones are deep to your muscles. An organ like the kidney is deep within the abdominal cavity.
Ipsilateral: Refers to structures on the same side of the body (e.g., the right arm and the right leg are ipsilateral).
Contralateral: Refers to structures on the opposite side of the body (e.g., the right arm and the left leg are contralateral).

Anatomical landmarks are specific, easily identifiable points on the surface of the body or even internal structures that serve as reference points. These are super useful in healthcare for many reasons. For example, when giving injections, nurses use specific bony landmarks on the buttock or thigh to identify the safest site to administer medication and avoid nerves or blood vessels. When describing the location of a wound, rash, or pain, using nearby landmarks helps pinpoint the area precisely (e.g., "pain reported just inferior and lateral to the umbilicus"). Surgeons rely heavily on internal anatomical landmarks during operations to navigate within the body. Palpable bony points (like the tip of your elbow, your kneecap, or the front of your hip bone), prominent muscles, tendons, or even visible veins can serve as important landmarks. Learning these helps you orient yourself on the patient's body during assessment and procedures.

For descriptive purposes, the body is often divided into two main parts:

Axial Part: This includes the main axis of the body – the head, neck, and trunk. It forms the central core and contains the main body cavities.
Appendicular Part: This consists of the appendages, or limbs, which are attached to the body's axial part. It includes the upper limbs (arms, forearms, wrists, hands) and the lower limbs (thighs, legs, ankles, feet). These parts are primarily for movement and interaction with the environment.

[Placeholder for diagrams illustrating anatomical position and directional terms clearly marked on a body figure from different views (anterior, posterior, lateral). Similar to pages 17, 18, 25, 26, 27, 28 from the PDF.]

[Placeholder for diagrams showing examples of key anatomical landmarks on the body surface, maybe pointing to bony prominences or common injection sites. Similar to page 19 from the PDF.]

[Placeholder for a diagram illustrating the Axial and Appendicular parts of the body, perhaps highlighting them in different colors.]

Body Planes and Sections

When studying the internal structure of the body or looking at medical images like CT scans or MRIs, it's essential to be able to describe "slices" or cuts through the body. These cuts are made along imaginary flat surfaces called planes. Think of slicing a loaf of bread – each slice is a section made along a plane. The relationship between the plane and the resulting section is important: a section is named after the plane along which the cut is made. Understanding these planes helps us visualize 3D structures in 2D images. There are three standard anatomical planes that lie at right angles to each other:

Sagittal Plane: A vertical plane (running from front to back or back to front) that divides the body or an organ into **right and left parts**.
- Median Plane (or Midsagittal Plane): A specific sagittal plane that lies exactly in the midline of the body, dividing it into **equal** right and left halves. This plane passes through structures like the naval and the spine.
- Parasagittal Plane: Any sagittal plane that is offset from the midline, dividing the body into **unequal** right and left parts ("para" means near or beside).
A cut along a sagittal plane produces a sagittal section.
Frontal Plane (or Coronal Plane): A vertical plane (running from side to side) that divides the body or an organ into **anterior (front) and posterior (back) parts**. ("Coronal" refers to the crown of the head, aligning with the plane's orientation). Imagine slicing the body as if putting on a crown. A cut along a frontal plane produces a frontal (or coronal) section.
Transverse Plane (or Horizontal Plane or Cross-sectional Plane): A horizontal plane (running parallel to the ground) that divides the body or an organ into **superior (upper) and inferior (lower) parts**. These are often called cross-sections, like slicing a sausage. A cut along a transverse plane produces a transverse (or horizontal or cross) section.

These planes and sections are vital for interpreting medical images. When a doctor or nurse looks at a CT scan, they need to know if they are looking at a transverse section (a view as if you cut across the body horizontally), a frontal section (a view as if you cut front from back vertically), or a sagittal section (a view as if you cut side-to-side vertically) to correctly identify structures and understand their relationships in 3D space.

[Placeholder for a diagram clearly illustrating the Sagittal (Median and Parasagittal), Frontal (Coronal), and Transverse (Horizontal) planes on a body figure. Show the orientation of the cut for each plane. Similar to page 24 from the PDF.]

[Placeholder for images showing examples of Sagittal, Frontal, and Transverse sections of key body parts (like the brain or abdomen) from actual imaging scans (like CT or MRI) to show how planes are used in clinical practice.]

Body Cavities and Divisions

Within the body's trunk, there are large internal spaces called body cavities. These cavities are closed to the outside (except for some smaller ones we'll mention) and contain internal organs, providing them with protection, cushioning, and space to move (like the heart beating or the lungs expanding). They are typically lined by membranes. There are two major body cavities:

Dorsal Body Cavity: Located along the posterior (back) side of the body, within the bony skull and vertebral column. Its primary role is to protect the delicate and vital organs of the central nervous system. It has two continuous subdivisions:
- Cranial Cavity: Located within the skull (cranium), it houses and protects the brain.
- Vertebral Cavity (or Spinal Cavity): Runs within the bony vertebral column (spine) from the skull down to the pelvis, and it encloses and protects the spinal cord. The cranial and vertebral cavities are directly connected.
Ventral Body Cavity: Located along the anterior (front) side of the body. This is the larger of the two major cavities and is more anterior than the dorsal cavity. It houses a variety of internal organs involved in maintaining homeostasis, collectively called the viscera (singular: viscus) – these are the soft, internal organs within the body cavities. The ventral body cavity is separated into two major subdivisions by a large, dome-shaped muscle called the diaphragm, which is crucial for breathing:
- Thoracic Cavity: The superior (upper) subdivision of the ventral cavity, located within the rib cage (chest area). It is protected by the ribs, sternum, and vertebral column. The thoracic cavity is further subdivided internally by membranes:
  - Two Lateral Pleural Cavities: Each of these cavities surrounds and protects a lung. The space within the pleural cavity contains a small amount of fluid that reduces friction as the lungs expand and contract.
  - Mediastinum: This is the central compartment of the thoracic cavity, located between the two pleural cavities. It contains the Pericardial Cavity (which directly surrounds and encloses the heart), as well as other vital structures like the esophagus (the tube for food), trachea (the windpipe), major blood vessels (aorta, vena cavae), and lymph nodes.
- Abdominopelvic Cavity: The inferior (lower) subdivision of the ventral cavity, located below the diaphragm and extending down into the pelvis. This is the largest cavity. Although it's a single continuous space, it's conventionally divided into two regions for descriptive purposes:
  - Abdominal Cavity: The superior portion of the abdominopelvic cavity, located primarily within the abdominal wall. It contains many digestive organs (stomach, intestines, liver, gallbladder, pancreas), as well as the spleen and kidneys.
  - Pelvic Cavity: The inferior portion of the abdominopelvic cavity, located within the bony pelvis. It contains the urinary bladder, some reproductive organs (uterus, ovaries, prostate), and the rectum (the final part of the large intestine).
  Note that there isn't a physical barrier separating the abdominal and pelvic cavities, they are continuous.

In addition to these large, closed body cavities, there are several smaller body cavities, mostly located within the head. Many of these connect to the outside of the body:

Oral Cavity (Buccal Cavity or Mouth): The space inside the mouth, containing the teeth and tongue. It's the beginning of the digestive tract.
Nasal Cavity: Located within and posterior to the nose, separated into left and right halves by the nasal septum. It's part of the respiratory system and filters, warms, and moistens inhaled air.
Orbital Cavities (Orbits): These are bony sockets in the skull that house the eyes, along with muscles, nerves, and blood vessels associated with the eyes.
Middle Ear Cavities: Located within the temporal bone of the skull, just medial (towards the midline) to the eardrums. These small cavities contain the auditory ossicles (tiny bones – malleus, incus, stapes) that transmit sound vibrations from the eardrum to the inner ear.
Synovial Cavities: These are narrow spaces found within the capsules of freely movable joints (like the knee, elbow, shoulder). They are lined by a synovial membrane that secretes synovial fluid, which lubricates the joint and reduces friction between the articulating bones as they move. These cavities are NOT open to the outside of the body.

[Placeholder for a diagram showing the major body cavities (Dorsal - Cranial, Vertebral; Ventral - Thoracic, Abdominopelvic) and their subdivisions, with key organs labeled. Use different colors for the dorsal and ventral cavities. Similar to page 36 from the PDF.]

[Placeholder for a diagram showing the subdivisions of the Thoracic cavity (Pleural, Mediastinum, Pericardial) and the Abdominopelvic cavity (Abdominal, Pelvic).]

[Placeholder for a diagram showing the location of the smaller body cavities (Oral, Nasal, Orbital, Middle Ear, Synovial - perhaps showing a joint cross-section). Similar to page 40 from the PDF.]

Abdominopelvic Regions and Quadrants

Because the abdominopelvic cavity is so large and contains many different vital organs, it's essential for healthcare professionals to be able to pinpoint locations within it accurately. To do this, the cavity is commonly divided into smaller areas or compartments for easier reference and communication. There are two main division schemes used:

Nine Abdominopelvic Regions: This method provides a more detailed map of the abdominopelvic cavity and is used more often by anatomists for precise anatomical studies and by clinicians for more specific localization of symptoms or abnormalities. It involves drawing four imaginary lines on the anterior abdominal wall: two horizontal (transverse) planes and two vertical (sagittal or parasagittal) planes. These lines intersect to divide the cavity into nine distinct regions:
1. Right Hypochondriac Region: Located on the upper right side, just below the cartilage of the ribs (hypo = below, chondro = cartilage). Key organs here include the superior part of the liver, the gallbladder, and part of the right kidney.
2. Epigastric Region: Located in the upper central area, above the stomach (epi = above, gastro = stomach). Contains part of the stomach, the duodenum (first part of small intestine), part of the pancreas, and part of the liver. Pain here is common in conditions like gastritis or ulcers.
3. Left Hypochondriac Region: Located on the upper left side, below the cartilage of the ribs. Contains part of the stomach, the spleen, the tail of the pancreas, and part of the left kidney.
4. Right Lumbar Region: Located on the middle right side, near the waist (lumbus = loin or lower back). Contains the ascending colon (part of the large intestine) and part of the right kidney.
5. Umbilical Region: Located in the central area, surrounding the umbilicus (navel). Contains most of the small intestine and part of the transverse colon. Pain around the navel is common in early appendicitis or small intestine issues.
6. Left Lumbar Region: Located on the middle left side, near the waist. Contains the descending colon and part of the left kidney.
7. Right Iliac Region (or Right Inguinal Region): Located on the lower right side, near the groin (iliac = relating to the ilium, part of the hip bone; inguinal = relating to the groin). This region is particularly important as it contains the cecum (the beginning of the large intestine) and the appendix. Pain in this region is a classic sign of appendicitis.
8. Hypogastric Region (or Pubic Region): Located in the lower central area, below the umbilical region, just above the pubic bone. Contains the urinary bladder, the sigmoid colon (part of the large intestine), the rectum, and reproductive organs (uterus, ovaries in females; prostate, seminal vesicles in males).
9. Left Iliac Region (or Left Inguinal Region): Located on the lower left side, near the groin. Contains the sigmoid colon (part of the large intestine) and part of the descending colon. Pain here can indicate conditions like diverticulitis.
When documenting patient findings or communicating with other healthcare team members, referring to these specific regions provides a precise description of where a problem is located, which helps narrow down the potential cause.
Four Abdominal Quadrants: This is a simpler and more widely used division scheme among clinicians (like nurses and doctors) for a quick and general reference during physical examination and assessment. It involves drawing just two imaginary lines that intersect at the umbilicus: a horizontal line and a vertical line (the median plane). This divides the abdominopelvic cavity into four quadrants:
1. Right Upper Quadrant (RUQ): Contains the majority of the liver, the gallbladder, the right kidney, part of the pancreas, and parts of the small and large intestines.
2. Left Upper Quadrant (LUQ): Contains the stomach, the spleen, the left kidney, part of the pancreas, and parts of the small and large intestines.
3. Right Lower Quadrant (RLQ): Contains the appendix, parts of the small and large intestines, the right ovary and fallopian tube (in females), the right spermatic cord (in males), and part of the bladder and right ureter. Assessing for pain in the RLQ is a crucial part of checking for appendicitis.
4. Left Lower Quadrant (LLQ): Contains most of the small intestine, the descending colon, the sigmoid colon, the left ovary and fallopian tube (in females), the left spermatic cord (in males), and part of the bladder and left ureter.
When a patient complains of abdominal pain, asking them to point to the location helps the nurse or doctor quickly identify which quadrant is affected, which immediately suggests a list of possible organs involved and helps guide further assessment and diagnostic tests.

[Placeholder for a diagram illustrating the Nine Abdominopelvic Regions with their names and perhaps major organs located in each. Similar to page 43 (left side) from the PDF.]

[Placeholder for a diagram illustrating the Four Abdominal Quadrants with their abbreviations (RUQ, LUQ, RLQ, LLQ) and perhaps major organs located in each. Similar to page 45 from the PDF.]

Nomenclature in Human Anatomy and Medical Terminology

Learning anatomy and working in healthcare means learning a whole new language! We use a very precise set of terms, called anatomical nomenclature (for naming structures) and medical terminology (for terms related to diseases, procedures, etc.), to name and describe body structures, functions, conditions, and treatments. This system isn't just random names; it's a standardized international vocabulary, agreed upon by experts worldwide. This standardization, primarily based on ancient Greek and Latin words, is absolutely crucial for clear, unambiguous, and accurate communication among healthcare professionals worldwide – doctors, nurses, therapists, researchers, everyone. Imagine the chaos if every hospital or country used different names for the same body part or medical condition! If you say "brachial artery," any healthcare professional with anatomical training knows exactly that you are talking about the major artery located in the upper arm, running from the shoulder to the elbow, no matter what country they are from or what language they primarily speak. This precision in language is vital for patient safety, accurate documentation in patient charts, clear communication during handovers or emergencies, and effective teamwork in healthcare.

Many anatomical and medical terms might seem long and complicated at first, but they are often built like puzzles using root words, prefixes (small parts added at the beginning of a word), and suffixes (small parts added at the end of a word). Understanding these building blocks makes learning new terms much easier because you can often deduce the meaning of unfamiliar words by recognizing their components. Think of it like learning basic Swahili or Luganda word parts – knowing the meaning of the parts helps you understand the whole word! Here are some common examples of these word parts:

Root "cardio-" means heart (e.g., cardiology - the study of the heart and its diseases; cardiac - related to the heart; electrocardiogram - a record of the electrical activity of the heart).
Root "pulmo-" means lung (e.g., pulmonary - related to the lungs; pneumonia - inflammation of the lungs; pulmonologist - a doctor who specializes in the lungs).
Root "gastro-" means stomach (e.g., gastric - related to the stomach; gastritis - inflammation of the stomach; gastroscopy - visual examination of the stomach).
Root "nephro-" or "reno-" means kidney (e.g., nephrology - the study of the kidneys; renal artery - artery supplying the kidney; nephrectomy - surgical removal of a kidney).
Root "osteo-" means bone (e.g., osteocyte - a bone cell; osteoporosis - a condition of weak bones; osteomyelitis - inflammation of bone and bone marrow).
Root "myo-" means muscle (e.g., myocardium - heart muscle; myopathy - a disease of muscle; fibromyalgia - chronic muscle pain).
Root "hepato-" means liver (e.g., hepatitis - inflammation of the liver; hepatomegaly - enlargement of the liver).
Root "neuro-" means nerve or nervous system (e.g., neurology - the study of the nervous system; neuritis - inflammation of a nerve).
Prefix "hyper-" means above normal, excessive, or high (e.g., hypertension - high blood pressure; hyperglycemia - high blood sugar; hyperthyroidism - excessive thyroid hormone).
Prefix "hypo-" means below normal, deficient, or low (e.g., hypotension - low blood pressure; hypoglycemia - low blood sugar; hypothyroidism - deficient thyroid hormone).
Prefix "sub-" means under or below (e.g., subcutaneous - below the skin; subdural hematoma - collection of blood below the dura mater).
Prefix "inter-" means between (e.g., intercostal muscles - muscles between the ribs; intervertebral disc - disc between vertebrae).
Prefix "intra-" means within (e.g., intravenous - within a vein; intramuscular - within a muscle).
Suffix "-itis" means inflammation (e.g., appendicitis - inflammation of the appendix; arthritis - inflammation of a joint; bronchitis - inflammation of the bronchi).
Suffix "-ectomy" means surgical removal of an organ or part (e.g., appendectomy - surgical removal of the appendix; hysterectomy - surgical removal of the uterus; lobectomy - removal of a lobe).
Suffix "-ostomy" means surgically creating an opening (e.g., colostomy - creating an opening into the colon; tracheostomy - creating an opening into the trachea).
Suffix "-scopy" means visual examination using an instrument (e.g., endoscopy - visual examination inside the body; laparoscopy - visual examination of the abdominal cavity).
Suffix "-ology" means the study of (e.g., biology - the study of life; pathology - the study of disease; microbiology - the study of microorganisms).
Suffix "-oma" means tumor or swelling (e.g., carcinoma - a cancerous tumor; lipoma - a benign fatty tumor; hematoma - a collection of blood outside blood vessels).
Suffix "-pathy" means disease (e.g., neuropathy - disease of the nerves; cardiomyopathy - disease of the heart muscle).
Suffix "-algia" means pain (e.g., myalgia - muscle pain; neuralgia - nerve pain).

By dedicating time to learn these common roots, prefixes, and suffixes, you build a powerful vocabulary foundation that helps you understand and use anatomical and medical terms correctly and confidently. This precision in language is absolutely vital for patient safety, accurate diagnosis, clear communication within the healthcare team, and effective treatment in nursing practice. Make it a habit to break down new terms you encounter!

[Placeholder for a table or diagram showing common anatomical and medical prefixes, suffixes, and root words with their meanings and examples. This could be a really helpful visual tool, potentially using different colors or icons for prefixes, roots, and suffixes.]

Revision Questions: Introduction to Anatomy & Physiology

Test your understanding of the key concepts covered in this section:

Explain, in your own words, the difference between Anatomy and Physiology. Why is it important for a nursing student to study them together?
List and briefly describe the six main levels of structural organization in the human body, starting from the simplest (Chemical) to the most complex (Organismal). Give an example of a structure found at each level.
What is Homeostasis, and why is it a fundamental concept in physiology? Describe one example of how the body maintains homeostasis through a feedback mechanism, identifying the stimulus, receptor, control center, and effector.
Identify and briefly describe three different branches or approaches to studying anatomy (e.g., Gross, Microscopic, Developmental, Regional, Systemic, Radiographic). How might a nurse use knowledge gained from each of these branches in their practice?
Describe the anatomical position in detail. Explain why using the anatomical position and standardized directional terms is crucial for clear and unambiguous communication in healthcare, especially when documenting patient assessments or describing the location for procedures or surgery.
Using anatomical directional terms, describe the relative position of the following pairs of structures:
a) The stomach relative to the heart
b) The wrist relative to the elbow
c) The muscles relative to the skin
d) The lungs relative to the heart
e) The fingers relative to the wrist
f) The eyes relative to the nose
Name and briefly describe the two main structural divisions of the body. Which division primarily deals with movement and interaction with the external environment?
Explain the concept of anatomical planes. Name and describe the three standard anatomical planes (Sagittal, Frontal, Transverse) and how they each divide the body. Why is understanding these planes essential for interpreting medical images like CT scans or MRIs?
Identify and describe the two major body cavities (Dorsal and Ventral) and their main subdivisions (Cranial, Vertebral, Thoracic, Abdominopelvic). Name at least two organs found in the Thoracic cavity (excluding the heart and lungs) and two organs found in the Abdominopelvic cavity.
Explain the difference between the nine abdominopelvic regions and the four abdominal quadrants. When might a healthcare professional prefer to use the quadrant system over the region system? Name the abdominal quadrant where pain is most commonly associated with appendicitis.
Explain how understanding common anatomical and medical prefixes, roots, and suffixes can significantly help you learn and understand new medical terms. Provide three examples of medical terms not explicitly broken down in these notes and try to explain their possible meaning based on common word parts (you might need to look up the parts).
Briefly describe the location and function of Synovial cavities and explain how they differ from other body cavities like the Oral or Nasal cavities.

References for Introduction

Tortora, G.J. & Derickson N.,P. (2006) Principles of Anatomy and Physiology; Harper and Row
Drake, R, et al. (2007). Gray's Anatomy for Students. London: Churchill Publishers
Snell, SR. (2004) Clinical Anatomy by Regions. Philadelphia: Lippincott Publishers
Marieb, E.N. (2004). Human Anatomy and physiology. London: Daryl Fox Publishers.
Young, B, et al. (2006). Wheater's Functional Histology: A Text and Colour Atlas: Churchill
Sadler, TW. (2009). Langman's Medical Embryology. Philadelphia: Lippincott Publishers

Anatomy Introduction Read More »

PYELONEPHRITIS

The term “Pyelonephritis” originates from Greek:

“Pyelum” (or “Pyelos”) meaning renal pelvis.
“Nephros” meaning kidney.
“-itis” meaning inflammation.

Pyelonephritis is an inflammation of the kidney parenchyma (the functional tissue) and the renal pelvis (the collecting system).

It is fundamentally an upper urinary tract infection (UTI). It most commonly results from an ascending infection, where bacteria travel upwards from the lower urinary tract (bladder – cystitis, urethra – urethritis) to infect the kidney(s). Less commonly, it can result from hematogenous (bloodstream) spread from another infection site.

Epidemiology of Pyelonephritis

More common in females than males, largely due to anatomical factors (shorter urethra, proximity to the anus).
Incidence peaks in young, sexually active women, pregnant women, and older adults (often associated with comorbidities like BPH or neurogenic bladder).
Significant cause of morbidity and healthcare expenditure, including hospitalizations.

Pathophysiology of Pyelonephritis

Ascending Route (Most Common):

Colonization: Uropathogenic bacteria (most often from the fecal flora) colonize the periurethral area.
Urethral Ascent: Bacteria ascend the urethra into the bladder, often facilitated by factors like sexual intercourse or catheterization.
Bladder Multiplication: Bacteria multiply within the bladder (cystitis).
Vesicoureteral Reflux (VUR): Normally, the ureterovesical junction prevents urine backflow. If this mechanism is incompetent (due to congenital abnormality, inflammation, high bladder pressures, or obstruction), infected urine refluxes up the ureter(s) to the renal pelvis.
Intrarenal Reflux: Infected urine can then reflux further from the renal pelvis into the renal tubules, particularly at the poles of the kidney where papillae structure may be more permissive.
Parenchymal Invasion & Inflammation: Bacteria invade the renal interstitium, triggering an acute inflammatory response involving neutrophils, edema, and cytokine release. This leads to tubulointerstitial nephritis.

Hematogenous Route (Less Common):

Occurs when bacteria from another infected site (e.g., endocarditis, osteomyelitis) travel through the bloodstream and seed the kidneys.
Often associated with specific organisms (e.g., Staphylococcus aureus, Candida spp.) and may result in multiple small abscesses.
Bacterial Virulence Factors: Certain bacterial characteristics enhance their ability to cause pyelonephritis, e.g., P-fimbriae in E. coli promote adherence to uroepithelial cells.
Host Defense Mechanisms: Include flushing action of urine flow, urine pH and osmolality, anti-adherence factors (Tamm-Horsfall protein), secretory IgA, and the integrity of the ureterovesical junction. Impairment of these defenses increases risk.

Etiology (Causative Organisms)

Gram-Negative Bacteria (Most Common):

Escherichia coli (E. coli): Responsible for 75-95% of cases, especially community-acquired.
Proteus mirabilis: Often associated with kidney stones (struvite) due to urease production.
Klebsiella pneumoniae: More common in hospital-acquired or complicated cases.
Enterobacter spp.
Pseudomonas aeruginosa: Often seen in catheter-associated or recurrent infections.

Gram-Positive Bacteria (Less Common):

Staphylococcus saprophyticus: Particularly in young, sexually active women.
Enterococcus faecalis: More common in hospitalized patients or those with prior instrumentation.
Staphylococcus aureus: Suggests possible hematogenous spread.

Risk Factors of Pyelonephritis

Female Gender: Shorter urethra, proximity to rectum.
Urinary Tract Obstruction: Anything blocking urine flow increases stasis and risk of infection (e.g., kidney stones, benign prostatic hyperplasia (BPH), tumors, strictures, pregnancy-related compression).
Vesicoureteral Reflux (VUR): Especially important in children and chronic pyelonephritis.
Instrumentation: Urinary catheters, cystoscopy, surgery.
Sexual Activity: Particularly in women (increases risk of urethral colonization).
Pregnancy: Hormonal changes cause ureteral dilation and decreased peristalsis; mechanical compression by the uterus.
Neurogenic Bladder: Incomplete bladder emptying (e.g., spinal cord injury, spina bifida, multiple sclerosis).
Diabetes Mellitus: Impaired immune function, glucosuria (promotes bacterial growth), autonomic neuropathy affecting bladder emptying.
Immunosuppression: HIV/AIDS, chemotherapy, long-term steroid use, organ transplant recipients.
Congenital Abnormalities: Of the urinary tract.
Previous UTIs: History of recurrent infections.

Classification & Specific Types of Pyelonephritis

ACUTE PYELONEPHRITIS

This is characterized by acute inflammation of the parenchyma(core substance of the kidney/kidney tissue) and the pelvis of the kidneys, Characterized by a sudden onset of symptoms.

The disease may be bilateral or unilateral. This usually results from untreated bacterial cystitis and may be associated with pregnancy, trauma of the urinary bladder, and urinary obstruction Also Ascending and Descending infections.

Can range from mild, manageable outpatient cases to severe infections requiring hospitalization, potentially complicated by sepsis or abscess. Severity can be increased in the elderly, immunocompromised individuals (e.g., cancer, AIDS), or those with underlying structural abnormalities.

Morphology:

Gross Anatomy: Kidney(s) are often enlarged and swollen due to inflammation and edema. The capsule may be tense. On the cut section, characteristic yellowish, raised, discrete abscesses or streaks of pus may be visible on the cortical surface and extending into the medulla, often following the path of collecting ducts. The renal pelvis and calyces may show hyperemia (redness) and purulent exudate.
Microscopic Examination: Shows characteristic tubulointerstitial inflammation. Neutrophils infiltrate the interstitial tissue and accumulate within tubular lumens (forming pus casts). There is associated tubular necrosis and destruction. Glomeruli are typically spared initially, although surrounding inflammation can occur. Blood vessels usually show resistance to infection but can be involved in severe cases or vasculitis.

Clinical Features of Acute Pyelonephritis

Systemic Symptoms: Fever (often high-grade >38.5°C), chills, rigors, malaise, nausea, vomiting.
Localizing Symptoms: Flank pain or back pain (typically unilateral, localized to the costovertebral angle – CVA tenderness on examination is a key sign).
Lower UTI Symptoms (May or May Not be Present): Dysuria (painful urination), frequency, urgency. Absence doesn’t rule out pyelonephritis.
Urine: May appear cloudy or malodorous; hematuria (blood in urine) can occur.
Examination Findings: Fever, tachycardia, CVA tenderness. Abdominal tenderness may be present. Signs of dehydration. In severe cases, signs of sepsis (hypotension, altered mental status).
Laboratory Findings: Urinalysis typically shows pyuria (pus/WBCs), bacteriuria, often hematuria, mild proteinuria, and crucially, WBC casts (formed in tubules, indicating renal parenchymal involvement). Urine culture confirms the diagnosis and identifies the organism (>10^4 or >10^5 CFU/mL typically significant). Blood tests show leukocytosis (high WBC count) with a left shift (increased neutrophils), elevated inflammatory markers (ESR, CRP). Blood cultures should be drawn if sepsis is suspected (positive in 15-30% of cases).

Presentation; flunk tenderness,

fever, chills
Dysuria
Urgency
frequency

Complications of Acute Pyelonephritis

Papillary Necrosis: Ischemic necrosis of the renal papillae, more common in diabetics, those with obstruction, or sickle cell disease. Can lead to sloughing of papillae, obstruction, and worsening renal function.
Pyonephrosis: Pus collection within an obstructed renal collecting system, essentially converting the kidney into a sac of pus. Requires urgent drainage.
Perinephric Abscess: Collection of pus in the space surrounding the kidney, between the renal capsule and Gerota’s fascia. Often requires drainage (percutaneous or surgical).
Intrarenal Abscess: Abscess formation within the kidney parenchyma.
Sepsis/Urosepsis: Systemic inflammatory response syndrome (SIRS) due to infection originating in the urinary tract. Can lead to septic shock and multi-organ failure.
Emphysematous Pyelonephritis: A rare, life-threatening necrotizing infection characterized by gas formation within the kidney parenchyma. Often associated with diabetes and requires aggressive management, sometimes nephrectomy.
Renal Scarring: Can occur even after a single episode, especially if treatment is delayed or infection is severe.
Acute Kidney Injury (AKI): Temporary decline in kidney function due to infection and inflammation.

Chronic pyelonephritis

A chronic, ongoing, or recurrent inflammatory process leading to irreversible scarring of the renal parenchyma (specifically tubulointerstitial damage), and deformity of the pelvicalyceal system.

This occurs due vesicoureteral reflux ( back flow of urine from the bladder to the ureters allowing spread of infection upwards to the kidneys. The condition is also called reflux nephropathy(This can lead to kidney distention called Hydronephrosis)

It implies chronic tubulointerstitial disease resulting from repeated or persistent kidney infection, often superimposed on underlying structural abnormalities.

Etiopathogenesis: Usually arises from recurrent acute infections, often linked to:

Chronic Obstructive Pyelonephritis: Persistent or recurrent obstruction (stones, BPH, tumors, congenital anomalies like posterior urethral valves) leads to urinary stasis, predisposing to infection and increased pressure, which damages the kidney over time. Obstruction can be unilateral or bilateral.
Reflux Nephropathy (Reflux Pyelonephritis): Chronic vesicoureteral reflux (VUR), often congenital, allows repeated episodes of infected urine reaching the kidney parenchyma, particularly during voiding (micturition). This is a major cause, especially in children, leading to characteristic polar scarring. Infection superimposed on reflux causes the damage.

Morphology:

Gross Anatomy: Kidney(s) are often small and contracted (atrophic). Scarring is typically irregular and asymmetric (unlike the diffuse, symmetrical scarring of vascular disease like nephrosclerosis). Scars are often broad, flat-based, depressed areas overlying deformed, dilated (blunted) calyces, particularly at the upper and lower poles (characteristic of reflux). The capsule may be adherent to the cortex over scarred areas. The renal pelvis may be dilated and thickened.
Microscopic Examination: Shows patchy interstitial fibrosis and chronic inflammation (lymphocytes, plasma cells, sometimes macrophages). There is marked tubular atrophy in scarred areas. Some remaining tubules may become dilated and filled with pink, homogenous colloid-like material (thyroidization – resembling thyroid follicles). Periglomerular fibrosis and eventual glomerulosclerosis occur. Arteriosclerosis (thickening of blood vessel walls) is common.

Clinical Features:

Often insidious onset; patients may be asymptomatic for long periods or present late with complications.
Recurrent UTIs (may be subtle).
Vague symptoms: Flank pain (less severe than acute), malaise, low-grade fever, fatigue, decreased appetite, unintentional weight loss.
Signs of infection (fever, pyuria, bacteriuria) may be present during acute exacerbations.
Hypertension: Often develops as a consequence of renal scarring and renin-angiotensin system activation.
Progressive loss of renal function: Leading to Chronic Kidney Disease (CKD) and eventually end-stage renal disease (ESRD).
Polyuria and nocturia (due to impaired tubular concentrating ability).
Proteinuria (usually mild to moderate, reflecting tubular and glomerular damage).

It clinical presents with

bacteriuria,
hypertension,
flunk tenderness,
septic shock,
dizziness fainting and signs of renal insufficiency

Diagnosis: Often suggested by imaging findings (ultrasound, CT, IVP – historically) showing small, scarred kidneys with blunted calyces and cortical thinning, especially if asymmetric or polar. Urinalysis may show pyuria, bacteriuria (especially during exacerbations), proteinuria. Renal function tests (creatinine, BUN, GFR) assess the degree of CKD. Voiding cystourethrogram (VCUG) can identify VUR.

Diagnosis (General Approach)

History: Symptoms (fever, chills, flank pain, dysuria, frequency, urgency, nausea/vomiting), duration, previous UTIs, risk factors (diabetes, stones, VUR history, pregnancy, catheter use, immunosuppression).

Physical Examination: Vital signs (fever, tachycardia, hypotension?), CVA tenderness assessment, abdominal examination (tenderness, masses).

Laboratory Examination:

Urinalysis (UA): Key initial test. Look for:

Leukocyte esterase (positive suggests pyuria)
Nitrites (positive suggests Enterobacteriaceae)
White Blood Cells (WBCs) / Pyuria (>10 WBCs/hpf or per mm³)
Red Blood Cells (RBCs) / Hematuria
Bacteria
WBC Casts: Highly suggestive of renal parenchymal involvement (pyelonephritis) vs. lower UTI.
Proteinuria (usually mild)

Urine Dipstick Test: Rapid screening tool for leukocyte esterase and nitrites. Useful but less sensitive/specific than microscopy. A negative test in a symptomatic patient (especially pregnant women) does not rule out infection; microscopy and culture are needed.

Urine Culture & Sensitivity: Essential to confirm bacteriuria, identify the causative organism, and determine antibiotic susceptibility.

Culture Criteria: Colony counts >10^5 CFU/mL are traditionally considered significant, but lower counts (e.g., >10^4 or even >10^3 CFU/mL) can be significant in symptomatic patients, especially if pyuria is present. Specific criteria can vary (e.g., >10^2 CFU/mL in women with dysuria/pyuria, >10^3 CFU/mL in men).

Blood Tests:

Complete Blood Count (CBC): Shows leukocytosis with neutrophilia (left shift). Anemia may be present in chronic cases (XGP, CKD).
Basic Metabolic Panel (BMP): Assesses renal function (BUN, Creatinine) and electrolytes. Important for drug dosing and assessing severity (AKI).
Inflammatory Markers: C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR) are elevated.
Blood Cultures: Obtain in hospitalized patients or if sepsis is suspected

Imaging: Not always required for uncomplicated acute pyelonephritis in women responding to therapy. Indicated for:

Severe illness or suspected sepsis
Lack of clinical improvement after 48-72 hours of appropriate antibiotics
Suspected complications (obstruction, abscess, pyonephrosis, emphysematous pyelonephritis)
Recurrent pyelonephritis
Atypical presentation or diagnostic uncertainty
Male patients (higher likelihood of underlying abnormality)
Known urinary tract abnormalities
Renal Ultrasound (US): Good initial modality. Can detect hydronephrosis (suggesting obstruction), stones, large abscesses, pyonephrosis. May show kidney enlargement or altered echogenicity in acute pyelonephritis, but can be normal. Useful in pregnancy.

Computed Tomography (CT) Scan: More sensitive and specific, especially contrast-enhanced CT. Considered the gold standard for evaluating complicated pyelonephritis. Can show:

Focal or diffuse areas of decreased enhancement (inflammation/edema)
Striated nephrogram
Abscesses (perinephric, intrarenal)
Gas (emphysematous pyelonephritis)
Obstruction (stones, masses)
Scarring and caliectasis (chronic pyelonephritis)
Findings suggestive of XGP (enlarged kidney, low-density masses, central stone).

Intravenous Pyelography (IVP): Largely replaced by CT/US, but historically used. Shows pelvicalyceal system anatomy, can detect obstruction, scarring (blunted calyces).

Voiding Cystourethrogram (VCUG): Used primarily in children or selected adults to diagnose VUR.

Nuclear Renal Scan (DMSA scan): Can detect acute inflammation (photopenic defects) and quantify differential renal function and scarring, particularly useful in pediatric reflux nephropathy assessment.

Management of Pyelonephritis

Aims of management:

Eradicate the infection.
Relieve symptoms (pain, fever).
Prevent complications (sepsis, abscess, renal damage).
Identify and address any underlying structural or functional abnormalities.

General Measures:

Hydration: Encourage adequate fluid intake (oral or intravenous) to maintain urine flow, unless contraindicated.
Analgesia: Pain relief with acetaminophen or NSAIDs (use NSAIDs cautiously if renal function is impaired). Opioids may be needed for severe pain.
Antipyretics: For fever control (e.g., acetaminophen).

Antibiotic Therapy: Cornerstone of treatment.

Empiric Therapy: Initial antibiotic choice based on likely pathogens, local resistance patterns, severity of illness, patient factors (allergies, comorbidities, pregnancy, prior antibiotic use), and whether treatment is inpatient or outpatient.

Outpatient (Mild-Moderate, Non-pregnant, Able to tolerate PO): Oral fluoroquinolones (ciprofloxacin, levofloxacin – use declining due to resistance/side effects), Trimethoprim-sulfamethoxazole (TMP-SMX – if local resistance <20%), oral cephalosporins (e.g., cefpodoxime, cefixime), or sometimes an initial IV dose (e.g., ceftriaxone, gentamicin) followed by oral therapy.
Inpatient (Severe illness, Sepsis, Unable to tolerate PO, Pregnant, Comorbidities, Suspected resistance): Intravenous antibiotics initially. Options include fluoroquinolones, extended-spectrum cephalosporins (ceftriaxone, cefepime), aminoglycosides (gentamicin, tobramycin – often in combination initially for broad coverage, requires monitoring), piperacillin-tazobactam, carbapenems (meropenem, ertapenem – reserved for suspected highly resistant organisms or severe sepsis).

Tailored Therapy: Adjust antibiotics once culture and sensitivity results are available to the narrowest-spectrum, effective agent.
Duration: Typically 7-14 days for acute pyelonephritis. Longer courses may be needed for complicated cases, bacteremia, or slow response. Fluoroquinolones may allow shorter courses (5-7 days) in some uncomplicated cases. TMP-SMX often requires 14 days.

Hospitalization Criteria:

Severe illness (high fever, intractable vomiting, dehydration, hemodynamic instability, sepsis).
Inability to maintain hydration or take oral medications.
Pregnancy.
Significant comorbidities (diabetes, immunosuppression, known renal disease).
Suspected urinary tract obstruction or complication (abscess).
Diagnostic uncertainty.
Failure of outpatient therapy.
Social factors precluding safe outpatient management.

Management of Complications:

Obstruction: Requires relief (e.g., ureteral stent, percutaneous nephrostomy tube).
Abscess/Pyonephrosis: Often requires percutaneous or surgical drainage in addition to antibiotics.
Emphysematous Pyelonephritis: Aggressive medical management, often requires urgent nephrectomy or drainage.

Follow-up:

Monitor clinical response closely. Improvement expected within 48-72 hours.
Repeat urine culture after treatment completion may be considered in some cases (e.g., pregnancy, recurrent infections) to ensure eradication, but not routinely necessary for uncomplicated cases with resolution of symptoms.
Investigate for underlying causes (stones, obstruction, VUR) in patients with recurrent pyelonephritis, males, children, or atypical features.

Nursing Care & Interventions

Risk for Infection related to the presence of bacteria in the kidneys:

Assessment: Monitor vital signs frequently (temperature, heart rate, blood pressure, respiratory rate) – especially temperature every 4 hours initially. Report temperature >38.5°C or signs of sepsis promptly. Assess for worsening flank pain, changes in urine characteristics (color, odor, clarity, presence of blood/pus).

Interventions:

Administer antibiotics as prescribed, on time, ensuring correct route and dose.
Monitor response to antibiotics (defervescence, symptom improvement).
Monitor urine culture and sensitivity results and collaborate with medical team regarding antibiotic adjustments.
Encourage fluid intake (2-3 liters/day unless contraindicated) to promote urinary flow and flushing of bacteria. Monitor intake and output accurately.
Instruct patient on proper perineal hygiene (wiping front to back for females).
Provide perineal care, especially if incontinent or bedridden, keeping the area clean and dry to prevent ascending infection.
Instruct patient to empty bladder completely and regularly (every 2-4 hours) to prevent urine stasis and bladder distension.
Maintain sterile technique for any urinary catheterization or instrumentation. Provide routine catheter care if indwelling catheter is present. Advocate for catheter removal as soon as possible.
Educate patient on signs/symptoms of worsening infection or recurrence to report.

Rationale: Early detection of deterioration (fever spike, sepsis signs) allows prompt intervention. Adequate hydration helps flush bacteria. Proper hygiene and complete bladder emptying reduce bacterial load and stasis. Monitoring response ensures treatment effectiveness.

Acute Pain related to inflammation and infection of the kidney:

Assessment: Assess pain intensity (using a standardized scale like 0-10), location (flank, back, abdomen), quality (aching, sharp, colicky), and factors that aggravate or relieve it. Assess for CVA tenderness. Monitor non-verbal pain cues.

Interventions:

Administer analgesics (acetaminophen, NSAIDs cautiously, opioids if severe) as prescribed and assess effectiveness.
Provide comfort measures (positioning, back rub if tolerated, quiet environment).
Encourage adequate rest periods to reduce metabolic demands and promote comfort. Balance rest with activity levels that can be tolerated to prevent complications of immobility.
Encourage fluid intake (can sometimes help dilute inflammatory mediators).
Reassure patient that pain should decrease as the infection is treated.
Educate on non-pharmacological pain relief techniques (relaxation, distraction).

Rationale: Accurate pain assessment guides management. Analgesics block pain pathways. Rest reduces muscle tension and conserves energy. Treating the underlying infection is key to resolving the inflammatory pain.

Risk for Deficient Fluid Volume related to fever, nausea, vomiting, decreased intake:

Assessment: Monitor intake and output strictly. Assess for signs of dehydration (dry mucous membranes, poor skin turgor, tachycardia, hypotension, decreased urine output, concentrated urine). Monitor daily weights if indicated.

Interventions: Encourage oral fluid intake. Administer IV fluids as prescribed if unable to tolerate oral intake or significantly dehydrated. Administer antiemetics as needed for nausea/vomiting. Provide frequent oral care.

Rationale: Maintaining hydration is crucial for renal perfusion, flushing bacteria, and overall physiological stability.

Deficient Knowledge related to condition, treatment, and prevention:

Assessment: Assess patient’s understanding of pyelonephritis, its causes, treatment plan, potential complications, and prevention strategies.

Interventions: Explain the disease process in simple terms. Educate on the importance of completing the full course of antibiotics, even if feeling better. Teach signs/symptoms of recurrence or complications to report. Discuss prevention strategies (see below). Explain rationale for prescribed medications, fluid intake, and follow-up.

Rationale: Patient understanding promotes adherence to treatment and empowers self-care and prevention.

Prevention

General Measures:

Adequate Fluid Intake: Maintain good hydration daily to promote regular flushing of the urinary tract.
Proper Hygiene: Females wipe front to back after urination and bowel movements.
Voiding Habits: Void regularly, especially after sexual intercourse (females). Avoid delaying urination. Ensure complete bladder emptying.

Specific Measures:

Treat Lower UTIs Promptly: Prevent ascension.
Manage Underlying Conditions: Control diabetes, treat BPH, manage neurogenic bladder, treat/remove kidney stones, surgically correct significant VUR or obstruction.
Probiotics/Cranberry: Consuming blueberry/cranberry juice or products, and fermented milk products containing probiotic bacteria (e.g., Lactobacillus) may help inhibit bacterial adherence and reduce UTI recurrence in some individuals, but evidence is mixed and should not replace standard medical care or prevention strategies. Discuss with healthcare provider.
Antibiotic Prophylaxis: Low-dose antibiotics may be considered for individuals with frequent, recurrent UTIs/pyelonephritis, especially if associated with sexual activity or known structural issues, but benefits must outweigh risks (resistance, side effects).
Avoid Catheterization: When possible, or remove catheters as soon as medically feasible. Use strict aseptic technique during insertion and care.

Prognosis

Acute Pyelonephritis: Generally good with prompt and appropriate antibiotic treatment. Most patients recover fully without long-term renal damage. However, prognosis is worse with delayed treatment, severe sepsis, underlying complications (obstruction, abscess), resistant organisms, or in patients with significant comorbidities or immunosuppression.
Chronic Pyelonephritis: Prognosis depends on the underlying cause, extent of scarring, presence of hypertension, and degree of renal impairment at diagnosis. Can lead to progressive CKD and ESRD over time. Managing the underlying cause (e.g., correcting VUR/obstruction) and controlling blood pressure are crucial.

Summary / Key Takeaways

Pyelonephritis is an infection of the kidney parenchyma and pelvis, usually ascending from the lower urinary tract.
E. coli is the most common pathogen.
Risk factors include female sex, obstruction, VUR, instrumentation, pregnancy, diabetes, and immunosuppression.
Acute pyelonephritis presents with fever, chills, flank pain, CVA tenderness, and often lower UTI symptoms. WBC casts in urinalysis are highly suggestive.
Chronic pyelonephritis results from recurrent infection/inflammation leading to scarring, often related to obstruction or reflux, and can cause CKD and hypertension.
Diagnosis relies on clinical presentation, urinalysis (pyuria, bacteriuria, WBC casts), urine culture, and often imaging (US or CT) for complicated cases or diagnostic uncertainty.
Management involves antibiotics (empiric then tailored), hydration, analgesia, and addressing underlying causes or complications (obstruction, abscess).
Prompt treatment is crucial to prevent complications like sepsis, abscess, papillary necrosis, and renal scarring.
Nursing care focuses on monitoring, administering treatment, managing pain and fluids, preventing complications, and patient education.
Prevention strategies target hygiene, voiding habits, fluid intake, and managing underlying risk factors.

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