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Atoms, molecules and compounds

Module Unit CN-111: Anatomy and Physiology (I)

Contact Hours: 60

Module Unit Description: Introduces students to the anatomy and physiology of the human body, covering the structure and function of different body parts and systems, specifically skeletal, muscular, circulatory, and digestive systems.

Learning Outcomes for this Unit:

By the end of this unit, the student shall be able to:

  • Identify various parts of the human body and their functions.
  • Differentiate the normal structure and functioning of various systems from that of abnormal conditions of the skeletal, muscular, cardiovascular and digestive systems.

Topic: Introduction to Anatomy and Physiology (Part 2)

Atoms, molecules and compounds

Everything around us, including our bodies, is made up of tiny particles. Let's look at these basic chemical components.

  • Atoms: These are the smallest particles of an element. An element is a pure substance like oxygen, hydrogen, or carbon. Atoms are extremely small. Inside an atom, there's a central nucleus (like the sun in our solar system). The nucleus contains positively charged particles called protons and particles with no charge called neutrons. Tiny, negatively charged particles called electrons orbit around the nucleus. In a neutral atom, the number of protons and electrons is equal, so the positive and negative charges balance out.
  • Molecules: When two or more atoms are joined together by a strong link called a chemical bond, they form a molecule. If the molecule is made of atoms from the same element (like O₂, two oxygen atoms joined), it's just a molecule of that element. If the molecule is made of atoms from different elements joined together (like H₂O, two hydrogen atoms and one oxygen atom joined), it's called a compound. Water is a compound. Many substances in the body are compounds.
  • Chemical Bonds: The links that hold atoms together in molecules are chemical bonds. They are formed by the electrons in the outer part of the atoms.
    • Covalent bonds: Atoms share electrons to become more stable. These bonds are often strong and create stable molecules like water.
    • Ionic bonds: Electrons are transferred from one atom to another. This creates electrically charged atoms called ions (e.g., sodium atom loses an electron and becomes a positive sodium ion, Na⁺; chlorine atom gains an electron and becomes a negative chloride ion, Cl⁻). These charged ions are attracted to each other, forming an ionic bond.
  • Electrolytes: When ionic compounds (like sodium chloride, NaCl, which is table salt) dissolve in water, they separate into their positive and negative ions (Na⁺ and Cl⁻). These ions in water can conduct electricity. In the body, these ions are called electrolytes and are very important for nerve signals, muscle contraction, and balancing fluids.

(A simple diagram of an atom showing a nucleus with protons and neutrons, and electrons orbiting it.)

Cell structure and its functions

Cell: Cell is the basic living structural and functional unit of the body, and the study of cells is called Cytology.

  • Cell membrane: This separates the cells from their external environment. Cell membrane also protects the cell from injury.
  • Cytoplasm: This is the substance that surrounds the organelles and is located between the nucleus and the plasma membrane. This contains raw materials and provides these raw materials to cell organelles for their normal functioning.
  • Nucleus: This is usually the largest organelle and is often found near the center of the cell. It's the control center. It contains the cell's genetic material (DNA), organized into structures called chromosomes. The DNA contains the instructions for all the cell's activities, like making proteins and dividing. The nucleus is surrounded by a nuclear envelope (a membrane with pores).
  • Organelles (The Cell's "Machines"): These are small structures within the cytoplasm, each doing a specific job:
    • Mitochondria: Often called the "powerhouses" of the cell. They perform a process called aerobic respiration, using oxygen to convert sugar and fats into energy (ATP). Cells that need a lot of energy (like muscle cells) have many mitochondria.
    • Ribosomes: Tiny structures that are the sites of protein synthesis. They read instructions from the nucleus (carried by mRNA) and assemble amino acids into proteins. Some are free in the cytoplasm, others are attached to the ER.
    • Endoplasmic Reticulum (ER): A network of interconnected membranes that extends throughout the cytoplasm. Rough ER: Has ribosomes attached and is involved in making proteins that will be sent outside the cell or to other organelles. Smooth ER: Involved in making fats and steroids, and detoxifying harmful substances like drugs.
    • Golgi Apparatus: Modifies, sorts, and packages proteins and fats made in the ER. It prepares them for transport out of the cell or to other parts of the cell. Think of it as the cell's "packaging and shipping department."
    • Lysosomes: Contain powerful enzymes that break down waste materials, old organelles, bacteria, and other foreign invaders. They are like the cell's "recycling and waste disposal center."
    • Cytoskeleton: A network of protein fibres that provides support for the cell, helps maintain its shape, and is involved in cell movement and moving organelles within the cell.

Tissue structure and function

TISSUE Cells are highly organized units. But in multi-cultural organisms, they don’t function alone. They work together in groups of similar cells called tissues. A tissue is a group of similar cell and their inter-cellular substance that have the similar embryological origin and they function together to perform a specialized activity. The study of tissues or a science that deals with the study of tissues is called Histology

Tissues are classified according to their structure and their function:

  • Epithelial tissue
  • Connective tissue
  • Muscle tissue
  • Nervous tissue

Epithelial Tissue

Epithelial tissues cover body surfaces, lines the body cavities and ducts and form glands. They are subdivided into:

  • – Covering & lining epithelium
  • – Glandular epithelium

Covering and lining epithelium:

This forms the outer covering of the external body surface and outer covering of some internal organs. It lines body cavity, interior of respiratory and gastrointestinal tracts, blood vessels and ducts and make up along with the nervous tissue (the parts of sense organs for smell, hearing, vision and touch). This is a tissue from which gametes (egg and sperm) develop from.

Covering and lining epithelium are classified based on the arrangement of layers and cell shape.

According to the arrangement of layers covering and lining epithelium is grouped into:

  • a) Simple epithelium: This is specialized for absorption, and filtration with minimal wear and tear. It is a single layered.
  • b) Stratified epithelium: This is many layered and found in an area with high degree of wear and tear.
  • c) Pseudo-stratified: This is a single layered but seam to have many layer.

Based on the cell shape covering and lining the epithelium, is grouped into:

  • a) Squamous Epithelium: – These are flattened and scale like
  • b) Cuboidal Epithelium: – These are cube shaped
  • c) Columnar Epithelium: – These are tall and cylindrical
  • d) Transitional Epithelium: – These are combinations of cell shape found where there is a great degree of distention or expansion, these may be cuboidal to columnar, cuboidal to polyhedral and cuboidal to Squamous

Therefore considering the number of layers and cell shape we can classify covering and lining epithelium in to the following groups:

Simple epithelium:

  • a) Simple – Squamous epithelium:, contain single layer of flat, scale like resemble tiled floor. It is highly adapted to diffusion, osmosis & filtration. Thus, it lines the air sacs of lung, in kidneys, blood vessels and lymph vessels.
  • b) Simple – cuboidal epithelium:, Flat polygon that covers the surface of ovary, lines the anterior surface of lens of the eye, retina & tubules of kidney
  • c) Simple – columnar epithelium:, Similar to simple cuboidal. It is modified in several ways depending on location & function. It lines the gastro-intestinal tract gall bladder, excretory ducts of many glands. It functions in secretions, absorption, protection & lubrication.

Stratified epithelium: It is more durable, protects underlying tissues form external environment and from wear & tear.

  • a) Stratified Squamous epithelium: In this type of epithelium, the outer cells are flat. Stratified squamous epithelium is subdivided in to two based on presence of keratin. These are Non-Keratinized and Keratinized stratified squamous epithelium. Non-Keratinized stratified squamous epithelium is found in wet surface that are subjected to considerable wear and tear. Example: – Mouth, tongue and vagina. In Keratinized stratified squamous epithelium the surface cell of this type forms a tough layer of material containing keratin. Example: skin. Keratin, is a waterproof protein, resists friction and bacterial invasion.
  • b) Stratified cuboidal epithelium:, rare type of epithelium. It is found in seat glands duct, conjunctiva of eye, and cavernous urethra of the male urogenital system, pharynx & epiglottis. Its main function is secretion.
  • c) Stratified columnar epithelium:, uncommon to the body. Stratified columnar epithelium is found in milk duct of mammary gland & anus layers. It functions in protection and secretion.

Transitional epithelium: The distinction is that cells of the outer layer in transitional epithelium tend to be large and rounded rather than flat. The feature allows the tissue to be stretched with out breakage. It is found in Urinary bladder, part of Ureters & urethra.

Pseudo stratified epithelium: Lines the larger excretory ducts of many glands, epididymis, parts of male urethra and auditory tubes. Its main function is protection & secretion.

Glandular Epithelium

Their main function is secretion. A gland may consist of one cell or a group of highly specialized epithelial cell. Glands can be classified into exocrine and endocrine according to where they release their secretion.

  • Exocrine: Those glands that empties their secretion in to ducts/tubes that empty at the surface of covering. Their main products are mucous, oil, wax, perspiration and digestive enzyme. Sweat & salivary glands are exocrine glands.
  • Endocrine: They ultimately secret their products into the blood system. The secretions of endocrine glands are always hormones. Hormones are chemicals that regulate various physiological activities. Pituitary, thyroid & adrenal glands are endocrine.

Classification of exocrine glands

They are classified by their structure and shape of the secretary portion. According to structural classification they are grouped into:

  • Unicellular gland: Single celled. The best examples are goblet cell in Respiratory, Gastrointestinal & Genitourinary system.
  • Multicultural gland: Found in several different forms. By looking in to the secretary portion, exocrine glands are grouped into
    • (a) Tubular gland: If the secretary portion of a gland is tubular.
    • (b) Acinar gland: If the secretary portion is flask like.
    • (c) Tubulo-acinar: if it contains both tubular & flask shaped secretary portion.

Connective tissue

Connective tissues of the body are classified into embryonic connective tissue and adult connective tissue.

Embryonic connective tissue:

Embryonic connective tissue contains mesenchyme & mucous connective tissue. Mesenchyme is the tissue from which all other connective tissue eventually arises. It is located beneath the skin and along the developing bone of the embryo. Mucous (Wharton’s Jelly) connective tissue is found primarily in the fetus and located in the umbilical cord of the fetus where it supports the cord.

Adult connective tissue: It is differentiated from mesenchyme and does not change after birth. Adult connective tissue composes connective tissue proper, cartilage, osseous (bone) & vascular (blood) tissue

  • a) Connective tissue proper:, connective tissue proper has a more or less fluid intercellular martial and fibroblast. The various forms of connective tissue proper are:
    • • Loose (areolar) connectives tissue:, which are widely distributed and consists collagenic, elastic & reticular fibers and several cells embedded in semi fluid intercellular substances. It supports tissues, organ blood vessels & nerves. It also forms subcutaneous layer/superficial fascia/hypodermis.
    • • Adipose tissue: It is the subcutaneous layer below the skin, specialized for fat storage. Found where there is loose connective tissue. It is common around the kidney, at the base and on the surface of the heart, in the marrow of long bone, as a padding around joints and behind the eye ball. It is poor conductor of heat, so it decrease heat loss from the body
    • • Dense (Collagenous) connective tissue: Fibers are closely packed than in loose connective tissue. Exists in areas where tensions are exerted in various directions. In areas where fibers are interwoven with out regular orientation the forces exerted are in many directions. This occurs in most fascia like deeper region of dermis, periosteum of bone and membrane capsules. In other areas dense connective tissue adapted tension in one direction and fibers have parallel arrangement. Examples are tendons and ligaments. Dense connective tissues provide support & protection and connect muscle to bone.
    • • Elastic connective tissue: Posses freely branching elastic fibers. They stretch and snap back in to original shape. They are components of wall of arteries, trachea, bronchial tubes & lungs. It also forms vocal cord. Elastic connective tissue allows stretching, and provides support & suspension.
    • • Reticular connective tissue: Lattice of fine, interwoven threads that branch freely, forming connecting and supporting framework. It helps to form a delicate supporting stoma for many organs including liver, spleen and lymph nodes. It also helps to bind together the fibers (cells) of smooth muscle tissue.
  • b) Cartilage: Unlike other connective tissue, cartilages have no blood vessels and nerves. It consists of a dense network of collagenous fibers and elastic fibers firmly embedded in chondroitin sulfate. The strength is because of collagenous fibers. The cells of a matured cartilage are called chondrocyte. The surface of a cartilage is surrounded by irregularly arranged dense connective tissue called perichondrium. Cartilages are classified in to hyaline, fibro and elastic cartilage.
    • Hyaline cartilage is called gristle, most abundant, blue white in color & able to bear weight. Found at joints over long bones as articular cartilage and forms costal cartilage (at ventral end of ribs). It also forms nose, larynx, trachea, bronchi and bronchial tubes. It forms embryonic skeleton, reinforce respiration, aids in free movement of joints and assists rib cage to move during breathing.
    • Fibro cartilage: they are found at the symphysis pubis, in the inter-vertebral discs and knee. It provides support and protection.
    • Elastic cartilage: in elastic cartilage the chondrocyte are located in thread like network of elastic fibers. Elastic cartilage provides strength and elasticity and maintains the shape of certain organs like epiglottis, larynx, external part of the ear and Eustachian tube.
  • c) Osseous tissue (Bone): The matured bone cell osteocytes, embedded in the intercellular substance consisting mineral salts (calcium phosphate and calcium carbonate) with collagenous fibers. The osseous tissue together with cartilage and joints it comprises the skeletal system.
  • d) Vascular tissue (Blood tissue): It is a liquid connective tissue. It contains intercellular substance plasma. Plasma is a straw colored liquid, consists water and dissolved material. The formed elements of the blood are erythrocytes, leukocytes and thrombocytes. The fibrous characteristics of a blood revealed when clotted

Muscle tissue

Muscle tissue consists of highly specialized cells, which provides motion, maintenance of posture and heat production.

Classification of muscles is made by structure and function.

Muscle tissues are grouped in to skeletal, cardiac and smooth muscle tissue.

  • – Skeletal muscle tissue are attached to bones, it is voluntary, cylindrical, multinucleated & striated
  • – Cardiac muscle tissue: It forms the wall of the heart; it is involuntary, un-nucleated and striated.
  • – Smooth muscle tissue: located in the wall of hallow internal structure like Blood vessels, stomach, intestine, and urinary bladder. It is involuntary and non-striated.

Nervous tissue

Nervous tissue contains two principal cell types. These are the neurons and the neuroglia. Neurons are nerve cells, sensitive to various stimuli. It converts stimuli to nerve impulse. Neurons are the structural and functional unit of the nervous system. It contains 3 basic portions. These are cell body, axons and dendrites. Neuroglia’s are cells that protect, nourish and support neurons. Clinically they are important because they are potential to replicate and produce cancerous growths.

Membranes

Membranes are thin pliable layers of epithelial and/or connective tissue. They line body cavities, cover surfaces, connect, or separate regions, structures and organs of the body. The three kinds of membranes are mucous, serous and synovial.

  • • Mucous membranes (mucosa) lines body cavity that opens directly to the exterior. It is an epithelial layer. Mucous membranes line the entire gastro intestine, respiratory excretory and reproductive tracts and constitute a lining layer of epithelium. The connective tissue layer of mucous membrane is lamina propria. To prevent dry out and to trap particles mucous membranes secret mucous.
  • • Serous membrane / serosa: contains loose connective tissue covered by a layer of mesothelium. It lines body cavity that does not open directly to the exterior. Covers the organs that lie with in the cavity. Serosa is composed of parietal layer (pertaining to be outer) and visceral layer (pertaining to be near to the organ). Pleura and pericardium are serous membrane that line thoracic and heart cavity respectively. The epithelial layer of a serious membrane secret a lubricating fluid called serious fluid. The fluid allows organs to glide one another easily.
  • • Synovial membrane: Unlike to other membranes this membrane does not contain epithelium. Therefore, it is not epithelial membrane. It lines the cavities of the freely movable joints. Like serious membrane it lines structures that do not open to the exterior. Synovial membranes secret synovial fluid that lubricate articular cartilage at the ends of bones as they move at joints.

Blood and its composition

Blood is a vital connective tissue that circulates throughout the body, acting as a transport system and playing roles in defense and maintaining balance. About 7% of your body weight is blood.

Blood Composition: Blood is made of a liquid part and solid (cell) parts:

  • Plasma: This is the liquid matrix (about 55% of blood volume). Mostly water (about 90%), contains proteins (like albumin for fluid balance, globulins for defense, fibrinogen for clotting), nutrients (like sugar, amino acids, fats), waste products (like urea), hormones, salts (electrolytes), and gases (like a small amount of oxygen and carbon dioxide). Function: transport of substances.
  • Formed Elements: The blood cells (about 45% of blood volume): They are produced in the bone marrow.
    • Erythrocytes (Red Blood Cells - RBCs): These are the most numerous blood cells. Their main job is to transport oxygen from the lungs to the body tissues and also carry some carbon dioxide back to the lungs. They contain a protein called haemoglobin which binds to oxygen and makes the cells red.
    • Leukocytes (White Blood Cells - WBCs): These are larger than RBCs and are part of the body's defence system (immune system). Function: defend against infection and disease. Different types exist (e.g., neutrophils, lymphocytes).
    • Platelets (Thrombocytes): These are very small cell fragments. Their main job is to help stop bleeding (blood clotting) by forming a plug at the site of injury in a blood vessel.

Revision Questions for Page 1 (Part 2):

1. Describe the basic structure of an atom.

2. What is the difference between a molecule and a compound?

3. What are electrolytes and why are they important in the body?

4. List the main parts of a cell and briefly describe the function of the mitochondria and the nucleus.

5. Name the four main types of tissue found in the human body.

6. Briefly describe the main function of epithelial tissue, connective tissue, muscle tissue, and nervous tissue.

7. Name the three types of muscle tissue and state whether each is voluntary or involuntary.

8. Describe the two main parts of blood and list the three main types of blood cells found in the blood.

9. What is the main function of red blood cells, white blood cells, and platelets?

10. Name the three kinds of membranes found in the body and give an example of where each is located.

References (from Curriculum for CN-111):

Below are the core and other references listed in the curriculum for Module CN-1102. Refer to the original document for full details.

  • Cohen, JB and Hull, L.K (2016) Memmlers – The Human body in Health and diseases 13th Edition, Wolters, Kluwer. (Core Reference)
  • Cohen, J.B and Hull, L.K (2016) Memmler's Structure and Function of the Human Body. 11th Edition. Wolters Kluwer, China
  • Kumar, M and Anand, M (2010) Human Anatomy and Physiology for Nursing and Allied Sciences. 2nd Edition. Jaypee Brothers Medical Publishers Ltd.
  • Scott, N.W. (2011) Anatomy and Physiology made incredibly easy. 1st Edition. Wolwers Kluwers, Lippincotts Williams and Wilkins.
  • Moore, L. K, Agur, M.R.A and Dailey, F.A. (2015) Essential Clinical Anatomy.15th Edition. Wolters Kluwer.
  • Snell, S. R. (2012) Clinical Anatomy by Regions. 9th Edition. Wolters Kluwer, Lippincott Williams and Wilkins, China
  • Wingerd, B, (2014) The Human Body-Concepts of Anatomy and Physiology. 3rd Edition Lippincott Williams and Wilkins and Wolters Kluwer.
  • Rohen, Y.H-Orecoll. (2015) Anatomy.A Photographic Atlas 8th Edition. Lippincott Williams & Wilkins
  • Waugh, A., & Grant, A. (2014). Ross and Wilson Anatomy & Physiology in Health and Illness (12th ed.). Churchill Livingstone Elsevier. (Added as per user's reference)

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Last Office

Last Office (PEX 2.1.9: Perform Last Office)

Objectives:

  • Define the term last offices.
  • Perform preliminary steps of last offices.
  • Identify the requirements for carrying out last offices.
  • Prepare the requirements for carrying out last offices.
  • Perform procedure of first phase of last offices.

Definition:

Last offices (also known as post-mortem care or care of the deceased) is the care given to a deceased person to ensure a clean body and maintain dignity, respect, and prepare the body according to cultural, religious, and legal requirements.

Aims:

  • To prepare the deceased for mortuary or a funeral home or morgue (a place where dead bodies are kept pending identification, autopsy or burial.
  • To minimize any risk of cross infection to relatives, health care workers or persons who may need to handle the deceased.

Requirements:

Trolley (Top Shelf):

  • Two jugs of warm and cold water
  • Small tray with:
    • Soap in a dish
    • Nail brush
    • Vaseline or lubricant
    • Comb
    • Nail cutter
    • Pair of scissors
  • 2 Receivers (kidney dishes)
  • Dissecting forceps (or artery forceps) - often for packing orifices
  • Mortuary labels with tapes (at least 3 - wrist, toe, and shroud)
  • A roll of toilet paper (or cotton wool)
  • Brown cotton wool in a bowl (for packing orifices) - **Note:** Brown cotton wool is less common now; plain cotton wool or gauze is typically used.
  • Dressing pack (or sterile pack with swabs)
  • Flannels (or washcloths)
  • Antiseptic lotion
  • Jik (or other disinfectant for surfaces/equipment)

Trolley (Bottom Shelf):

  • Plastic apron
  • 2 pairs of clean sheets (one for the bed, one for the shroud)
  • Dressing mackintosh and sheets
  • A pair of mortuary sheets (or shroud/body bag)
  • Strapping and sticking plaster (adhesive tape/bandage)
  • Notification of death forms
  • Bottle of antiseptic lotion (for washing body)
  • 2 buckets (one containing disinfectant solution for contaminated items)

Bedside:

  • Hand washing equipment (access to sink, soap, water, towel)
  • Screens (for privacy)
  • Bucket for wastes (clinical and general)
  • Dirty linen container
  • Deceased Burial Clothes:
    • Clean sheets
    • Dressing clothes as preferred by family/culture (e.g., Men - underwear, trousers, shirt, coat, tie; Traditional wear according to culture or religion).
    • Diapers/pads (if needed)

Procedure (Preliminary Steps & First Phase):

Steps Action Rationale
1. Observe the general rules. Promotes adherence to standards and patient safety/dignity.
2. Confirm the patient has ceased breathing and check for absence of pulse, heart sounds, and pupillary reflexes. Note the exact time of death. To confirm death and for legal and documentation purposes. Ensures timely attendance by the medical team.
3. Notify the In-charge or Doctor immediately as soon as the patient ceases to breathe. To confirm death and for legal purposes. Ensures timely attendance by the medical team.
4. Provide a calm and respectful environment. Remove excess equipment from around the bed. Close adjacent windows and screen the bed/room for privacy. To promote serenity in the ward, respect the dignity of the deceased, and provide privacy for the procedure and the remaining patients/staff.
5. Inform the relatives or next of kin about the death with empathy and counsel them appropriately. Allow relatives time to be with the deceased if desired, providing them with privacy and support. Request relatives to bring burial clothes if applicable. Ask about cultural/religious preferences for handling the body. To support the grieving family, fulfill emotional needs, and gather information about specific requests or cultural/religious practices for handling the body.
6. Remove any jewelry, necklace, watches, or other valuables that have been worn by the deceased. Document these items carefully and hand them over to the next of kin or store them according to hospital policy, obtaining signatures on an accountability book/form. To prevent loss of personal effects and ensure proper handling and accountability.
7. Remove any tubes, catheters (e.g., IV lines, NG tubes, urinary catheters, drainage tubes) as per policy or doctor's order. Clamp or tie off puncture sites.
Note: If a medico-legal case, tubes may need to remain in situ.		 To prepare the body for cleaning and dressing and to prevent leakage from sites. Prevents misinterpretation in medico-legal cases.
8. Stop any running IV infusions. Not applicable after death.
9. Put on protective wear (plastic apron, gloves). To prevent cross-infection and protect staff from contact with body fluids.
10. Strip the bed of soiled linen, carefully removing and placing it in the dirty linen container. If the body has soiled the bed, place a clean sheet under the body. If infectious disease, decontaminate linen in an antiseptic solution before sending to laundry. To maintain cleanliness of the environment and prevent spread of infection.
11. Clean the body thoroughly, providing a full wash (refer to Bed Bath procedure 5.1), paying attention to all areas. If necessary, shave the face (for males) or comb/style hair as preferred by the deceased or next of kin. To ensure the body is clean and presentable, respecting the dignity of the deceased. To maintain good memories for the family.
12. Final Care Given to the deceased:
Laying out of the deceased is done with respect and according to the dead person's religious rights and cultural values.
- Straighten the upper limbs and tie the lower limbs together at the big toes (ankles) with a bandage or piece of soft material.
- Close the eyes gently if they cannot remain closed; place a wet swab over the eyelids if needed.
- Close the mouth; if necessary, place a small rolled towel under the chin or use a bandage around the head and chin to keep the mouth closed. Dentures should be left in place if possible.
- Pack orifices (mouth, nostrils, anus, vagina in females) with cotton wool or gauze using forceps to prevent leakage of body fluids. Ensure packing is not visible.		 This is for continuity of respect of human beings even after death.
To allow correct body alignment before rigor mortis sets in.
To create a natural, peaceful appearance.
To prevent soiling of the linen and body from natural discharges.
13. Dress the body in clean clothes or the burial clothes provided by the family, according to cultural/religious practices. If burial clothes are not available or used, use a clean shroud or mortuary sheet/body bag. To respect the dignity of the deceased and prepare the body for viewing or transfer.
14. Place a clean sheet over the body, covering up to the neck or as appropriate for cultural/religious viewing. To maintain modesty and dignity.
15. Fill out the mortuary labels with the particulars: name, age, date and time of death, ward, next of kin, any specific instructions (e.g., infectious precautions). Attach one label to the wrist, one to the ankle/toe, and one to the shroud/body bag. To ensure accurate identification of the deceased for legal and administrative purposes.
16. Assist with transferring the body to the mortuary trolley or body bag as per policy. To prepare the body for transfer.
17. Transport the body to the mortuary securely and respectfully. Ensures safe custody and transfer.
18. Document the procedure fully, including the time of death, time last offices were completed, care given, items removed (valuables, tubes) and their disposition, persons notified, and any specific instructions or cultural considerations followed. For continuity of care, monitoring, and legal record.
19. Clear away and disinfect all used equipment, surfaces (bed, locker, floor), and the room as per terminal disinfection policy. Dispose of waste appropriately. Wash hands. To prevent the spread of infection and maintain a clean environment.

Points to Remember (Adult Last Offices):

  • Maintain a calm, quiet, and respectful atmosphere throughout the procedure.
  • Always handle the deceased body gently and with dignity.
  • Be sensitive to the cultural and religious beliefs of the patient and family regarding death and body preparation. Consult with the family or spiritual advisors if unsure.
  • If the death is a medico-legal case, follow specific protocols regarding removal of tubes, handling of clothing, and notification of authorities.
  • Ensure proper identification of the body with labels before transfer to the mortuary.
  • Wash hands thoroughly before and after the procedure.
  • Terminal disinfection of the patient's unit is essential.

LAST OFFICE IN PERINATAL DEATH

Objectives:

  • Define the term perinatal mortality.
  • Display the ability to break news of death and counsel the parents of a deceased baby.
  • Identify the requirements for carrying out last office to a deceased new born baby.
  • Prepare the requirements for carrying out last office to a deceased new born baby.
  • Perform last office of the deceased new born baby.

Definition:

Perinatal mortality is the death of a baby in the first 28 days of life, including stillbirths (death before birth after 28 weeks gestation).

Requirements (Perinatal Death):

Additional requirements to adult last office requirements:

  • Baby clothes (as provided by parents/family)
  • Diapers (or pads)
  • Small artery forceps (for packing orifices)
  • Small blanket or receiving cloth (for wrapping the baby)
  • Mortuary label (specifically for stillbirths/neonates)

Procedure (Last Office in Perinatal Death):

Steps Action Rationale
1. Observe the general rules. Promotes adherence to standards.
2. Communicate the news of the death to the mother and father empathetically, providing privacy and support. Counsel them appropriately about the cause of death (if known) and the next steps. To initiate coping mechanism and support the parents through their grief.
3. If the death was an intra-uterine fetal death (stillbirth), inform the mother and next of kin of what has happened and the next steps (e.g., delivery process). To provide necessary information and prepare the parents for the process ahead.
4. Ask the parents if they would like to see, hold, and spend time with the baby. Handle the baby gently and wrap in a clean cloth. Remove any tubes or lines. Wash hands and put on protective wear (gloves). To allow parents to bond with their baby, initiate the grieving process, and create memories. Maintains hygiene and safety.
5. Ask the parents if they would like to take a photo of their dead baby. A photo can be used for future remembrance and healing.
6. Bathe the baby gently with warm water and mild soap. Dry thoroughly with a soft towel. To provide a clean body, respecting the dignity of the deceased baby, and create a descent appearance.
7. Pack all orifices (mouth, nostrils, anus, and vagina if applicable) with cotton wool or gauze using small forceps. Ensure the packing is not visible. Apply a diaper. Packing reduces the risk of soiling the linen and body from natural discharges and prevents the spread of infection. Maintains cleanliness and dignity.
8. Dress the baby fully in the clothes provided by the parents or in clean hospital clothes. Wrap the baby completely in a clean blanket or receiving cloth. To make the baby presentable, respect the parents' wishes, and provide a sense of comfort and completeness.
9. Fill the mortuary label with the necessary particulars: baby's name (if given), mother's name, date and time of birth (if born alive), date and time of death, sex, state if stillbirth or not, ward name. Attach the label securely to the baby's wrist or ankle. To ensure accurate identification of the deceased baby for legal, administrative, and ethical purposes.
10. Ask the mother and next of kin where the body is to be kept or sent (e.g., mortuary, specific location as per cultural practice). Inform them of the process for collecting the body. Promotes safe custody and transfer, builds confidence in the parents/next of kin, and ensures legal/cultural requirements are met.
11. Take the body to the mortuary well labeled, or hand over to the designated person according to policy/request, obtaining signatures on a handover form/accountability book. Enables identification and for ethical and legal purposes. Ensures accountability for the body.
12. Clear away and disinfect all used equipment and the environment as per policy. Dispose of waste appropriately. Wash hands. To prevent spread of infection and maintain cleanliness.
13. Document the procedure completely, including the time of death, time last offices were completed, care given, interactions with parents (seeing/holding baby, photos taken), disposition of the body, and any specific cultural considerations followed. For continuity of care, monitoring, and legal record. Essential documentation for perinatal deaths.

Points to Remember (Perinatal Death):

  • Be exceptionally sensitive, supportive, and compassionate when caring for parents experiencing perinatal loss.
  • Allow parents adequate time to see and hold their baby if they wish. This is a vital part of the grieving process.
  • Provide privacy for the family. Ideally, the last offices for a perinatal death should be performed in a separate room, not in the main ward where other mothers with babies are present.
  • Ensure the environment is quiet and conducive to grieving.
  • Handle the baby gently and with the utmost respect throughout the procedure.
  • Follow hospital policy and cultural/religious practices regarding the disposition of the body.
  • Minimize psychological trauma for the mother and family.
  • Ensure appropriate follow-up support is offered to the parents.
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Physical Examination of the Patient

Physical Examination of the Patient (PEX 2.3.3: Perform physical examination of the patient)

Objectives:

  • Identify the requirements for assessing the patient.
  • Prepare the requirements for assessing the patient.
  • Carry out assessment of the patient.
  • Define the term nursing process (part of 3.0).
  • State the characteristics of the nursing process (part of 3.0).
  • Describe the components of the nursing process (part of 3.0).
  • Apply nursing process when giving nursing care (part of 3.0).

Definition:

Physical examination of a patient is done from head to toe and assessment of the major systems.

Physical Examination calls for 4 techniques :

  • Inspection: Means looking at the client carefully to discover any signs of illness.
  • Palpation: Means using hands to touch and feel. Different parts of hands are used for different sensations such as temperature, texture of skin, vibration, tenderness, etc. (e.g., fingertips for fine tactile surfaces, back of fingers for temperature, flat of palm and fingers for vibrations).
  • Percussion: Determines the density of various parts of the body from the sound produced by them, when they are tapped with fingers. Helps find abnormal solid masses, fluid, and gas, and map out size and borders of organs. Methods include indirect percussion (tapping a finger placed on the body).
  • Auscultation: Means listening to the sounds transmitted by a stethoscope, used to listen to the heart, lungs, and bowel sounds.

Functional health pattern approach (from 3.2):

Based on Gordon's functional health patterns, allows collection of data according to each pattern. Includes eleven health functional patterns (e.g., Health perception, Nutritional, Elimination, Activity/Exercise, Sleep/Rest, Cognitive/Perceptual, Self-perception, Role/Relationship, Sexuality/Reproductive, Coping/Stress, Value/Belief).

Requirements:

Same as for Taking History (from 3.1), particularly the Observation Tray contents and equipment for vital signs, measurements, and physical assessment tools.

Top Shelf (Observation Tray):

  • Thermometer
  • Watch (with seconds hand)
  • Stethoscope
  • Blood pressure machine (Sphygmomanometer)
  • Neurological tray (Torch light/penlight, Spatula, Patella hammer, Otoscope, Tuning fork, Gallipot with cotton swabs/gauzes, Skin pencil, Snellens chart, Ophthalmoscope, Atropine 1% eye drops)
  • Auroscope set (Jobson Horne ring probe, Wool and applicator, Dissecting aural forceps)
  • Sterile throat swab
  • Dental mirror laryngoscope
  • Nasal speculum
  • Alcohol swabs
  • Lubricant
  • Drape
  • Vaginal speculum
  • Disposal pads

Bottom Shelf:

  • Record forms (History forms, assessment charts)
  • Disposable gloves
  • Specimen bottles

At the side:

  • Weight scale (electronic or sling scale)
  • Measuring tape
  • Ruler
  • Record chart
  • Screen (for privacy)
  • Examination table (if needed)
  • Hand washing equipment

Special Senses Assessment tools (from 3.1.1/3.2):

  • Bottle for cold and hot water (to test temperature sensation).
  • Bottles with distinctive smelling liquids e.g. lavender (to test olfactory sense).
  • Bottles with salt, sugar, bitter, and sour substances (to test taste sensation).

Procedure (General Physical Examination - Head to Toe Approach):

Steps Action Rationale
1. Observe the general rules of nursing procedure. Promotes adherence to standards.
2. Explain the purpose of the physical examination to the patient. Ensure privacy, provide adequate lighting, and assist the patient into a comfortable position. To gain cooperation, reduce anxiety, and ensure a proper examination environment.
3. General Appearance: Observe overall appearance: posture, gait, movement, hygiene, state of nourishment, level of consciousness, and apparent age. Note any obvious changes or distress. To identify obvious changes, assess mobility, hygiene, and overall health status.
4. Vital Signs: Measure temperature, pulse, respiration, and blood pressure. Obtain height and weight (as per procedure 3.1.2). Provides baseline data on patient's physiological status.
5. Orientation & Cognitive Function: Observe patient's ability to respond to verbal commands, level of consciousness, orientation to person, place, and time. Note ability to think, remember, process information, and communicate. Note articulation on speech, style, and content. Responses and cognitive processes indicate the patient's brain function and mental status.
6. Integumentary System (Skin, Hair, Nails): Inspect and palpate the skin: Note appearance, color, texture, sensation, moisture, temperature, turgor. Observe for any lesions, rashes, growths, trauma, edema. Check capillary refill by pressing the nail bed, noting the return of color. Assess hair for color, texture, growth, distribution. Inspect nails for color, shape, texture, and condition. To assess the integrity and function of the skin, hair, and nails. Helps identify dehydration, anemia, circulation problems, or skin abnormalities.
7. Head: Inspect and palpate the head: Note size, shape, and symmetry. Palpate for any deformities, depressions, or tenderness. Inspect face for facial expression, asymmetry, involuntary movements, edema, and masses. To detect abnormalities, assess for signs of paralysis, or masses.
8. Eyes: Inspect both eyes for position and alignment, symmetry, colour (sclera, conjunctiva). Observe pupils for size, shape, equality, and reaction to light (PERRLA). Test visual acuity (using Snellen chart if available). Observe ability to see. To detect any abnormalities, assess visual function and neurological status related to the eyes.
9. Ears: Inspect and palpate ear shape, size, symmetry, and patency of the ear canal using an otoscope. Test hearing (e.g., whisper test or tuning fork tests). Observe ability to hear. To detect abnormalities in ear structure and canal, and assess auditory function.
10. Nose: Inspect the anterior and inferior surface of the nose. Palpate the nose. Inspect the nasal vestibule with penlight; observe symmetry, size, flaring, and sensation. Observe ability to smell. To detect any abnormalities or obstruction in the nasal passages.
11. Mouth: Observe lips, mucous membrane, gum, tongue, teeth, and palate for color, moisture, texture, and sensation. Inspect the throat (uvula, tonsils, pharynx) using a penlight and tongue depressor. Observe ability to taste. To detect any abnormalities or signs of infection in the oral cavity and throat.
12. Neck: Inspect and palpate the neck: Note symmetry, range of motion. Inspect and palpate the lymph nodes (pre-auricular, post-auricular, occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical, deep cervical chain, supra clavicular) for location, size, shape, texture, and pain. Inspect and palpate jugular veins. Inspect and palpate thyroid gland for enlargement, contour, and symmetry. Ask patient to swallow while palpating the thyroid. To detect enlargement of lymph nodes (infections/conditions), assess jugular venous distension (JVD - indicates increased venous pressure), and assess thyroid abnormalities.
13. Chest, Lungs, and Heart: Inspect chest movement and symmetry during breathing. Palpate chest. Auscultate lung sounds in all lobes (anterior, posterior, lateral) for normal breath sounds and adventitious sounds (crackles, wheezes). Percuss the chest. Auscultate heart sounds (rate, rhythm, murmurs) at the appropriate locations. To assess respiratory and cardiovascular function and detect abnormalities such as congestion or abnormal heart rhythms.
14. Breasts and Axilla: Inspect breasts appearance, color, size, symmetry, shape, and texture. Palpate breasts for lumps or tenderness. Inspect nipples for symmetry, shape, dry scaling, fissure, ulceration, bleeding or other discharge. Inspect and palpate axilla for lymph nodes. To detect any abnormalities, lumps, or signs of infection/inflammation.
15. Abdomen: Assist patient to lie in supine position with knees slightly flexed (if possible) to relax abdominal muscles. Inspect the abdomen: Note skin color, symmetry, shape, distension. Observe pulsations from the aorta (if visible). Auscultate bowel sounds in all four quadrants (presence, character, frequency). Percuss the abdomen for tone. Palpate the abdomen (light and deep palpation) for tenderness, masses, and size/consistency of organs (liver, spleen, kidneys). To assess abdominal function, detect abnormalities such as distension, abnormal bowel sounds, tenderness, masses, or organ enlargement.
16. Musculoskeletal System: Inspect and palpate neck, shoulders, arms, hands, hips, knees, legs, ankles, and feet for symmetry, size, contour of joints, skin condition, tenderness, swelling, or deformities. Assess range of motion (active and passive) of all major joints, noting any pain or limitation. Assess muscle strength and tone. Observe gait. To detect swelling, deformities, pain, and limitations in movement. Assesses functional mobility.
17. Neurological System: Assess level of consciousness (already done in step 5), orientation, cognitive function. Assess cranial nerves. Assess motor function (strength, coordination, balance). Assess sensory function (light touch, pain, temperature, vibration, position). Assess reflexes. To assess the function of the nervous system and detect any deficits.
18. Thank the patient for their cooperation and assist them back to a comfortable position. Dispose of used materials and clean equipment. Wash hands. To conclude the examination respectfully and maintain hygiene.
19. Document findings accurately and completely on the patient's chart. Report any significant or abnormal findings immediately to the doctor. For continuity of care, monitoring, and legal record.
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Taking History of the Patient

Taking History of the Patient (PEX 2.3.2: Take history of the patient)

Objectives:

  • Identify the requirements for assessing the patient.
  • Prepare the requirements for assessing the patient.
  • Carry out assessment of the patient.

Definition of Data Collection (from 3.1):

Data collection consists of gathering information about the patient in order to develop a "data base" which can be analyzed in various ways depending on the intended use. There are two types of data:

  • Subjective data (Symptoms felt by the patient)
  • Objective data (Observable signs)

Sources of Data:

  • Patient (primary source of data)
  • Family members and significant others
  • Various patient's records (medical charts, previous notes)
  • Other members of the health team.

Requirements :

Top Shelf (Observation Tray):

  • Thermometer
  • Watch (with seconds hand)
  • Stethoscope
  • Blood pressure machine (Sphygmomanometer)
  • Neurological tray (Torch light/penlight, Spatula, Patella hammer, Otoscope, Tuning fork, Gallipot with cotton swabs/gauzes, Skin pencil, Snellens chart, Ophthalmoscope, Atropine 1% eye drops)
  • Auroscope set (Jobson Horne ring probe, Wool and applicator, Dissecting aural forceps)
  • Sterile throat swab
  • Dental mirror laryngoscope
  • Nasal speculum
  • Alcohol swabs
  • Lubricant
  • Drape
  • Vaginal speculum
  • Disposal pads

Bottom Shelf:

  • Record forms (History forms, assessment charts)
  • Disposable gloves
  • Specimen bottles

At the side:

  • Weight scale (electronic or sling scale)
  • Measuring tape
  • Ruler
  • Record chart
  • Screen (for privacy)
  • Examination table (if needed)
  • Hand washing equipment

Procedure (Taking History of the Patient):

Steps Action Rationale
1. Observe the general rules (e.g., introduce yourself, wash hands). Promotes professionalism, hygiene, and sets a positive tone.
2. Explain the purpose of taking the history and ensure patient privacy by using screens or a private room. Build rapport and a therapeutic relationship with the patient. Providing information fosters cooperation and helps reduce anxiety. Respecting privacy is fundamental.
3. Take history in the following order, encouraging the patient to speak freely and using open-ended questions:
Biographical/Personal Information: Name, age, tribe, address, occupation, religion, marital status, level of education, next of kin, relationship to next of kin, telephone number patient or and next of kin, nearest health facility.		 To create a therapeutic relationship, identify the patient, for legal purposes and follows up.
4. Presenting/Main Complaint: Establish the reason for seeking health care, focusing on:
- Onset (When did it begin; is it better, worse, or the same since it began).
- Character (How does it feel, look, smell, sound, severity etc).
- Anatomic location (Where is it? Where does it radiate).
- Duration (How long it last/ does it recur).
- The setting in which it occurs.
- Pattern or precipitating factors (What makes it worse or better).
- Associated factors (What other symptoms do you have with it?)		 A detailed description of the concern helps the nurse to gain an insight into the problem and is a basis to develop a nursing care plan for managing the patient.
5. Past Medical History: Inquire about past diseases or recurrent conditions (e.g., sickle cell, asthma, malaria, kidney diseases, diabetes, STIs, poliomyelitis, rickets, any past infection or hospitalization). To identify previous conditions or complications that may be aggravating the presenting complaint.
6. Past Surgical History: Inquire about accidents, injury, blood transfusion history, and reasons for past surgeries/fractures. To understand previous health events that may impact current condition or care.
7. Past Medications Received: Ask about patient's response to past/current medications, whether still on medication, any allergies (including food and environmental), use of home remedies or herbs. To establish the past/current medication use, identify allergies, and assess potential side effects.
8. Social History: Inquire about alcohol and tobacco consumption, source of income, housing conditions, source of water, marital status, number of children, health of children and spouse, occupation and environment, sexual activities, sex partners, and family planning. To identify risk of conditions or diseases related to stated social history and understand the patient's living situation.
9. Family History: Establish if both parents are dead or alive (if died, what was the cause?). Inquire about spouse, siblings (number, illness), and children (age, illness). Ask about inherited diseases in the family. To find problems related to daily living activities and general wellbeing, and identify genetic predispositions.
10. Gynecological History (for female patients): Inquire about menarche (age of first period), menstrual cycle (number of days, amount of blood, regularity), date of last menstrual period (LMP), obstetric history (number of pregnancies, births, abortions, living children, complications), use of contraception, history of sexually transmitted infections (STIs), vaginal discharge, tumor history (cervical/uterine cancer), pap smear history (if applicable). To rule out gender-related conditions and inform care related to reproductive health.
11. Male History (for male patients): Establish male fertility related conditions, prostate problems (e.g., BPH), history of STIs, scrotal or penile problems. To rule out gender-related conditions and inform care related to reproductive health.
12. Systems Review: Ask about symptoms related to each body system (e.g., respiratory, cardiovascular, gastrointestinal, genitourinary, neurological, musculoskeletal, integumentary). To identify additional symptoms or problems the patient may not have mentioned initially.
13. Thank the patient for their cooperation. To conclude the interview respectfully.
14. Document the complete history accurately and legibly on the patient's chart/form. For continuity of care and legal record.

Special Senses Assessment :

  • (Note: This seems like a sensory assessment included in the section)
  • Bottle for cold and hot water (to test temperature sensation).
  • Bottles with distinctive smelling liquids e.g. lavender (to test olfactory sense).
  • Bottles with salt, sugar, bitter, and sour substances (to test taste sensation).
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Catheterization

Catheterization (PEX 2.1.13: Prepare and perform Catheterization)

Objectives:

  • Define the term catheterization.
  • Name the types of catheters according to:
    • Nature of procedure done (e.g., intermittent, indwelling)
    • Types of catheter (e.g., non-retaining, self-retaining, metallic, non-metallic, rubber, plastic)
  • State the indications for catheterization.
  • Identify the requirements for passing a urethral catheter.
  • Prepare the requirements for passing a urethral catheter.
  • Perform the procedure of passing a urethral catheter.

Definition:

Catheterization is the introduction of a fine plastic or rubber tube (catheter) through the urethra into the urinary bladder in order to remove urine or to keep the urethra open.

Types of Catheters:

  • Non-retaining or self-retaining (e.g., Foley catheter with inflatable balloon).
  • Metallic and non-metallic (e.g., plastic, rubber, silicone).
  • Rubber catheters.
  • Plastic catheters.

Catheter sizes are according to the French (Fr) scale. Sizes include 8 to 10 Fr for children, 14 to 16 Fr for adult females, and 18 to 20 Fr for adult males. Generally, sizes range from 8 to 24 Fr. The smallest effective size should be used to minimize trauma.

Indications for Catheterization:

  • To obtain a sterile specimen of urine for examination or investigations (e.g., when a clean catch midstream sample is not possible).
  • To relieve urinary retention when other nursing measures have failed (e.g., after surgery, due to obstruction, or neurogenic bladder).
  • To ensure that the bladder is empty before (pre-operatively), during, and after pelvic or abdominal surgeries to prevent injuries to the bladder.
  • To measure the amount of residual urine after voiding (post-void residual). It is done when partial obstruction of the bladder outlet is suspected (e.g., in BPH, VVF patients, patients on bladder training).
  • Emptying the bladder before giving a bladder irrigation or installation of medication.
  • Splinting the urethra following urethral surgery or trauma.
  • In cases of incontinence of urine to prevent bed sores which may occur in diseases of the nervous system, trauma, and other conditions requiring strict intake and output monitoring.
  • Monitoring accurate hourly urine output in critically ill patients.

Requirements:

Trolley (Top Shelf):

  • A sterile catheterization pack containing: Sterile towels (2), Drape (1), Sterile receiver (2), Gauze swabs, Cotton wool swabs.
  • Sterile Foley catheter (appropriate size, have a spare)
  • Sterile KY Jelly or Lubricant (water-soluble)
  • Antiseptic solution (e.g., Povidone-iodine or Chlorhexidine solution) in a gallipot
  • A 10 ml syringe (for inflating the balloon)
  • Sterile water (or normal saline) for inflating the balloon (amount specified on catheter)
  • Specimen bottle(s) with labels (if specimen is required)
  • Spigot or clamp
  • Drainage bag and tubing (if inserting an indwelling catheter)
  • Dressing mackintosh and towel
  • Sterile gloves (at least 2 pairs)
  • Non-sterile gloves (for initial preparation)

Bedside:

  • Hand washing equipment (access to sink, soap, water, towel)
  • Screens (for privacy)
  • Adequate lighting (e.g., torch or lamp)
  • Waste receptacle
  • Urine collection container (if not using a drainage bag, e.g., receiver or measuring jug)
  • Patient's chart and Fluid balance chart (if monitoring output)

Procedure (Catheterization of a Female Patient):

Steps Action Rationale
1. Observe the general rules. Promotes adherence to standards.
2. Explain the procedure to the patient, obtain consent (if conscious). Provide privacy with screens. To reduce anxiety, gain cooperation, and respect patient rights.
3. Assist the patient to adopt the dorsal recumbent position (lying on back with knees flexed and spread apart). Dorsal position makes it easy for the nurse to carry out the procedure by exposing the meatus.
4. Place the dressing mackintosh and towel under the patient's buttocks. To protect the bed linen from urine spillage.
5. Wash hands and put on clean non-sterile gloves. Open the outer wrapper of the sterile catheterization pack and place on the trolley. Open sterile gloves and place on the trolley. Prevents infection and prepares the sterile field.
6. Pour antiseptic solution into a gallipot. Open sterile catheter and place on the sterile area. Draw up sterile water/saline into the syringe for balloon inflation. Lubricate the catheter tip (about 2-4 cm). Maintains sterility and prepares the catheter for insertion.
7. Remove non-sterile gloves and wash hands. Put on sterile gloves. Maintains sterile technique.
8. Drape the patient's genitalia, exposing the urethral orifice. Place a sterile receiver on the drape between the patient's thighs to collect urine. To create a sterile field and prepare for urine collection.
9. Separate the labia with the thumb and index finger of the non-dominant hand to visualize the urethral meatus. Maintain separation throughout the procedure (this hand is now contaminated). To visualize the meatus clearly and prevent contamination from the labia.
10. Clean the urethral meatus thoroughly with cotton wool swabs soaked in antiseptic solution, using the forceps. Wipe from anterior to posterior (front to back), using a fresh swab for each stroke. Clean from the meatus outwards. Discard used swabs. To prevent the introduction of microorganisms into the bladder.
11. Using the dominant hand (which is sterile), gently insert the lubricated catheter tip into the urethral meatus. Advance the catheter slowly 4-6 cm until urine begins to flow into the receiver. Lubrication minimizes trauma to the urethra. Gentle insertion prevents injury. Length ensures entry into the bladder.
12. Once urine flows, advance the catheter a further 2-3 cm to ensure the balloon is fully within the bladder. Hold the catheter in place with the non-dominant hand. To ensure the balloon is not inflated in the urethra, which would cause pain and damage.
13. Inflate the balloon slowly with the pre-drawn sterile water/saline using the syringe. The amount is specified on the catheter (usually 5-10 ml for adult Foley). To secure the catheter in the bladder and prevent it from slipping out.
14. Gently pull back on the catheter slightly until resistance is met, indicating the balloon is seated at the bladder neck. Confirms correct placement and anchors the catheter.
15. Connect the catheter to the drainage bag and tubing system, ensuring a closed system. Ensure the drainage bag is positioned below the level of the bladder. To allow continuous drainage of urine and maintain a closed sterile system to prevent infection.
16. Secure the catheter to the patient's inner thigh with adhesive tape, allowing for some slack to prevent tension on the meatus. Prevents accidental dislodgement and irritation of the urethra.
17. Dispose of used equipment and materials appropriately. Wash hands. Maintains cleanliness and infection control.
18. Leave the patient comfortable and check that urine is draining freely into the bag. Provide post-procedure care and instructions to the patient (e.g., signs of infection, hydration). To ensure patient comfort and well-being and prevent complications.
19. Document the procedure, including the date, time, type and size of catheter inserted, amount of fluid used to inflate the balloon, characteristics and amount of urine obtained (if initial drainage), patient's response, and name/signature of nurse. For continuity of care, monitoring, and legal record.

Procedure (Catheterization of a Male Patient):

Steps Action Rationale
1. Follow the general steps for catheterization preparation as for a female patient (Steps 1-7 Female Procedure), including explaining the procedure, ensuring privacy, preparing equipment, and washing hands/donning sterile gloves. The principles of catheterization preparation remain the same in both male and female patients.
2. Assist the patient to lie in the supine position with legs extended. Drape the patient's genitalia, exposing the penis. To provide privacy and easy access to the penis.
3. Using the non-dominant hand (now contaminated), grasp the penis just below the glans and retract the foreskin if uncircumcised. Hold the penis perpendicular to the body. To expose the urethral meatus and straighten the urethra for easier catheter passage.
4. Cleanse the glans penis with cotton wool swabs soaked in antiseptic solution, using the forceps. Wipe in a circular motion from the meatus outwards, using a fresh swab for each stroke. Discard used swabs. Maintain hold of the penis with the non-dominant hand. To prevent the introduction of microorganisms into the bladder.
5. Lubricate the tip of the catheter (about 6-8 inches) and inject some lubricant directly into the urethra using the syringe (or use a pre-lubricated catheter). Lubrication minimizes trauma and friction and helps the catheter pass through the longer male urethra.
6. Using the dominant hand (which is sterile), gently insert the lubricated catheter tip into the urethral meatus. Ask the patient to take slow, deep breaths or bear down gently as if to void, and advance the catheter slowly. Deep breathing helps relax the external sphincter. Gentle insertion follows the natural curves of the urethra.
7. Advance the catheter about 15-20 cm until urine flows into the receiver. The male urethra is longer than the female. Ensures the catheter reaches the bladder.
8. If resistance is met, do not force. Ask the patient to relax and breathe deeply. Gently rotate the catheter or apply slight traction to the penis. If resistance persists, withdraw the catheter and consult the mentor or doctor. Forcing can cause trauma, stricture, or false passages in the urethra. Relaxing can help the sphincters open.
9. Once urine flows, advance the catheter a further 2-3 cm to ensure the balloon is fully within the bladder. To ensure the balloon is not inflated in the urethra.
10. Inflate the balloon slowly with the pre-drawn sterile water/saline using the syringe. Amount specified on catheter (usually 5-10 ml for adult Foley). To secure the catheter in the bladder.
11. Gently pull back on the catheter slightly until resistance is met. Confirms correct placement.
12. Replace the foreskin if it was retracted. To prevent paraphimosis (foreskin trapped behind the glans).
13. Connect the catheter to the drainage bag and tubing system, ensuring a closed system. Ensure the drainage bag is below the level of the bladder. To allow continuous drainage and maintain a closed sterile system.
14. Secure the catheter to the patient's inner thigh or lower abdomen with adhesive tape, allowing for some slack. Securing to the abdomen directs the catheter upwards, reducing pressure on the penoscrotal angle of the urethra. Prevents accidental dislodgement and tension on the meatus.
15. Complete the procedure as per steps 17-19 of the female catheterization procedure (Dispose of equipment, Wash hands, Patient comfort, Documentation). Maintains cleanliness, ensures patient comfort, and provides a record.

Points to Remember (Catheterization):

  • Catheterization is a sterile procedure; therefore, strict aseptic precautions must always be followed throughout the procedure. Any break in sterile technique should be corrected immediately.
  • The procedure should be performed with extreme care to prevent trauma to the delicate urethral and bladder organs.
  • Always verify catheter placement before inflating the balloon.
  • Never force the catheter against resistance.
  • Use adequate lubrication, especially for male patients.
  • Choose the correct size catheter to minimize discomfort and trauma.
  • Ensure the drainage system is always below the level of the bladder to facilitate gravity drainage and prevent backflow.
  • Provide ongoing catheter care (cleaning meatus, checking drainage, ensuring patency) to prevent infection.
  • Monitor the patient for signs of complications such as pain, bleeding, inability to pass urine, or signs of infection (fever, cloudy urine, foul odor).
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Naso-Gastric Tube and Tube Feeding

Passing Naso-Gastric Tube and Tube Feeding (PEX 2.1.10)

Indications for Passing Naso-Gastric Tube:

  • Unconscious patients.
  • After operations in the mouth, pharynx or larynx.
  • Obstruction or stricture of the oesophagus due to inflammation or tumour.
  • Severe dysphagia (difficulty swallowing).
  • Babies; too weak to feed or to suck.
  • Severely burnt patients (due to increased metabolic needs or inability to take oral feeds).
  • Mentally ill patient who cannot eat.
  • In cases of persistent nausea and vomiting (to decompress the stomach or provide nutrition).
  • Gastric lavage (washing out the stomach).
  • Collection of gastric specimens.

Requirements:

Trolley (Top Shelf):

  • Sterile naso-gastric tubes (appropriate size) in a bowl
  • A bowl of warm water (to soften the tube)
  • A gallipot with gauze swabs
  • Orange sticks (or nasal speculum if needed for nostril inspection)
  • Receiver (or kidney dish) with blue litmus paper
  • Mackintosh cape and towel/dressing mackintosh
  • A 10 ml syringe
  • Spigot (or clamp)
  • Cup of water (for rinsing patient's mouth)
  • Vomit bowl (kidney dish)
  • Strapping (adhesive tape to secure the tube)
  • A receiver for used swabs/materials

Bedside:

  • Hand washing equipment (access to sink, soap, water, towel)
  • Screens (for privacy)
  • Stethoscope (for checking placement)
  • Patient's chart (for checking order and documentation)
  • Waste receptacle

Procedure (Passing Naso-Gastric Tube):

Steps Action Rationale
1. Observe the general rules. Promotes adherence to standards and patient safety.
2. Assist the patient to be in a sitting up position or lateral position if unconscious but slightly raised to an angle of about 450. Promotes patient ability to swallow during the procedure.
3. Explain the procedure to the patient (if conscious). Protect the patient's neck and chest with a mackintosh cape and towel. To gain cooperation, reduce anxiety, and protect the linen from soiling.
4. Assess the patency of the nostrils and clean the nostrils using orange sticks or gauze. Identify the preferred nostril (usually the more patent one). To facilitate easy passage of the tube and promote hygiene.
5. Wash hands and put on clean gloves. Minimize the risk of infection.
6. Measure the required length of the tube which should be inserted. This should start from the tip of the nose to the ear lobe, and then down to the xiphoid process (chest bone). Mark the measured distance on the tube with a small piece of tape. To ensure that the tube reaches the stomach.
7. Lubricate the tip of the tube (about 4-6 inches) with KY jelly or warm water. For easy insertion and to prevent traumatizing the mucous membranes.
8. Select the clear nostril and insert the lubricated tube gently, directing it backward and downward. To follow the natural passage and prevent trauma.
9. Once the tube reaches the nasopharynx (usually felt as resistance or gagging), ask the conscious patient to bend their head slightly forward (chin to chest) and swallow repeatedly (dry swallows or sips of water). Advance the tube as the patient swallows. Swallowing closes the epiglottis over the trachea and helps guide the tube into the esophagus. Bending the head forward helps close the airway entrance.
10. If the patient coughs or shows signs of respiratory distress (cyanosis, inability to speak), the tube may be in the trachea. Withdraw the tube immediately, allow the patient to recover, and re-attempt insertion. To prevent choking and aspiration.
11. Continue passing the tube until the measured length is reached. If there is any resistance, rotate the tube gently; avoid using force. Forcing against resistance can cause trauma to mucosa and cause anxiety.
12. Secure the tube temporarily with tape while checking for placement. To prevent displacement while confirming location.
13. Check to make sure the tube is in the stomach by:
a. Aspirating stomach contents with a syringe and testing aspirates with blue litmus paper. If blue litmus paper turns red (acidic), it indicates that the tube is in the stomach.
b. Injecting air (about 10-20 ml) using a syringe into the tube while listening over the stomach area with a stethoscope. A whooshing or bubbling sound should be heard as air enters the stomach.
c. X-ray confirmation (most reliable method, especially for critical patients or those at high risk of aspiration).		 Aspiration of contents provides evidence of placement. Testing pH confirms the acidic environment of the stomach. Hearing air confirms the location in the stomach. X-ray is definitive.
14. Once placement is confirmed, secure the tube firmly to the patient's nose or cheek with adhesive tape, avoiding pressure points. Ensure the tape is not too tight. Secures the tube in position and prevents dislodgement.
15. Clamp the end of the tube with a spigot or connect it to a drainage bag if the purpose is drainage or decompression. Prevents leakage or allows continuous drainage.
16. Clear away the equipment and ensure the patient is comfortable. Wash hands. Maintain cleanliness and patient comfort.
17. Document the procedure, including the date, time, type and size of tube, nostril used, measured length, method of placement confirmation, amount and characteristics of aspirate (if any), patient's response, and name/signature of nurse. To promote follow up and ensure continuity of care.

Points to Remember (Passing NG Tube):

  • Never force the tube if resistance is met.
  • Listen carefully for signs of respiratory distress during insertion.
  • Always verify tube placement before administering anything through the tube.
  • Change the tube as per policy or doctor's prescription (often weekly).
  • Ensure a communication system (e.g., pen and paper, bell) is available for the patient if they cannot speak.

Feeding the patient using a naso-gastric tube (PEX 2.1.10 - Continued)

Naso-gastric feeding can be given in two ways:

  • Intermittent feeding: Given at intervals as ordered by the doctor (e.g., four hourly).
  • Continuous drip: Given as a continuous infusion over a specified period (e.g., 24-hour period).

Requirements (Feeding):

Trolley:

  • Prepared feed (correct type, amount, and temperature)
  • A feed bowl of warm water (if feed needs warming)
  • A cup with warm water (for rinsing the tube)
  • A 50 ml syringe barrel or a funnel with tubing and connection (appropriate for the tube)
  • Vomit bowl (kidney dish)
  • Mackintosh cape and towel/dressing mackintosh
  • Stethoscope (for checking placement)
  • Spigot or clamp
  • Patient's chart
  • Waste receptacle

Bedside:

  • Hand washing equipment
  • Screens (for privacy)

Procedure (Feeding):

Steps Action Rationale
1. Observe the general rules. Promotes adherence to standards and patient safety.
2. Assist the patient to be in a sitting up position or lateral position if unconscious but slightly raised to an angle of about 450 (or higher, up to 90 degrees for conscious patients). Ensure patient is comfortable. Promotes patient ability to swallow (if conscious) and reduces the risk of aspiration during feeding.
3. Protect the patient's neck and chest with a mackintosh cape and towel. To protect the bed linen and patient's clothing from spillage.
4. Wash hands and put on clean gloves. Minimize the risk of infection.
5. Check tube placement and patency:
a. Aspirate stomach contents and check pH with litmus paper (should be acidic, pH 1-4).
b. Inject air (about 10-20 ml) while listening over the stomach with a stethoscope.
c. Observe for signs of distress (coughing, cyanosis) during injection of air.
d. Flush the tube with 10-20 ml of water to check patency and clear any obstruction.		 To confirm that the tube is still in situ in the stomach and is not blocked.
6. Prepare the feed. Ensure the feed is at the correct temperature (room temperature or slightly warmed in a warm water bath, 37°C-38°C). Check the feed amount as per order. To ensure patient comfort and prevent discomfort or cramping.
7. Pinch the tube and remove the spigot. Connect the syringe barrel or funnel to the end of the NG tube. To prevent air entry into the stomach.
8. Pour the warm water (about 10-20 ml) into the syringe barrel/funnel to prime the tube. Allow it to flow by gravity. To ensure patency and clear any residual material.
9. Pour the prescribed feed slowly into the syringe barrel/funnel. Adjust the height of the syringe/funnel (usually about 12-18 inches above the patient) to control the rate of flow by gravity. Do not push the feed. Allows gravity to facilitate flow and prevents overloading the stomach, reducing the risk of vomiting and aspiration.
10. As the level of the feed in the syringe barrel/funnel gets low, add more feed before it completely empties to prevent air from entering the stomach. To prevent entry of air into the stomach which can cause discomfort and distension.
11. After the feed has run through, rinse the tube with a prescribed amount of warm water (e.g., 10-20 ml or as ordered) to clear any remaining feed. Prevents clogging of the feeding tube.
12. Pinch the tube and remove the syringe barrel/funnel. Clamp the end of the tube with the spigot. To prevent leakage and air entry.
13. Keep the patient in the upright or semi-upright position (at least 30-45 degrees) for at least 30-60 minutes after feeding. To promote digestion and reduce the risk of regurgitation and aspiration.
14. Give the patient water to rinse the mouth and provide oral hygiene. To stimulate secretion of saliva and promote oral hygiene and comfort.
15. Clear away the equipment and wash hands. Maintain cleanliness and infection control.
16. Document the feeding, including the date, time, type and amount of feed given, amount of water for rinsing, patient's tolerance, any complications (e.g., nausea, vomiting, distension), and confirmation of tube placement method used. Monitor input and output, ensure continuity of care.

Points to Note (Feeding):

  • Always verify tube placement before each feeding or medication administration.
  • Never push feeds into the tube using the plunger of the syringe; allow gravity to control the flow rate.
  • Keep the patient in a semi-Fowler's or Fowler's position during and after feeding.
  • Monitor the patient for signs of intolerance such as nausea, vomiting, abdominal distension, diarrhea, or coughing.
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Vulva Toilet / Swabbing

Vulva Toilet / Swabbing (PEX 2.1.6: Perform Vulval Toilet (Swabbing))

Objectives:

  • State the indications for vulva swabbing.
  • Identify the requirements for vulva swabbing.
  • Prepare requirements for vulva swabbing.
  • Perform vulva swabbing procedure.
  • Prepare requirements for vulva swabbing.
  • Perform vulva swabbing procedure.

Indications:

  • To remove vaginal discharge.
  • To keep the vulva clean and dry.

Requirements:

A Trolley (Top Shelf):

  • 3 Bowels
  • 2 Receivers
  • Sponge holding forceps (or artery forceps)
  • Sims speculum (if needed for inspection/discharge)
  • 1 Drum of swabs
  • 1 Drum of cotton balls
  • 1 Drum of drapes
  • Antiseptic solution (e.g., warm sterile water, saline, or mild soap solution as per policy)

Bedside:

  • Bedpan (if patient is unable to use the toilet)
  • Mackintosh (or waterproof sheet)
  • Sanitary towels (or pads)
  • Screens (for privacy)
  • Hand washing equipment (access to sink, soap, water, towel)
  • Waste receptacle (for soiled swabs and pads)
  • Adequate lighting
  • Clean gloves

Procedure:

Steps Action Rationale
1. Observe the general rules. Promotes adherence to standards and patient safety.
2. Offer a bed pan if necessary. Promotes patient comfort and avoids interruption during procedure.
3. Position the patient in a dorsal position and cover the trunk. To enable easy performance of the procedure and provide privacy.
4. Place the dressing mackintosh and towel under the patient's buttocks. To expose the required part and protect the bed linen from soiling.
5. Assemble the equipment on the top shelf. To save time and ensure efficiency.
6. Wash hands and put on clean gloves. Prevents cross infection.
7. Drape the thighs. To minimize exposure and provide a sterile area.
8. Observe the vulva for any discharge or any abnormality. To provide appropriate intervention and assess the need for swabbing.
9. Separate the labia majora and minora with the left hand (non-dominant). Swab the vulva using a fresh swab held with forceps for each part, wiping from front to back (anterior to posterior). To provide a sterile area and prevent contamination from the anal region.
10. Swab the following areas, using a fresh swab for each stroke and discarding each used swab into the waste receptacle: - Left labia Majora - Right labia Majora - Left labia Minora - Right labia Minora - The vagina introitus - Perineum (if necessary) To ensure thorough cleaning and prevent spread of microorganisms.
11. Dry the vulva and perineum using a fresh swab or cotton ball for each stroke, wiping from front to back. Apply a sanitary pad as required. Promotes hygiene and comfort.
12. Turn the patient on her left hand side, clean and dry the perianal area with fresh swabs using a front to back motion. To prevent irritation and promote comfort.
13. Leave the patient in a comfortable position and ensure their privacy. To promote rest and comfort.
14. Clear away the equipment and wash hands thoroughly. Promotes hygiene and infection control.
15. Document the procedure, including the amount and nature of discharge, the patient's response, and any abnormalities observed. To promote follow-up and ensure continuity of care.

Points to Remember:

  • In case of too much discharge or if internal inspection is needed, a Sims speculum may be used to visualize the vaginal walls and cervix.
  • Always wipe from front to back (anterior to posterior) to prevent contamination of the urethra and vagina with fecal microorganisms.
  • Dispose of soiled materials immediately and appropriately in the designated waste receptacle.
  • Maintain clear communication with the patient throughout the procedure to ensure comfort and cooperation.
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Carryout admission transfer and discharge of patients

Topic: Carryout admission transfer and discharge of patients (Topic 2.5, PEXs 2.5.1 - 2.5.3)

Admission (PEX 2.5.1: Admit patients)

ADMISSION, OBSERVATION AND DISCHARGE OF PATIENTS

Admission Is the allowing of a patient(s) to stay in hospital for observation, investigation, treatment and care purposes.

Purpose (of Admission):

  • For proper management of the patient’s condition.
  • To assess the patient’s status from which a nursing care plan can be initiated and implemented.
  • To make the patient feel welcome, comfortable and at ease.
  • To acquire vital information regarding the patient for further management.
  • To monitor the patient’s progress and sudden changes; this produces fear and anxiety.

Types of admission:

  • Emergency admission: This means the patient are admitted in acute conditions requiring immediate treatment e.g. patient with accidents, poisoning, burns and heart attacks. Routine admission is postponed until the patient is out of danger.
  • Routine/planned admission: The patients are admitted for investigations, medical or surgical treatment given accordingly e.g. patients with hypertensions, diabetes and bronchitis. Preparation before the arrival of the patient on ward is started when the ward is informed of incoming patient and all the necessary items are made ready according to the patient’s condition.

General Rules on Admission:

  • Nurses should make every effort to be friendly and courteous with the patient (good nurse-patient relationship)
  • Make proper observations of the patient’s condition, record and report.
  • Orient the patient and relatives to hospital and ward policies.
  • Observe policies in dealing with medico-legal cases.
  • Deal with the patient’s belongings very carefully to prevent communicable diseases.
  • Isolate the patients who are suffering from communicable diseases.
  • The nurse should recognize the various needs of the patient and meet them without delay.
  • There is need to understand the fears and anxieties of the patient and help them to over come.
  • The nurse should find out the likes and dislikes of the patient and include the patient in his plan of care.
  • The nurse should address the patient by their name and proper title.
  • The patient’s valuables and clothes should be handed over to the relatives with proper recording.

Equipment needed for admission:

  • Admission bed
  • Vital observation equipment
  • Equipment used for physical examination such as weighing scale, inch tape measure etc.
  • Admission forms (patient’s case sheet, doctors, nurses’ and progress notes)
  • Investigation forms (blood, x-ray, urine stool and sputum)
  • Bath trolley if needed.
  • Complete record in a file.
  • Emergency treatments, oxygen apparatus, suction apparatus.
  • Admission book.

Procedure (Admitting a Patient):

  1. When the ward has been informed that a new patient is going to be admitted, a bed is prepared either; an admission bed for a seriously ill patient as this patient needs a bed bath OR an occupied bed for walking patient as s/he will be able to go to the bathroom.
  2. On arrival: - greet the patient and relatives and introduce yourself to them.
  3. Receive the patient cordially and seat them comfortably.
  4. Introduce the patient to other persons in the ward if necessary.
  5. Complete the admission record and should be filled in block letters especially full name, age, address, phone number if possible.
  6. Collect history and carry out simple physical examination e.g. vital observations, weight and consent form signed if required. The charts are filled by the nurse in charge.
  7. Issue visitor a pass or explain to the relatives rules about visiting hours and then they can leave. Do not let them go if you will need consent form signed in case of minors.
  8. Handover the patient’s valuables to the relatives if need be.
  9. Orient the patient to the ward; toilet, bathroom, drinking water supply, nurse’s station and treatment room.
  10. Help the patient to maintain personal hygiene and change into hospital clothes. A bed bath should be given to patients who cannot do it for themselves and those who can go to the bathroom depending on the condition.
  11. Encourage the patient to take hospital diet if any, especially when therapeutic diet is ordered.
  12. A specimen of urine should be obtained, tested or sent to the laboratory for investigation.
  13. A nurse should observe the patient, during the admission especially when giving a bed bath and note any obvious deformities or skin conditions and report or record in the patient’s chart.

Observations made on admission: The nurse should observe the patient for the following;

  • Observe the whole patient, whether weak, paralyzed, emaciated edematous, dehydrated etc.
  • Special observations:
    • Skin: color; pale, blue, jaundice, on touch, warm/cold, clammy or dry, sores, operation scars etc.
    • Eyes: yellow, infected, sunken
    • Mucous membrane: pale, blue, dry, moist, tongue; coated, conjunctiva; pale, infected
    • Skeletal system: deformities, injuries, wounds, paralyzed, gait.
    • Excreta: stool; color, quantity, smell, formed or diarrhea, with blood. Urine; color, quantity, smell, frequency. Vomit; frequency, quantity, content. Sputum; mucus, blood, purulent.
  • Vital observations: Temperature, Pulse rate, Respiration, Blood pressure.
  • Mental state: oriented, conscious, semi-conscious, unconscious, delirious.
  • Position in bed: posture
  • Facial expression: anxious, worried, feeling pain.

Equipment for diagnostic examination: All the equipment needed for the physical examination are kept ready at hand.

  • Sphygmomanometer
  • Stethoscope
  • Fetoscope
  • TPR tray (thermometer, wrist watch and patient’s chart)
  • Tongue depressor
  • Pharyngeal retractor
  • Laryngoscope
  • Tape measure
  • Flash light (torch)
  • Weigh machine and height measurement
  • Ophthalmoscope
  • Otoscope
  • Tuning fork and head mirror
  • Nasal speculum
  • Patellar hammer (percussion hammer)
  • Safety pins
  • Cotton wool
  • Cold and hot water
  • Snelle’s chart
  • Alcohol swabs
  • Drape or sheet
  • Dressing gauze
  • Gloves (sterile and non-sterile)
  • Lubricants
  • Pen light
  • Wool or cotton applicator
  • Skin pencil
  • Substance for testing smell (e.g. pepper, mint) and taste (sugar, salt)
  • Toilet paper
  • Swabs
  • Sponge forceps
  • Specimen containers and slides
  • Protoscope
  • Spatula
  • Vaseline or KY jelly
  • Hebitane/antiseptic lotion
  • Labels and lab forms
  • Test tubes and pipettes
  • Vaginal speculum

Methods of Examination:

  • Inspection: Visual examination of the body is called inspection. It is the observation with the naked eyes to determine the structure and functions of the body.
  • Palpation: It is the feeling of the body or parts with the hands to note the size and positions of the organs. In palpation the finger pads are used to feel, not the finger tips.
  • Percussion: Is the examination by tapping with the fingers on the body to determine the condition of the internal organs by the sound that’s produced. It is done by placing a finger of the left hand firmly against the part to be examined and tapping with the finger tips of the right hand.
  • Auscultation: It is the listening to sounds within the body with the aid of a stethoscope, fetoscope or directly with the ear placed on the body.
  • Others:
    • Manipulations: It is moving of the part of the body to note the flexibility. A limitation of movements is discovered by this method.
    • Testing reflexes: The response of the tissues to external stimuli is tested by the means of percussion patellar hammer, safety pins, wisp of cotton, hot and cold water etc.

ROLES OF NURSE BEFORE, DURING AND AFTER THE DIAGNOSTIC EXAMINATION

Before (Diagnostic Examination):

  • Nurse prepares patient by ensuring the patient understands and compliance with the pre-procedure requirements.
  • Reassurance of the patient and care taker/family.
  • Teach relaxation techniques e.g. deep breathing exercises.
  • Ensure the patient is in the **list of patients to be worked on**.
  • Collect the specimen for investigation including blood for grouping and cross matching.
  • Pass catheter if need be.
  • Nil per mouth if ordered by the physician.
  • Removal of objects e.g. jewellery or hair clips and any other object which will interfere with the procedure.
  • Ensure all supplies and equipment to be used available
  • Review patient’s history and physical information to determine current condition, chief complaint.
  • The patient’s identity is checked
  • Ensure safe keeping of the patient’s valuables
  • Determine current medications patient is taking, existence of allergies, history of drug use or abuse including tobacco and alcohol, adverse experience with anesthesia, sedatives or analgesics and last oral intake.
  • Reinforce physician’s explanations of procedure to patient and family-patient education.
  • Minimize anxiety through anxiety management techniques, ensuring short waiting time and offering reassurance and support
  • Ensure written consent is obtained
  • Obtain and document baseline data on patient; temperature, heart rate, and rhythm, respiratory status including oxygen requirements, depth of respirations, breath sounds and oxygen saturation, blood pressure, skin condition, level of consciousness and mental status, ability to ambulate, weakness and/or sensory loss in extremities (if indicated), and description and intensity of any current painful condition.
  • Pass I.V line and regulate continuous infusion at a keep open rate.
  • Prepare all drugs to be administered including readying reversal agents for possible administration.

During (Diagnostic Examination):

  • Administer medications under direct supervision of responsible physician.
  • Continuously observe and document patient responses.
  • Provide reassurance and emotional support throughout the procedure.
  • Inform the physician immediately of adverse response or any significant changes in baseline parameters.
  • Maintain continuous I.V line if required.
  • Perform emergency management procedure if necessary.
  • Continuous reassurance of the patient and care take (if any) during the procedure.
  • Encourage relaxation of the muscles.
  • Check the patient’s identification band to ensure the correct patient.
  • Review the medical record of allergies.
  • Assess vital signs including pain throughout the procedure.
  • Assist the physician with the procedure.
  • Assess the patient’s ability to maintain and tolerate the prescribed position.
  • Assess for related symptoms indicating complications specific to the procedure.
  • Remain with the patient during induction and maintenance of anesthesia.
  • Position, drape and monitor the patient’s condition e.g. monitor the patient’s air way.
  • Explain what the physician is doing so that the patient knows what to expect.
  • Label and handle the specimen according to the type of materials obtained.
  • Secure clients transport from the diagnostic area.

After (Diagnostic Examination):

  • Check the identification band and call the patient by name.
  • Assess the patient closely for signs of air way distress, adverse reaction to anesthesia or other medications.
  • Assess for bleeding in those areas where a biopsy was performed.
  • Continue monitoring the patient’s condition - observe and record the vital parameters
  • Position the patient in recommended position for comfort and accessibility to facilitate performance of nursing measures.
  • Assess and document vital signs including pain and monitor according to the frequency required for the specific test.
  • Notify the physician when any results are obtained from the diagnostic test
  • Reassure the patient and family
  • Maintain I.V line if required and administer medications prescribed.
  • Implement the physician’s orders regarding the post procedure care of the patient.
  • Evaluate the patient’s tolerance to exercises and oral fluids.
  • Record the procedure.
  • Notify the physician when the patient is fully alert or recovered for an order to discharge.
  • Review discharge instructions.

Transfer (PEX 2.5.2: Transfer patients) & Referral

REFERRAL/TRANSFER PROCEDURE Transfer/referral is the preparation of a patient and the referral records in order to shift or move the patient to another department within the same hospital or to another hospital/home.

Purpose (of Transfer/Referral):

  • To provide necessary treatment and nursing care
  • To provide specialized treatment/care
  • To obtain necessary diagnostic tests and procedures
  • To place most appropriate utilization of available personnel and services
  • To match intensity of care, based on the patient’s level of needs and problems

Types of transfer of the patient:

  • Internal transfer: Is the transfer of the patient to a unit that provided special care or care suiting to his needs within the hospital e.g. from the general wards to intensive care unit (ICU)
  • External transfer: Is the transfer of the patient from one hospital to another for the purpose of special care e.g. from a general hospital to a specialized hospital i.e. cancer centre/institute.

Equipment needed (for Transfer):

  • Wheel chair/stretcher (transport)
  • Identification labels
  • Patient’s belongings
  • Patient’s investigation records and file

Procedure (Transferring a Patient):

  1. Check the doctor’s order for the transfer of the patient
  2. Inform the patient and relatives, concerned department about the transfer of the patient.
  3. Assess the method for transport
  4. Inform the receiving ward in-charge/hospital where the patient is to be transferred.
  5. Check the patient’s chart for complete recording of vital signs, nursing care and treatment given.
  6. Collect all the patient’s investigation reports e.g. x-rays and help the relatives to collect other belongings.
  7. Maintain the patient’s physical well being during transport to a new nursing unit/hospital, as you assist his arrival to the new unit.
  8. Cancel the hospital diet of the transferring patient if she has been on special diet.
  9. Make arrangements to settle the due bills if going to another hospital.
  10. Record the date, time, mode of transfer and general condition of the patient by the time of transfer.
  11. Assist in transferring the patient to a wheel chair or stretcher and accompany the patient to the new area.
  12. On arrival, hand over the patient, documents, belongings and report verbally to the in-charge nurse of the receiving unit/hospital about the patient’s condition and what has been done.
  13. Collect the ward/previous hospital’s articles and come back with it (them)
  14. Clean the unit and equipment thoroughly and keep ready for the next patient/use.

Discharge (PEX 2.5.3: Discharge of patients)

(Note: The provided notes combine Admission, Observation, and Discharge in a single title, but detailed procedural steps specifically for "Discharge of patients" are not explicitly outlined as a numbered procedure in the same way as others in your document. Based on the context and common nursing practice, the discharge process typically involves ensuring the patient is medically stable, providing discharge instructions, arranging follow-up care, and completing necessary paperwork.)

Discharge of a patient is the process of formally releasing a patient from the hospital or healthcare facility. It is a planned process that begins early in the patient's stay.

Key aspects of the discharge process generally include:

  • Confirmation of medical stability and readiness for discharge by the physician.
  • Providing clear and understandable discharge instructions to the patient and/or family, including medication schedules, dietary restrictions, activity limitations, and wound care (if applicable).
  • Educating the patient and family on signs and symptoms to watch for and when to seek further medical attention.
  • Arranging for follow-up appointments or home healthcare services if needed.
  • Completing all necessary discharge paperwork and documentation.
  • Ensuring the patient has transportation arranged to their next destination.
  • Gathering and returning the patient's personal belongings.
  • Answering any final questions the patient or family may have.

Topic: Carry out sterilization and disinfection (Topic 2.6, PEXs 2.6.1 - 2.6.2)

Decontamination (PEX 2.6.1: Carry out decontamination)

Decontamination Is the process of rendering objects and surfaces free of most organisms and safe to handle and use.

Decontamination is often the first step in reprocessing reusable medical devices, making them safe for further cleaning, disinfection, or sterilization. It reduces the risk of exposure to healthcare workers handling contaminated items.

This PEX focuses on demonstrating:

  • Handling contaminated items safely using appropriate PPE.
  • Cleaning visible soil from instruments and equipment.
  • Soaking items in appropriate disinfectant solutions (if applicable) before further processing.
  • Using cleaning procedures to remove microorganisms (approximately 80% of microorganisms are removed during cleaning).
  • Following facility policies for handling and initial processing of contaminated items.

(Note: Detailed procedural steps specifically for "Decontamination" as a separate procedure were not provided in the original notes, but the concept is integrated into cleaning and sterilization protocols).

Sterilization (PEX 2.6.2: Carry out sterilization) & Disinfection

Sterilization Is the process by which the pathogens as well as spores and viruses are destroyed.

Sterilization aims to eliminate *all* forms of microbial life, including highly resistant bacterial spores. It is essential for items that will penetrate sterile tissue or enter the vascular system.

Disinfection Is the means of destroying pathogenic organisms carried out to render instrument and surfaces free for safe handling and use.

Disinfection reduces the number of pathogenic microorganisms but does not necessarily eliminate all spores. It is used for items that come into contact with intact skin or mucous membranes.

This PEX focuses on demonstrating:

  • Selecting the appropriate sterilization or disinfection method based on the type of item and its intended use.
  • Preparing items for sterilization or disinfection (e.g., cleaning, packaging).
  • Operating sterilization equipment (e.g., autoclave - if applicable and trained).
  • Using appropriate disinfectants at the correct concentration and contact time.
  • Handling sterilized or disinfected items aseptically.
  • Monitoring and documenting the sterilization or disinfection process.

Principles related to Sterilization and Disinfection from the notes:

  • Proper 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.
  • Disinfect, clean and sterilize items like **Drainage under water seal gadgets**.
  • Wash the flatus tube with soap and water, autoclave or sterilize the tube for 5 minutes.

Underpinning knowledge/ theory for Admission, Transfer, Discharge, Sterilization, and Disinfection:

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

  • General principles in patient care
  • Nursing procedures and applications
  • Ethics in nursing care (related to patient rights, confidentiality)
  • Infection prevention and control principles
  • Patient rights (relevant to admission/discharge)
  • Body mechanics (relevant to patient transfer)
  • Communication skills (relevant to admission/transfer/discharge/reporting)
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Carry out adequate feeding of patients

Adquate Feeding and Ward Reports

Carry out adequate feeding of patients (PEX 1.3.1)

Providing adequate nutrition is fundamental to patient recovery and well-being. Nurses assist patients who are unable to feed themselves due to weakness, physical limitations, or medical conditions.

Purpose of Assisting with Feeding:

  • Ensure the patient receives adequate nutrition and hydration.
  • Promote comfort and dignity during meal times.
  • Monitor the patient's food intake and tolerance to the diet.
  • Prevent aspiration (food or liquid entering the lungs).
  • Provide an opportunity for social interaction and assessment of the patient's condition.

Patients Requiring Assistance with Feeding:

  • Weak or fatigued patients
  • Patients with difficulty swallowing (dysphagia)
  • Patients with physical limitations affecting hand or arm movement
  • Confused or disoriented patients
  • Patients with vision impairment
  • Patients with tubes or devices affecting the mouth or throat

Requirements:

  • Patient's prescribed meal tray with appropriate food and drink
  • Feeding utensils (spoon, fork, knife - as needed)
  • Drinking straw or cup with lid
  • Napkin or cloth
  • Moist washcloth or wet wipe for hand/face cleaning
  • Towel or bib to protect clothing
  • Barrier cream if needed for skin protection
  • Gloves (if potential contact with body fluids or patient has infection)
  • Comfortable chair or bed in a quiet environment

Procedure for Assisting with Feeding:

  1. Perform hand hygiene and gather all necessary equipment.
  2. Verify the patient's identity and explain the procedure.
  3. Assess the patient's readiness to eat and their ability to participate.
  4. Assist the patient to a comfortable and safe position for eating, preferably sitting upright in a chair or high-Fowler's position in bed (at least 45-60 degrees). This helps prevent aspiration.
  5. Ensure the environment is clean and pleasant, minimizing distractions.
  6. Offer the patient a moist washcloth or wet wipe to clean their hands.
  7. Place the tray on a table within the patient's reach or on a bedside table.
  8. Describe the food items on the tray, especially if the patient has vision impairment.
  9. Assist the patient with cutting food if necessary.
  10. Offer fluids periodically throughout the meal to help with swallowing and hydration.
  11. Feed the patient small amounts, allowing them time to chew and swallow completely before offering the next bite.
  12. Use a spoon for feeding most foods; avoid using a fork for patients with dysphagia or poor coordination.
  13. Check for pocketing (food held in the cheeks) frequently, especially in patients with dysphagia.
  14. Observe for signs of swallowing difficulty or aspiration, such as coughing, choking, or wet vocal quality. If these occur, stop feeding immediately and notify the nurse in charge.
  15. Engage in conversation with the patient if appropriate, making the meal a social experience.
  16. Monitor the patient's food and fluid intake. Note how much of each item is consumed.
  17. After the meal, offer the patient a moist washcloth to clean their face and hands, and assist with **oral hygiene**.
  18. Return the tray to the appropriate area.
  19. Document the amount of food and fluid intake, any difficulties encountered, and the patient's response.
  20. Clean and store equipment, and perform hand hygiene.

Demonstrate giving and receiving of ward reports/records (PEX 1.3.7)

Effective communication during handoff is vital for patient safety and continuity of care. Ward reports (or shift reports) are structured exchanges of information between healthcare providers at the change of shift.

Purpose of Ward Reports:

  • To transfer essential information about patients from one shift to the next.
  • To provide a clear overview of the patient's current condition, treatment plan, and any changes or concerns.
  • To ensure continuity of care and prevent errors.
  • To provide an opportunity to ask questions and clarify information.
  • To prioritize patient care for the upcoming shift.
  • To meet legal requirements for accurate documentation.

Key Information to Include in a Ward Report:

  • Patient's name, age, diagnosis, and physician.
  • Current condition and significant changes since the last report.
  • Vital signs and other monitoring data.
  • Current treatment plan and any recent interventions.
  • Medications administered and patient response.
  • Results of recent **tests or investigations**.
  • Patient's level of consciousness and ability to communicate.
  • Status of **IV lines, tubes, drains, or other devices**.
  • Recent intake and output.
  • **Skin integrity** and presence of pressure areas.
  • Any safety concerns or fall risks.
  • Patient's emotional or psychological status.
  • Family involvement and concerns.
  • Planned procedures, appointments, or tests for the upcoming shift.
  • Specific nursing interventions required.

Methods of Giving/Receiving Ward Reports:

  • Verbal Report: May be given face-to-face, during walking rounds at the patient's bedside, or over the phone (less common for comprehensive reports).
  • Written Report: Often involves using a standardized form or electronic health record summary.
  • Walking Rounds/Bedside Report: Healthcare providers from the off-going and on-coming shifts visit each patient together to discuss the plan of care.

General Guidelines for Giving a Ward Report:

  1. Be prepared and organized. Have all necessary information and notes readily available.
  2. Reports should be clear, concise, and accurate. Focus on essential information and any changes.
  3. Maintain confidentiality; use a private area if giving a verbal report not at the bedside.
  4. Report in a systematic manner, usually by patient or room number.
  5. Highlight any critical information, urgent concerns, or potential risks.
  6. Allow time for the receiving nurse to ask questions.
  7. Document the report given according to facility policy.

General Guidelines for Receiving a Ward Report:

  1. Be present and ready to receive the report at the designated time.
  2. Listen actively and take notes as needed.
  3. Ask questions to clarify any unclear information or to gather more details about specific patients.
  4. Verify information if necessary (e.g., double-check medication orders or vital signs).
  5. Acknowledge understanding of the report.
  6. Prepare to prioritize care based on the information received.

Carry out adequate feeding of patients Read More »

Perform bladder and bowel care 

Perform bladder and bowel care (PEX 1.3.3)

Bladder and bowel care is vital for patient comfort, hygiene, and preventing complications like incontinence-associated dermatitis, UTIs, constipation, and fecal impaction.

This PEX focuses on demonstrating the skills required to:

  • Assess the patient's bladder and bowel function (e.g., continence, frequency, consistency).
  • Assist patients with using a bedpan or urinal (as detailed in the 'Giving a Urinal' and 'Giving a Bed Pan' sections below).
  • Provide perineal care as needed (as detailed in the 'Perineal Care' section below).
  • Implement measures to promote regular bowel elimination, such as offering fluids and fiber (within dietary restrictions).
  • Monitor and record output/elimination.
  • Identify signs of bladder or bowel issues and report them.

Giving a Urinal

Urinal is used for male patients to void the urine; the nurse should be able to assist the bed ridden patient to void into a urinal (a plastic or steel receptacle for urine in bed) by taking the penis with a towel and placing it into the urinal.

In case of female patients, a nurse should provide a bedpan for the bedridden to collect the urine.

Purpose:

  • To promote comfort
  • To assist to void
  • To prevent bed wetting
  • To maintain the urinary output record
  • To minimize the physical and emotional strain.

Timing of patients to void: It is advisable to offer the patient a bed pan or urinal at the following times;

  • Early morning when the patient wakes up.
  • Before doctor’s round in the morning.
  • After mid-day meal.
  • After 4PM tea.
  • After supper.
  • When a night nurse comes on duty, and further when necessary at night.

Requirements (for giving a urinal/bedpan):

Trolley:

Top shelf:

  • Gloves
  • Clean linen if required
  • Hand washing basin/mug and water
  • Soap in a soap dish
  • Basin and rowel

Bottom shelf:

  • Clean urinal/bed pan (female patient)
  • Measuring jar
  • Toilet paper if required
  • Mackintosh and draw sheet
  • Mackintosh and towel

At the bedside:

  • Screens

Procedure:

  1. Collect the equipment needed.
  2. Explain the procedure to the patient.
  3. Provide adequate privacy to help the patient relax and able to void.
  4. Wash hands thoroughly and put on gloves.
  5. Place the patient in a proper body alignment.
  6. Place a mackintosh and draw sheet on the bed to prevent soiling of the bed or the patient’s body.
  7. Lift the beddings or roll back and position the urinal so that the patient may grasp the handle and allow him place it rightly, if he is conscious or else position the penis into the urinal when he is not able.
  8. Remain with helpless patients, get assistance from relatives if need be.
  9. Remove the urinal/bed pan after the patient has voided.
  10. Assist the patient to wash the perineal area or dry up with the tissue for the case of female patients and to wash hands.
  11. Change the bed linen if required.
  12. Place the patient in a proper comfortable position.
  13. Measure and empty the urine in the sluice room and clean the urinal/bed pan ready for the next use. Specimen is kept if necessary or sent to the laboratory as ordered.
  14. Remove the gloves and wash hands after the procedure.
  15. Record the procedure and the findings to the patient’s chart and remember to fill in the amount in the fluid balance chart of the patient (input output chart)
  16. Report any abnormalities to the nurse in-charge or physician.

Giving a Bed Pan

Bed pan is made of steel or plastic device to meet the elimination need of the patient confined in bed. Bed pans are used by female patients for voiding and fecal elimination and males for elimination of feces.

Purpose:

  • To promote comfort
  • To facilitate bowel and bladder emptying.
  • To collect specimen for diagnostic purpose.
  • To promote continence during bowel and bladder training.
  • To give perineal wash.

Indications (for giving a bedpan):

  • patients with spinal injury
  • post operative patients
  • patients with fractures and on traction
  • chronic bed ridden patients
  • Patients who are on strict bed rest.

Requirements: Same as for giving a urinal, but with a Bedpan with lid on the Bottom shelf.

Procedure:

  1. Collect all the equipment needed.
  2. Explain the procedure to the patient and to assist in the lifting of the hip.
  3. Provide adequate privacy to help in elimination.
  4. Position the patient for easy lifting by lowering the head of the bed so the patient in in supine position.
  5. Wash hands and put on gloves.
  6. Place the mackintosh under the buttocks to prevent soiling.
  7. Assist the patient to lateral position using the side rail for support or 2nd nurse or relative.
  8. Place the warm, dry bed pan under the patient’s buttocks; powder the bed pan if necessary.
  9. While holding the bed pan with one hand, help the patient to roll on his/her back while pushing against the bedpan towards the center of the bed to hold it in place. OR
  10. Assist the patient to lift the buttocks while in supine position by supporting the back with the left hand and slip the bed pan under the patient’s buttocks placing it firmly and in a right position. If the patient is not able to lift him/herself, two nurses or three nurses should help to lift the patient onto the bedpan.
  11. Encourage the patient to assume a normal position for defecation if possible.
  12. Provide adequate time to pass motion/urine.
  13. Once the patient has passed, permit to clean self by giving a toilet paper. Assist to pour water to wash hands on completion.
  14. If the patient is unable to clean, pour water and clean using long artery forceps and cotton balls.
  15. Remove the bed pan by carefully lifting the patient with the help of more nurses if not able by him/herself. OR
  16. Ask the patient to raise his/her hips and withdraw gently the bed pan.
  17. Cover it immediately and dry the wet mackintosh or remove if an extra one was used.
  18. Secure or put back the draw sheet and position the patient comfortably.
  19. Bring the bed pan to the sluice room, empty, clean and disinfect if necessary. Dry and keep for the next use.
  20. Specimen may be kept if needed or sent to the laboratory as ordered.
  21. Remove the gloves and wash hands thoroughly after the procedure.
  22. Record and report the findings to the nurse in-charge or physician.

Passing a flatus tube (PEX 1.3.4)

INSERTION OF THE FLATUS TUBE A flatus tube is passed to relieve flatulence in the abdomen. It is a special kind of tube with the opening at the end, not at the side like the catheter.

A flatus tube is passed to relieve abdominal distention due to accumulation of gas in the lower bowel often after abdominal operation.

Requirement: Tray

  • Galipot of swabs
  • Galipot of lubricant
  • Bowl containing; flatus tube, glass connection, rubber tubing
  • Receiver for used tube
  • Receiver for used swabs
  • Dressing towel
  • Bowl of water
  • Gloves

Procedure:

  1. Collect the equipment needed for the procedure.
  2. Explain the procedure to the patient.
  3. Provide the patient with privacy using screens and closing of adjacent windows.
  4. Position the patient in a comfortable position e.g. in left lateral position.
  5. Wash hands and put on gloves.
  6. Place the mackintosh and towel in position.
  7. Connect up the apparatus and lubricate the flatus tube.
  8. Place the end of the rubber tubing under the water in the bowl and pass the lubricated end of the flatus tube 10-15cm into the rectum. Watch for air bubbles passing out of the end of the tube through the water.
  9. The tube may be left in position for 30 minutes if necessary. If not, remove the tube.
  10. Leave the patient comfortable and clear away.
  11. Wash the flatus tube with soap and water, autoclave or sterilize the tube for 5 minutes. Wash the equipment, dry and put away (keep for the next use).
  12. Remove the gloves and wash hands.
  13. Record the procedure and report the results to the physician or in-charge.

Administration of enemata (PEX 1.3.5)

ENEMAS/CLYSIS An enema is a solution introduced into the rectum and sigmoid colon to remove fecal matter and/or flatus. Enema can also be used to instill medications or nutrition (nourishment.) The commonest enema used is the cleansing enema. This type of enema stimulates peristalsis via irritation of the colon/rectum and by causing intestinal distention with fluid.

There are types of cleansing enema i.e. the large volume and small volume enema.

  • Large volume enema - is designed to clean the colon off as much feces as possible, between 500 to 1000ml of fluid is instilled into the colon.
  • Small volume enema - is designed to clear the rectum and the sigmoid colon off the fecal matter, between 50 to 200ml is most frequently administered using pre-packed disposal kit making it ideal for home care use.

Purpose:

  • To promote defecation by stimulating peristalsis (primary purpose) - purgative enema.
  • To relieve constipation or fecal impaction.
  • To prevent involuntary defecation during surgical procedure.
  • To promote visualization of the intestinal tract by x-ray film or instrument examination; diagnostic purpose - barium enema.
  • To help establish regular bowel function during bowel training program.
  • To relieve flatulence and fecal matter.
  • To reduce temperature e.g. cold enema.
  • To check diarrhea e.g. starch opium enema.
  • To cleanse the bowel before x-ray studies.
  • To induce anesthesia e.g. anesthetic enema.
  • To administer medications.
  • To destroy intestinal parasites e.g. anti-helminthic enema.
  • To administer fluids and nutrients (for nutrition)
  • To relieve inflammation.

Classification of enemas: Enema is classified as cleansing, retention and return flow/Harris flush enema.

Cleansing enema: Removes feces from the colon, the most frequently used solution types are; tap water (hypotonic), normal saline solution (isotonic), soap suds solution and low volume hypertonic solution.

The large volumes of solution may present a danger to the patient with weakened intestinal walls, so the suggested maximum volume according to age group of the patients are as follows;

  • Infant - 150-250ml at the T° of 100°F
  • Toddler - 250-350ml at the T° of 100°F
  • School age - 350-500ml at the T° of 100°F
  • Adolescent - 500-750ml at the T° of 100°F
  • Adults - 750-1000ml at the T° 105 to 110°F

N.B. Soap suds may be added to tap water or saline to create the irritating effect to the intestinal tract. Only pure castle soap is safe or plain yellow soap/soft soap. Soaps or detergents can cause serious bowel inflammation. The recommended ratio of soap solution is 5ml (1 tea spoon) of castle soap to 100ml of warm water or saline.

Retention enema: These are retained in the bowel for a prolonged period for different reasons as given below;

  • Oil enema - it is given to soften the fecal matter in cases of constipation, to make defecation easier. It must be retained for ½ or 1 hour, about 115 to 200ml of solution is administered to adults at the temperature of 100°F (37.8°C). The solutions used are olive oil, gingerly oil, castor at the ratio of 1:2.
  • Carminative enema - it is also known as antispasmodic enema. It is given to relieve gaseous distention of the abdomen by increasing peristalsis and expulsion of flatus. Common solutions used include 8 to 16ml of turpentine mixed thoroughly with 600ml to 120ml of soap solution, milk (warm) and molasses enema 90 to 230ml well mixed with equal quantity, and the MCW enema (30ml of magnesium sulphate, 60ml of glycerin and 90ml of warm water)
  • Medicated enema - used to administer medication that are absorbed through the rectal mucosa e.g. dexamethasone for ulcerative colitis, neomycin solution before bowel surgery.
  • Anti-helminthic enema - is given to destroy and expel intestinal parasites (worms). Cleansing enema must be given prior to anti helminthic enema so that the drug comes in to direct contact with worms and the lining of the intestines. The solution used is infusion of quassia 15gm of chips to 600ml of water or hypertonic saline solution (sodium chloride) 60ml with 600ml of water - amount of solution given is 250ml.
  • Nutritive/nutrient enema - it is given to supply food and fluids to the body rectally. Secretion of the fluids depend upon the ability of the colon to absorb it, nutrient enema is particularly useful in condition like hemophilia. The solution used is normal saline, glucose saline 250ml 5%, peptonized milk 120ml. amount of solution used is 110 to 1700ml in 24 hours or 180 to 270ml 4 hourly intervals. The temperature of the solution is 100°F (37.8°C)
  • Cold enema/ice-water enema - is given to reduce body temperature in hyper pyrexia and heat stroke. It is given in the form of colonic irrigations, the temperature of the solution is 80 to 90°F (27 to 32°C)
  • Glycerin enema - given to children, fever patients and post operative patients. Pure glycerin and water at ratio of 1:2 is given.
  • Astringent enema - given to contract the tissues and blood vessels and helps to check bleeding and inflammation hence lessening the amount of mucus discharge and gives temporary relief in the inflamed area. It is usually given in colitis and dysentery. The solution used are tannic acid 25g to 600ml of water, alum 30g to 600ml of water and silver nitrate 2%(silver nitrate is dissolved in distilled water)
  • Sedative enema - this contains an anesthetic drug to produce anesthesia in the patient. The commonly used drugs are paraldehyde and over tin, the dose given is as per the doctor’s order. Or starch and opium is given.
  • Stimulant enema - given to treat shock and collapse. Coffee enema is given in case of opium poisoning. Solution used are black coffee 1 teaspoon of coffee powder to 300ml of water and amount used is 180 to 240ml at the temperature of 108 to 110°F (42- 43°C)
  • Emollient enema/starch enema - given in case of diarrhea to relieve irritation in an inflamed mucous membrane. The solution used is starch and opium Tr, opium 1 to 2ml added to 120-180ml of starch mucilage or rice water at the temperature of 100 to 105°F (37.8 to 40.5°C)

Contraindications (Enemas):

  • Acute myocardial infarction and cardiac problems
  • Acute renal failure (sodium retention problem)
  • Dehydrated patients
  • Young infants
  • Appendicitis
  • Obstetrical and gynecological problems e.g. fistulae (RVF) etc.

Methods of giving enema:

  • Enema can and tube method - when large amounts of fluid are to be given, this method is used e.g. soap and water enema.
  • Funnel and catheter method - when small quantity of fluid is to be given, this method is used e.g. oil enema.
  • Glycerin syringe and catheter method - when small quantity of fluid is to be given, this method is used e.g. purgative enema.
  • Rectal drip method - when fluid is to be administered very slowly in -order to aid in its absorption e.g. nutrient enema.

General Rules (Enema Administration):

  • The appropriate size of rectal catheter or rectal tube of enema is affine Jacques or French 22’’ for adults, 12’’ for infants and 14 to 18’’ for school age children.
  • The rectal tube needs to be smooth and flexible.
  • The rectal tube is lubricated with water soluble lubricant or Vaseline to facilitate insertion and to decrease irritation of the rectal mucosa.
  • The temperature of the solution needs to be adjusted according to the purpose of the enema.
  • The amount of the solution to be administered depends upon the type of enema, the age and the size of the person.
  • The patient should be placed in left lateral position, when enema is to be administered. In this position the sigmoid colon is below the rectum thus facilitating instillation of the fluid.
  • The distance to which the tube is inserted depends upon the age and the size of the patient. For an adult it is normally 7.5 -10cm (3 to 4 inches), for children 2.5 to 3.75cm (1 ½ inches)
  • The height of enema should not be above 18 inches (20cm) from the anus.
  • The length of the time that enema solution is to be retained depends on the purpose. For example oil enema retention is usually for 2-3 hours and other cleansing enemas are normally retained for 5 to 10 minutes.
  • Pre-packed enema will have its own instructions which need to be followed.
  • Prevent air from entering into the rectum by expelling air from the tube.
  • If the rectum is impacted, attempt to remove the fecal matter with a gloved finger.
  • Make sure the whole apparatus used for the administration of enema is in good condition before beginning the procedure.
  • Regulate the flow of fluid according to the type of enema.
  • Listen to the patient’ complaints while giving the enema and do not ignore and discomfort however small it is.
  • The solution should be given slowly. So that the patient does not experience discomfort and expel the solution for the case of retention enema.

Requirements (Enema Administration):

Trolley:

Top shelf:

  • Funnel or enema can/container
  • Rubber tubing
  • Glass connection
  • Rectal catheter in different sizes according to the patient in a kidney dish
  • Gate clip/screw clamp and nozzle
  • Lubricant and applicator (Vaseline or KY jelly)
  • Swabs in galipot
  • Jug of fluid/solution
  • Thermometer for enema solution (lotion thermometer)
  • Gloves

Bottom shelf:

  • Receiver for used swabs and applicator
  • Receiver for used catheter
  • Bed pan or bedside commode, if patient will not be able to ambulate to the toilet.
  • Urinal with cover.
  • Toilet paper
  • Strapping and scissors
  • Mackintosh and towel
  • Sterile drainage bottle, if catheter to remain in position
  • Basin and wash cloth
  • Clean bed linen, if needed

At the bedside:

  • Screens
  • Hamper if necessary
  • I.V stand pole

Procedure (Enema Administration - Detailed):

  1. Collect all the necessary equipment needed.
  2. Explain the procedure to the patient.
  3. Position the patient in left lateral position
  4. Wash hands thoroughly and put on gloves.
  5. Attach tubing to enema can and clamp the tube.
  6. Prepare the solution at required temperature and check the temperature using bath thermometer.
  7. Hang the enema can/solution on I.V stand and adjust the height to 18 inches from the bed.
  8. Place the mackintosh and towel beneath the patient.
  9. If there is a question regarding the patient’s ability to hold the solution, place a bed pan on the bed nearby.
  10. Pour the solution into the can, expel the air and clamp the tube. Air entry into the rectum may cause discomfort.
  11. Lubricate the tube (tip) 5cm (2 inches)
  12. Separate the patient’s buttocks and visualize the anus clearly, insert rectal tube gently to a distance of 2-4 inches.
  13. Encourage the patient to take deep breaths during administration of the fluid.
  14. Clamp or pinch the rectal tube if the fluid is about to get over to avoid air entry.
  15. Remove the rectal tube and dispose it off properly.
  16. Instruct the patient to hold the solution for 10-15 minutes.
  17. Clean the lubricant, any solution, any feces from the anus with toilet tissue.
  18. Have the patient to continue to lie on the left side for the prescribed length of time.
  19. When the patient has retained the enema for the prescribed time, assist to the bedside commode or toilet or position in supine onto the bedpan.
  20. When the patient has finished expelling the enema, assist to clean the perineal area if not able to do so.
  21. Return the patient to comfortable position. Place the clean dry protective pad under the patient to catch any solution or feces that may continue to be expelled.
  22. Clear away, clean and replace the equipment.
  23. Remove gloves and wash hands thoroughly.
  24. Record the procedure to the patient’s chart and report any abnormalities to the nurse in-charge or physician.

Assignment: Read and make short notes on other types of enemas.

Carry out relevant investigations (PEX 1.3.6)

Nurses assist with various investigations to help diagnose and monitor patient conditions. This PEX involves demonstrating the ability to prepare for and assist with these investigations, potentially including collecting specimens or preparing the patient.

Based on the detailed notes, the procedure for Urine Testing is provided, which aligns with carrying out relevant investigations.

Urine Testing

URINE TESTING Is the observation and examination of urine in order to diagnose illness.

Points to observe and report (“CASDORA”)

  • C-Color
  • A-Amount
  • S-Specific Gravity
  • D-Deposits
  • O-Odor
  • R-Reaction (PH)
  • A-Abnormalities

Color: Normal urine color is clear amber. It can be pale if a lot of fluids is taken and darker when no or little fluid is taken, in this case the urine is described as concentrated.

  • Blood - small amount give smoky appearance, large amount give a red color.
  • Bile - small amount give a dark brown color (like strong tea), larger amounts give a brownish green color.

Amount: The average adult passes 1 to 1 ½ liters of urine in 24 hours depending on fluid intake.

Specific gravity: Is the density of fluid compared to that of an equal volume of water. The specific gravity of normal urine is 1010-1025.

Deposits: Urine contains 4% solids which are in solution. Deposits which may be found in urine are;

  • Mucus - this forms a white fluffy cloud at the bottom of the glass.
  • Urates - these form a pink deposit at the bottom of the glass. Usually present when urine is concentrated.
  • Phosphates - white sediment at the bottom of the glass.
  • Pus - this is seen as a white ropy deposit in the urine.

Odor: The characteristic odor of urine may be altered by the presence of;

  • Acetone - the urine has a sweet smell like new mown grass.
  • Infection - the urine may have an offensive fishy odor e.g. in gonorrhea.
  • Ammonia - this is due to decomposition of urine.

Reaction: Urine is normally acidic but becomes alkaline if allowed to stand for some time, due to the presence of ammonia. The reaction is tested using a litmus paper or multi test urine sticks. Acid urine turns the blue litmus paper red. Alkaline urine turns the red litmus paper blue. Urine which does not change the color of either litmus paper is neutral.

Multi-test urine sticks have an indicator strip which gives the reaction of urine in terms of ph. The stick is dipped into the urine and the color change compared with the given chart.

Abnormality: The abnormalities to be detected are;

  • Protein - color changes to green indicating that protein is present.
  • Sugar/glucose - if glucose is present, the color turns to blue.
  • Acetone (ketone bodies) - the color turns to mauve to dark purple depending on the amount of ketones present in the urine.

Requirements:

Tray:

  • Rack of test tubes
  • Reagent: Benedict’s solution
  • Acetest tablets
  • Esbach’s tube
  • Spirit lamps or candles or paraffin lamp
  • Glass container
  • Glass rode
  • Acetic acid, acetest powder
  • Uristix/clinistix tablets
  • Box of matches
  • Ethylated spirit
  • White paper/filter paper

Or (for testing with litmus/urine sticks)

  • Red and blue litmus paper or urine sticks
  • Clean gloves
  • Receiver for used litmus paper or urine sticks
  • Receiver for used gloves
  • Urine container (must be clean) and marked and urine in it
  • Pipette in a kidney dish or dropper/syringe
  • Urinometer
  • Pen and form to record

Procedure:

  1. Collect the equipment needed.
  2. Wash hands and put on the gloves.
  3. Observe the urine for color and deposits/appearance. Presence of pus and mucus, blood, phosphates etc. color amber yellow or not
  4. Measure the amount of urine using the measuring jar.
  5. Place the urinometer in the container containing urine allow it to float to measure the specific gravity.
  6. Use a dropper/pipette and drop the urine onto the litmus paper and observe the color to test the ph. Or dip the urine stick into the urine and color change compared with the given color in the chart.
  7. Clear away and wash hands thoroughly.
  8. Record the findings and report any abnormalities to the nurse in-charge or physician.

Testing Urine Abnormalities

Testing urine abnormalities involves specific chemical tests:

Abnormality Reagent Method Result
Protein (any of the methods may be used) Boiling method Urine must be acidic in reaction. If necessary add 2-3 drops of acetic acid
Half fill the test tube with urine; boil the top 1/3 over the lamp.
If a white cloud appears, add 2 drops of acetic acid.		 If the cloud persists, protein is present. Interpret according to the thickness of the urine.
Albustix Dip the treated end of the stick into the urine. Remove immediately and wipe the back part of the strip on the edge of the container to remove the extra urine. Compare with the scale on the container. Do not handle the treated end with fingers. The result is read immediately. A change of color will show the approximate amount of protein present as shown on the color chart.
Sugar/glucose Benedict’s test Put 5mls of Benedict’s reagent in a clean test tube and add 8 drops of urine. Boil the bottom end of the test tube for 2 minutes over a spirit lamp. Sugar is present if the color changes as follows: green +, yellow ++, orange +++, brick red ++++.
Clinistix Dip the treated end of the stick into the urine. Compare with the scale on the container. Do not handle the treated end with fingers. The result is read immediately. A change of color will show the approximate amount of sugar present as shown on the color chart.
acetone Acetest tablets/powder One acetest tablet is placed on a clean white surface. One drop of urine is put on to the table and results read in 30 seconds. The tablet turns mauve to dark purple depending on the amount of ketones present in the urine. Compare the color of the tablet to the color chart.
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