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Labour

It is described as the process by which the fetus, placenta and membranes are expelled through the birth canal after 28 weeks of gestation.
OR
It is defined as rhythmic contraction and relaxation of the uterine muscles with progressive effacement (thinning) and dilatation ( opening) of the cervix, leading to expulsion of the products of conception.

Normal labour

Labour is said to be normal when;

It occurs at term.
Spontaneous in onset.
Fetus presenting by vertex.
The process is complete within 12-18 hours.
No complications arise.
Both mother and fetus suffer no injury.
No assistance is given in any way.

THREE P’S OF NORMAL LABOUR

Powers – uterine contractions
Passage – pelvis including the size and shape.
Passenger – Size, position and presentation of the fetus as well as bag of fore waters or amniotic sac.

TYPES OF LABOUR

True labour: This is characterized by regular uterine contractions slight at 1 st but increase in severity and frequency causes the cervix to dilate.
False labour: It is characterized by irregular uterine contractions which do not cause the cervix to dilate. They are painful, appear stronger when a mother is in bed and weaker when she is up and moving around.
> No cervical dilatation.
> No show.
> Pain remains stationary in the lower abdomen.
> Pain is continuous without any rhythm.
> Pain reduces after enema.
> No associated hardening of the abdomen.

Signs of impending labour.

These changes occur in the last weeks of pregnancy. This is termed as pre-labour.

Lightening
About 2-3 weeks before the onset of labour, the lower uterine segment expands and allows the fetal head to sink lower. The symphysis pubis widens and pelvic floor becomes more relaxed and softened, allowing the uterus to descend further into the pelvis.
Cervical changes
As labour approaches, the cervix becomes “ripe”. It becomes softer, like a lower lip and there is some degree of effacement and slight cervical dilatation.
False labour: It consists of painful uterine contractions that have no measurable progressive effect on the cervix and this is an exaggeration of the usually painless Braxton hick’s contractions which have been occurring since about 6weeks of gestation. It may occur for days intermittently even 3-4 weeks before the onset of true labour.
Premature rapture of membranes: Normally, membranes rapture at the end of 1 st stage of labour. When rapture occurs before the onset of labour, it is termed as PROM and occurs in about 12% of women. In 90% of women with PROM, labour begins spontaneously within 24 hours.
Bloody show: A mucus plug created by cervical secretions from proliferation of cervical mucosal glands in early pregnancy serves as protective barrier and closes the cervical canal throughout pregnancy. Bloody show is the expulsion of this mucus plug.
Energy spurt: Many women experience an energy spurt approximately 24-48 hours before the onset of labour. After days or weeks of feeling tired (physically tired and tired of being pregnant) they get up one day to find themselves full of energy and vigor.
G.I.T upset: In the absence of any causative factors for the occurrence of diarrhea, nausea, vomiting and indigestion, it is thought that they might be indicative of impending labour and there is no known explanation for this.

SIGNS OF LABOUR

They are divided into two;

Premonitory signs
Actual signs

Premonitory signs
– Lightening
It occurs 2-3 weeks before onset of labour. The lower uterine segment expands and allows the fetal head to sink further so as to engage. The fundus nolonger crowds the lungs and breathing is easier and the mother experiences relief
– Frequency of micturition
Congestion in the pelvis limits the capacity of the bladder requiring it to be emptied more often
– Effacement of the cervix
This is the taking up of the cervix-the cervix is drawn up and gradually merges into the lower uterine segment.
– Braxton hick’s contractions.
They become exaggerated and mother becomes anxious. She experiences backache or pains while walking due to relaxation of pelvic joints. This makes the mother think that she is in labour.

Actual signs
– Regular uterine contractions.
Mother feels painful, rhythmic uterine contractions slight at first but increase in severity and frequency.
– Dilatation of the cervix.
This is enlargement of the external os from a circular opening large enough to permit passage of the fetus.
– Show.
This is a bloody mucoid discharge which comes from the cervical canal. When it dilates, blood
comes from the raptured capillaries.
– Plus or minus rapture of membranes.
This is not so much relied on because it can occur in late 1 st stage or spontaneously at birth of the baby.

Causes of onset of labour.

The exact cause remains unknown but appears to be a combination of hormonal and mechanical
factors.

Hormonal factors.
Theories regarding the initiation of labour include the following;
1. Oxytocin stimulation theory:
– Although the mechanism is unknown, the uterus becomes increasingly sensitive to oxytocin as the pregnancy progresses.
2. Progesterone withdrawal theory:
– A decrease in progesterone production may stimulate prostaglandin synthesis and enhance the effect of Oestrogen which has stimulating effect on muscles. The fall of progesterone reduces the
relaxing effect of the uterine muscles.
3. Oestrogen stimulation theory: Oestrogen stimulates irritability of uterine muscles and enhances uterine contractions.
The raise in estrogen stimulates the decidua to release prostaglandins. Both prostaglandins and oxytocin cause the uterus to contract.
4. Fetal cortisol theory:
Cortisol may affect the maternal Oestrogen levels.
5. Prostaglandin stimulation theory:
Prostaglandin stimulates smooth muscles to contract.
A combination of the above mechanisms is likely to initiate labour.

Mechanical factors
1. over stretching and over distension of the uterus
2. Pressure from the presenting part on the nerve endings of the cervix stimulates the nerve plexus (cervical ganglion)
3. The increase in the strength and frequency of Braxton hick’s contractions may cause labour to begin.

Stages of labour

First stage
It begins with onset of regular, rhythmic uterine contractions and is complete when the cervix
is fully dilated.
It is a stage of dilation of the cervix.
It’s divided into 3 phases
-Latent phase
-Active phase
-Transitional phase
Latent phase:
This is a period of slow dilation of the cervix from 0-3cm.
It may last 6-8hours in first time mothers
Active phase:
This is the time when the cervix undergoes more rapid dilatation. It begins when the cervix is 4cm dilated and ends when the cervix is 8cm dilated.
Transitional phase
It begins when the cervix is 8cm dilated and is complete when Its fully dilated.
–
Second stage
It’s that stage of expulsion of the fetus. It begins when the cervix is fully dilated and is complete when the baby is completely born.
It also has two phases
– The propulsive phase
– The expulsive phase

Propulsive phase: It starts from full dilatation up to the descent of the presenting part to the pelvic floor.
Expulsive phase:
It is distinguished by maternal bearing down efforts and ends with delivery of the baby.

3. Third stage
It’s that stage of separation and expulsion of the placenta and membranes and involves control of bleeding.
OR
It begins with birth of the baby and ends with expulsion of placenta and membranes.
It takes 5-30 minutes. With active management, its completed within 5-15 minutes.

4. Fourth stage
It is also called recovery stage. It is defined as the 1 st one hour after delivery of the placenta.

Labour Read More »

Antenatal Care

This is a planned methodological care and supervision given to a pregnant woman by a midwife or obstetrician from the time the mother starts attending antenatal clinic until beginning of labour.

Aims of antenatal care

To monitor the progress of pregnancy in order to support maternal health and normal fetal development.
To prepare the mother for labour, lactation and subsequent care for her baby.
To detect early and treat appropriately high risk conditions be it medical or obstetrical that would endanger the life of the mother and the baby.
This is achieved by;
Developing a partnership with the woman.
Providing a holistic approach to the woman’s care that meets her individual needs.
Promoting awareness of the public health issues for the woman and her family.
Exchanging information with the woman and her family enabling them to make informed choices.
Being an advocate for the woman and her family, supporting her right to choose care that is appropriate for her own needs and those of the family.
Recognize complications of pregnancy and appropriately referring women within the multi- disciplinary team.
Facilitating the woman to make an informed choice about methods of infant feeding and giving appropriate and sensitive advice to support her decision.
Facilitating the woman and her family in their preparations to meet the demands of birth and making a birth plan.
Offering health education for parenthood.

Activities done in ANC

Registration
Booking (history taking)
Special tests and investigations
Health education
Immunization
Treatment of minor disorders
Provision of supplements
Examination i.e. physical and abdominal
Orientation of mothers
Formulating a birth plan
counseling.
Referral of cases

INITIAL ASSESEMENT (BOOKING DAY)

Objectives for initial assessment(booking visit)
– To assess the level of health by taking a detailed history and to offer appropriate
screening tests
– To ascertain a base line data of blood pressure, urinalysis, uterine growth and fetal
developmentto be used as standard for comparison as pregnancy progresses.
– To identify risk factors by taking accurate details of the past and present obstetric,
medical, family and personal history.
– To provide an opportunity to discuss any concerns the woman has.
– To give advice pertaining to pregnancy in order to maintain the health of the mother and
the developing fetus.
– To build the foundation for a trusting relationship in which the woman and the midwife
are partners in care.
– To make appropriate referral when additional health care or support needs have been
identified.

HISTORY TAKING

Demographic data
Name
Age
Address
Occupation
NOK; relationship, occupation, contacts.
LOE
Tribe
Religion
Nearest health facility and distance from home.

Social history
Habits
-Smoking; Cigarettes have nicotine which constricts blood vessels leading to placental
insufficiency, which can result in fetal hypoxia, small for dates, abortions etc. The woman should be advised to reduce on the number of sticks gradually to avoid withdrawal syndrome.
-Alcohol; There is a risk of trauma which can result into abortion, placenta abruption, loss of appetite thus malnutrition and small for dates.
Marital status; -Married or single, number of years spent in marriage, find out if she’s happy or not.
Home environment
-House; – Rented or own, number of rooms and number of occupants.
-Environmental hygiene
-Source of water and food.

Family history
Health status of woman’s parents and her siblings (if deceased, note cause of death).
Familial diseases e.g. h/o cancer, diabetes, cardiac diseases, allergies etc.
Other serious illnesses like mental illnesses or complications with pregnancy.

History of multiple pregnancies.
Past surgical history
History of accidents involving the spine, pelvis and lower limbs which would reduce the pelvic diameters.
History of major operations like C/S, and pelvic operations.
History of blood transfusion(risk of exposure to HIV/AIDS and iso immunization)

Past medical history
-Medical conditions that may complicate or be complicated by pregnancy, labour and
puerperiume.g. sickle cell, DM, HTN.
-Child hood illnesses e.g. rickets, polio myelitis which can reduce pelvic diameters, hence
contracted pelvis.
-Infectious diseases like TB, HepB
-Infections like syphilis, gonorrhea,

Gynecological history
Gynae conditions like abortions, ectopic pregnancy, fibroids etc.
Gynae operations like myomectomy, D and C, evacuation etc.
Menstrual history
Menarche, length, interval, amount of flow.
Dysfunctional uterine bleeding (DUB).
Pre- menstrual spotting.
Family planning
Method of F/P ever used any complaint about it, reason for stopping it.

Past obstetrical history
Previous pregnancies; ask about any abnormalities e.g. abortions, still births, living children
and their health status and immunization status.

Interval between pregnancies, length of gestation, birth weight, fetal outcome, length of labour,
presentation and type of delivery. Prenatal and post natal complications, if baby was breast fed
and for how long.
Labour; Any operations, induction, assisted delivery, PPH.
Puerperium; If it was normal, any h/o sepsis, PPH.

Present obstetric history
Gravidity
Parity
LMNP
EDD. This is calculated by adding 9 calendar months and 7 days to the date of the 1 st day of the
woman’s last menstrual period (Naegele’s rule). This method assumes that:
The woman takes regular note of regularity and length of time between periods.
Conception occurred 14 days after the first day of the last period. If the woman has a regular
cycle of 28 days.
The last period of bleeding was true menstruation. Implantation can cause slight bleeding.
Break through bleeding and anovulation can be affected by contraceptive pill thus impacting on
the accuracy of LNMP.
WOA

Present health
– Appetite; It is important to know because poor appetite leads to malnutrition and anaemia.
– Sleep; Find out if the mother sleeps well, if not, find out the cause which could be due to
worries, insects in bed, pain and any signs of illness.
– Micturition; It’s good to know whether the woman passes urine well because UTI is
common in pregnancy due to stagnation of urine in dilated and kinked ureters. In case of
increased frequency without pain, mother is counseled in relation to physiology of pregnancy.

– Bowel action; as constipation is very common in pregnancy, the mother is re assured and
advised to take plenty of fluids and roughages.
NB: Conclude history by asking mother if she has anything else she would like to tell you.

INVESTIGATIONS

On the first day, every woman should receive the following investigations
Blood pressure
Weight
Height
Urinalysis; – for albumen, acetone and sugars.
Albumen is indicative of PET, acetone-
dehydration, sugar- diabetes.
RPR/VDRL; done to exclude syphilis.
HIV screening to ensure
Emtct
Blood grouping
Hb level; It should be done on booking day, then at 32-34 weeks and lastly at 36weeks to rule out anaemia.
Comb’s test; It’s done to detect anti bodies in blood.

Clinical Tests

Weight; this is taken on every visit to ANC. The mother is expected to gain 12.5kg during
pregnancy, 4kg in the first 20 weeks and 8.5kg in the last 20 weeks. Excessive weight gain could be due to twins, big baby, polyhydramnios etc. Failure to gain weight could be due to poor fetal growth.
Height; It’s done on the booking visit or in labour if the mother has not been attending ANC. The normal height should range 152-170cm, below 150cm indicates a small
pelvis and above 170cm indicates a narrow pelvis.
Shoe size; if below 5 indicates a small pelvis. Normal shoe size ranges between 5 and 8
Blood pressure; this is done on every visit to ANC. The BP of a pregnant mother ranges from 90/60 to 140/90mmhg.A raised BP is a danger sign and may be due to PET and eclampsia. Any rise of 30mmhg (systolic) and15-20mmhg (diastolic) from what has been considered normal is dangerous and the mother’s urine should be tested for proteins. The mother is asked how she feels generally especially her sight (blurred vision), then referred to the doctor.

PHYSICAL EXAMINATION

This includes a review of the physical systems to ascertain the woman’s general health. The breasts, pelvis and abdomen receive particular attention. The examination is carried out systematically beginning with the head and ending with the pelvis and abdomen.

General appearance;
Body type, weight, energy level, grooming, posture. This is noted when the mother is entering the room or when she is sitting.
Head;
Scalp, hair whether treated and hair pattern distribution.
Eyes; conjunctiva- check for anaemia, sclera- check for jaundice, visions, discharge.
Nose; Sense of smell, bleeding, obstruction, abnormal growth and discharge.
Oral cavity; Toothache, denture, state of lips, chewing or swallowing problems, tongue and gums for anaemia, sense of taste.
Ears; Check for discharges, any hearing loss.
Neck;
Movement, Palpate for swelling or enlarged salivary glands i.e parotid, sub mandibular, sublingual, thyroid, lymph nodes i.e. superficial cervical and deep cervical glands, sub clavicles.
Palpate and observe jugular veins and pulsation of the thyroid gland. Swelling of the thyroid gland may be due to iodine insufficiency though during pregnancy there is a slight enlargement of the glands may be due to chronic cough. Extended jugular veins may be due to cardiac problems or anaemia.
Upper limbs;

They should be two with the same size and length, skin texture and muscle wasting. Palms examined for the colour, finger nails if capillary refill is good and oedema.
Chest; see how the mother is breathing to detect if the mother has problems with respiratory
system like pneumonia.

Breasts;
– Inspection.
Observe for size, equality, shape, pulling of breasts.
Signs of pregnancy, signs of abnormalities like changes in skin e.g. redness, orange like discoloration.
Nipple for prominence, dimpling retraction, size, flat, well protracted or not.
Presence of scars, cracks, sores, axillary extension.

– Palpation
Examined for breast abnormalities and deep seated masses.
This is done to promote proper breast feeding and exclude abnormalities.
Back; Check for any fungal infections, scars, sacral oedema( may indicate PET or Eclampsia)
Lower limbs
Size, muscle wasting, pain or stiffness of joints, pain in the calf muscles, oedema, varicose veins, extra digits, any infections, tibia and ankle oedema.
Feet; Hygiene, any fungal infections, nails check for venous return and colour. Sole of the feet for cleanliness and colour.
Perform a Homan’s test
Assess for maternal efforts.
Vulva;
Check for sores, warts, varicose veins, abnormal discharges etc.

Request mother to cough while observing for discharges.

Abdominal examination

It is carried out from 24 weeks gestation to establish and affirm that fetal growth is consistent
with gestational age during pregnancy.

AIMS

To observe signs of pregnancy.
To assess fetal size and growth.
To assess fetal health by auscultating the fetal heart.
To detect any deviations from normal
To diagnose the location of fetal growth.
To locate fetal parts.

Preparation/ procedure:
> Ensure mother has emptied the bladder within the last 30 minutes before abdominal examination.
> Ensure privacy
> Mother should be on a couch.
> Wash hands and expose only the area of the abdomen that needs to be palpated and cover the remainder of the woman to provide her privacy and protect her dignity.

STEPS

Inspection
Palpation
Auscultation

Inspection

Stand at the foot of the bed while mother is on her back with abdomen exposed from the xymphy sternum up to the symphysis pubis. Look at the size, shape, operational scars, signs of pregnancy like darkening of linea nigra below and above the umbilicus, fetal movements,
Striae gravidurum etc.

Palpation

> Abdominal palpation is also known as leopold’s maneuvers.
Stand at the right side of the mother, pads and not tips of fingers are used and palpate
as follows;-
> Superficial palpation for localized tenderness.
> Hypochondriac palpation for enlarged organs.
> Height of fundus estimation
Pelvic palpation for presentation
> Fundal palpation for the lie
> Lateral palpation for position
NOTE: During a deep pelvic palpation, a midwife grips the fetal head between the thumb and fingers to check for engagement, this maneuver is termed as pawlik’s grip/second pelvic grip.

Auscultation

This is the way of listening the fetal heart to determine fetal wellbeing by use of feto- stethoscope.
Abdominal summary
-Height of fundus
-Presentation
-Lie
-Position
-Fetal heart.
Case summary

Comment on all histories, general and abdominal examination.
> Feed back
> Advice
> Return date

ONGOING ANC

PURPOSE

To continue to observe for maternal health and freedom from infections.
To assess fetal wellbeing.
To ascertain that fetus has adopted a lie and presentation that will allow vaginal delivery.
To offer an opportunity to express any fear or worries about pregnancy and labour.
To ensure that mother and family are confident to decide when labour starts.
To discuss any views about the conduct of labour and formulate a birth plan if required.
Risk factors arising during pregnancy
Change in fetal mov’t pattern- increased or reduced
Hb less than 10g/dl
Poor weight gain or weight loss
Proteinuria
Bp above 140/90mmhg
Uterus large or small for dates
Excess or decreased liquor
Malpresentation
Any vaginal bleeding
Premature contractions
Vaginal infection
Head not engaged by 38weeks in PGs

On each visit, do the following
> Review the card and assess any past complaints
> Take BP, weight and test urine
> Carry out general and abdominal examination.
> Give drugs accordingly.

Indicators of fetal wellbeing

Increased maternal weight in association with increasing uterine size.
Fetal movements which follows a regular pattern throughout pregnancy.
Fetal heart rate between 120-160b/m

FOCUSSED ANC

FANC is goal oriented care that is client centered, timely, friendly, simple beneficial and safe to
pregnant women.
> It emphasizes quality over quantity of antenatal visits.
> It also looks at a woman as an individual and schedules the visits according to her needs.
The aim of FANC is to provide timely and appropriate care to women during pregnancy to
reduce the maternal morbidity and mortality as well as achieving the good outcome for the baby.

Goals of FANC

Early detection and treatment of existing diseases.
Prevention of diseases.
Promotion and maintenance of physical, mental and social health of the mother and the baby.
Early detection and management of complications during pregnancy, labour, delivery and puerperium.
Supporting clients to develop an individual birth plan and readiness plan for possible complications.

Elements of FANC

Identification and management of obstetric complications e.g. pre- eclampsia.
TT immunization.
IPT for malaria.
Identification and management of infections including HIV and other STIs.
Counseling for healthy behavior including nutrition, breastfeeding and family planning.

Characteristics of effective ANC

Well organized and prepared healthy facility.
Provision of care from a skilled and motivated health care provider.
Preparations for birth and potential complications.
Individualized based on mother’s needs.
Promotes linkage among providers and facilities to ensure continuity of care.
Woman- friendly care and inclusive of her partner or family to become active participants in the care.
Culturally appropriate.

FANC VISITS

Women with normal pregnancy should receive atleast 4 thorough, comprehensive, individualized
antenatal visits, spread out during the entire pregnancy.

1st visit: before 16 weeks of gestation.
2nd visit: from 20-24 weeks of gestation.
3rd visit: from 28-32 weeks of gestation.
4th visit: from 36-40 weeks of gestation.

Women of high risks should make 8 visits to ANC and different activities should be done on different visits.

STEPS OF FANC

Quick check:
Observation as the woman enters antenatal clinic/ room.
-General appearance i.e. facial expression, weight, energy, gait and stature.
Asking general screening questions to identify danger signs and symptoms such as severe
headache , PV bleeding, fever etc.
History taking:
This helps the service provider gather information about a woman.
It is important to ensure comfort and keeping privacy and keeping the information confidential.
Physical examination:
– General appearance
– Blood pressure
– Pulse and respiratory rates
– Weight, height
– Head to toe assessment
Investigations
– Hb, blood group and RH factor.
– Urinalysis for UTIs, albuminuria and glucosuria
– Stool for ova
– VDRL/ RPR for detection of syphilis
– VCT for HIV
Health education:
– Danger signs

For any of the following, seek immediate attention at the health facility

Mother	Fetus
Heavy bleeding	Breathing difficulties or no breathing
Severe headache	Yellowness of skin and eyes
Swelling of the feet and hands	Conulsions, twitching
High fever	Poor sucking /failure to feed
Placenta not delivered 30 minutes of the baby’s birth	Inactive child
Offensive vaginal discharge	Diarrhea or constipation
Blurred vision	Red swollen eyes
Convulsions	Redness or pus from umbilicus
Loss of consciousness	------------------------------------------------------------

Individual birth plan

The plan includes

A birth place where there is a skilled birth attendant
Identifying someone to take care of the family in her absence
My EDD
Her choice of birth companion.
Identifying a blood donor.
Her choice of clothes for labour.
Strategies for labour pain relief.
Position for labour and child birth.
Place of delivery.
Transportation to use and how it will be available
How to raise funds for transport and cost of delivery.
Family security and feeding provisions.
Family planning goals after baby is born.
Where to go after delivery.
Next appointment.

NB: Involve the partner in the birth planning process. Teach mother how to recognize onset of labour.
– Nutrition
– Sleep and resting
– Sexual counseling
– Hygiene
– Daily activities
– Weight gain
– Postnatal follow-up

6. Immunization:
– TT

RECORD AND INTERPRETE FINDINGS

After taking proper history, done a thorough physical examination and relevant investigations, record all findings in the antenatal card.
Interpret the findings so as to identify the risk factors.
Give care and management accordingly.
Give appointment for the next visit accordingly.

Assignment
Discuss the goal oriented antenatal protocol.

PELVIC ASSESSMENT.

This is estimation of the pelvic cavity so as to see whether its adequate for that particular baby to pass through.
OR It is an examination done by a doctor or midwife on a pregnant woman at or after 36weeks to
see that both the mother and baby are out of danger at the time of delivery.

It is always done at 36weeks because of the relaxation of the pelvic joints due to Relaxin hormone.

Aims
> To rule out poor obstetric history
> To ensure normal delivery of the mother without any assistance.
> To rule out abnormalities like prominent ischial spines, narrow sub pubic arch.
> To reduce infant and maternal mortality rate.
> To reduce injuries to both mother and fetus.

Pelvic assessment is done in 2 ways;-
-External Pelvic assessment
-Internal Pelvic assessment

EXTERNAL PELVIC ASSESSMENT /EXTERNAL PELVIMETRY

This is done on the 1st visit. It includes;-

History taking;

Age – Awoman of the age of 18 years is expected to have a mature pelvis but below 18 years, the bones are not fully ossified. A PG 35 years and above is expected to have difficult delivery because the ligaments of the pelvis are already fused there4 her give of the pelvis is impossible.
Tribe – it’s important to know the tribe because different tribes have different types of pelvis.
The Bakiga and Banyankole have a large normal pelvis but the Basoga and Baganda are at risk of contracted pelvis.
Marital status – It’s important to know the size of the husband because small women marrying giant men may carry big babies which can lead to CPD(Cephalopelvic Disproportion)
Medical history – It’s important to know because some diseases like poliomyelitis may affect the
growth of the pelvic bones and muscles.
Surgical history – Ask mother if she has ever had any accident involving her spine, pelvis and lower limbs.
Past obstetrical history – If the previous labour and delivery were normal, and if the baby weighed atleast 3kgs and over, she is expected to have an adequate pelvis. Hx of instrumental delivery or C/S may give a suspicion of an inadequate pelvis.

2. Observations

Gait;– always be alert on a woman who walks with a limp or who has muscle wasting of the legs.
A poor gait means a deformed pelvis hence reduced diameter. It indicates congenital hip deformity.
Height;– the normal average height in women is between 152-170 cm, below 152cm, may indicate a contracted pelvis and if above 170cm indicates a narrow birth canal.
Palms;-Those with short palms indicate a small pelvis
Shoe size;– the normal shoe size is 4-8. Shoe size below 4 indicates small pelvis.
Stature;- A woman of small stature and tiny waist is not expected to have an inadequate pelvis.

3. Abdominal examination

ENGAGEMENT OF THE FETAL HEAD(Head fitting)
NB: It’s no longer being practiced for fear of HIV transmission.
Procedure

Explain the procedure to the woman.
The bladder should be emptied.
The mother is relaxed flat on the bed with support on the pillow.
The midwife with the right hand locates the symphysis pubis while the other hand is under the mother’s head.
The mother takes a deep breath in and out
The head is pushed downwards and inwards
The fingers of the right hand should feel if the largest diameter of the fetal head is passing through the brim as the mother is supported to sit upright without relaxing the elbows.
The transverse diameter can be pushed through the pelvic brim. This test is called head fitting.

NB: It’s important that from 36weeks onwards, the abdomen is palpated to see if the head is engaged or can be made to engage.

INTERNAL PELVIC ASSESSEMENT(DIGITAL PELVIMETRY)

It’s done under aseptic technique. The midwife should know the measurement of her fingers.

Procedure:

Explain procedure and ask mother to empty bladder and rectum.
Prepare a VE tray and put it on the side of the bed.
Screen the bed
Ask mother to lie on her back and carry out abdominal examination.
The midwife measures the length of her fingers.
Position mother in dorsal and drape her.Right hand is gloved and two fingers of the gloved hand are lubricated, introduced and passed high into the vagina. The following are assessed.
Sacral promontory;
An attempt is made to reach the sacropromontory by assessing the diagonal conjugate which is 12-13cm. If short fingers less than 12-13cm reach it that shows it’s prominent.
Hollow of the sacrum;
It should be well curved and smooth. It should not be too long, if it’s flat the cavity is reduced and internal rotation of the fetal head will be difficult.
Pelvic walls;
These are felt and theyshould be smooth and flat. If they converge down wards, the mid cavity is
reduced.
Greater sciatic notches;
These should feel wide. If reduced, internal rotation of the head will be difficult.
Ischial spines;
They are palpated to see whether they are prominent. The distance between them is estimated.
Sub pubic arch;
Is measured and should not be less than 90 degrees. It should accommodate 2-3 fingers. A narrow sub pubic arch reduces the AP diameter of the pelvic outlet. Inter tuberous diameter; The distance between 2 ischial tuberosities can be assessed by inserting a closed fist between them, it should admit 4 knuckles.

NB: After the assessment, record findings and give feedback to the mother.

Antenatal Care Read More »

Normal Pregnancy

Normal Pregnancy refers to growth and development of a fertilized ovum and begins from when the ovum is fertilized until the fetus is expelled from the uterus.

Normally the fetus is expelled at term or 9 months or 40 weeks or 280 days.
If the fetus is expelled before 28 weeks, it is called an abortion and if fetus is expelled after 28
weeks but before 37weeks it’s called premature labour and if born after 42 weeks, the post- mature is used.

Pregnancy is said to be normal when;

The fertilized ovum is growing in the cavity of the uterus.
One fetus is forming, one placenta and two membranes.
There is about 1000-1500ml of liquor amnii.
There is vertex presentation.
There is no bleeding until show in first stage of labour.
The mother should remain healthy with no serious disorders of pregnancy.

SIGNS AND SYMPTOMS OF PREGNANCY

When a woman misses a period or two, she may suspect pregnancy and in most cases she is 98% correct if she has been menstruating regularly.

Signs of pregnancy are divided into 3 groups.

Presumptive
Probable
Positive

Presumptive signs

1. Amenorrhea; This is absence of menstruation. Mother may give a history of missing a period or two.
Amenorrhea may also be due to;- use of contraceptives, change of environment, long term illness and emotional upsets.

2. Breast changes; Mother may feel tingling and prickling sensations, breast enlargement and tenderness.

3. Morning sickness(nausea and vomiting); Occurs to 30-50% of the cases, it usually occurs from 4 th -14 th week of pregnancy. Other conditions may give raise to nausea and vomiting but vomiting in conjunction with amenorrhea is suggestive of pregnancy.(may disappear at end of first trimester).

4. Frequency of micturition; Caused by pressure of growing uterus on the bladder usually before 12weeks and decreases when
the uterus rises out of the pelvis at 12 weeks.

5. Skin changes; –
– Striae gravidurum appears on the 16 th week on the abdomen, thighs and breasts.
-Chloasma(mask of pregnancy).
-Linea nigra darkens and can be found below and above the umbilicus.
-Darkening of primary areolar and formation of secondary areolar.
The hormone responsible for the pigmentation of skin is produced by anterior pituitary gland and
it’s called melamine hormone.

6. Quickening; These are the first fetal movements experienced by the mother usually at 18-20 weeks in a PG
and 16-18 in a multi gravida. This helps a midwife to calculate the weeks of gestation if a mother does not know her dates.

7. Fatigue; due to increased blood production, lower blood sugar levels, and lower BP under the influence of progesterone.
Sleep disturbances and nausea may also contribute

8. Mood changes; Due to physical stress, metabolic changes, fatigue or by hormones progesterone and oestrogen.

Probable signs

1. Hagar’s sign;
This is detected from 6th -12th week. It is detected by performing a vaginal examination where 2 fingers are inserted into the anterior fornix of the vagina and another hand presses the uterus abdominally, when the fingers of both hands meet, softening if the isthmus is felt.

2. Jacquemier’s sign;
Is the bluish discoloration of the vaginal walls. It takes place from the 8th week onwards and is due to pelvic congestion an indication of pregnancy.

3. Osiander’s sign;
Its increased pulsation felt on the lateral vaginal fornices due to increased vascularity detected from the 8th week onwards.

4. Softening of the cervix (goodel’s sign)
This happens from the 8 th week onwards. The cervix of a pregnant woman is as soft as the lower lip and in a non- pregnant state is as soft as a tip of the nose.

5. Uterine soufflé;
This is a soft blowing sound heard on auscultation. It usually occurs from the 16th week due to increased vascularity of the uterus.

6. Abdominal enlargement;
The uterus enlarges rapidly and progressively from the 16 th week. This excludes gaseous distension, full bladder, fibroids and ascites.

7. Braxton hick’s contractions;
These are painless contractions which usually occur from the 16th week and are felt on abdominal palpation every 15 minutes.

8. Internal ballottement;
The uterus is given a sharp tap just above the cervix which causes the fetus to float upwards in amniotic fluid. The fetus sinks back again and it is felt by the fingers fixed in the vagina. Its detected from 16th-28th week of pregnancy.

9. Presence of HCG(Human chorionic gonadotrophin);
It can be detected in blood for 9 days and in urine 14 days. HCG can be detected in conditions like hydatid form mole.

Positive signs.

Those are signs that are definitely confirmed as pregnancy. They include;-

1. Fetal heart sounds; fetal heart begins beating by the 24th week following conception. It is audible with a Doppler by 10weeks and with a fetoscope by 24weeks. It should not be confused with uterine soufflé from pulsating fetal arteries. The normal fetal heart rate is 120-160 beats per minute.

2. Ultra sound scanning of the fetus; the gestation sac can be seen and photographed. An embryo as early as the 4th week can be identified. The fetal parts begin to appear by the 10th week of gestation.

3. Palpation of the entire fetus; Palpation must include fetal head, back, upper and lower body parts.

4. Palpation of fetal movement; this is done by a trained examiner. It is elicited after 24weeks of gestation.

5. X-ray; It will identify the entire fetal skeleton by the 12 th week. In utero the fetus receives total body radiation that may lead to genetic or gonadal alterations .An x-ray is not a recommended test for identifying pregnancy.

6. Actual delivery of the baby.

DIFFERENTIAL DIAGNOSIS

Enlargement of the abdomen may be caused by other conditions other than pregnancy, these
include;-

Ovarian cysts.
They may cause abdominal enlargement and when palpated abdominally, the swelling can be separated from the uterus and pregnancy tests will be negative.
Fibroids.
These may be mistaken for pregnancy and normally a hard mass is felt and when pregnancy tests are done, results are negative.
Distended urinary bladder.
In case of urine retention, the catheter will be passed and there will be no other signs of
pregnancy.
Pseudocyesis. In this condition, amenorrhea and other signs suggesting pregnancy will be given by a mother who is anxious to have a baby. When examination is carried out, signs of pregnancy are absent.

PHYSIOLOGY OF PREGNANCY

These are normal natural changes that occur in the body due to pregnancy. These result mainly from alteration of hormones and metabolism.

CHANGES IN THE ENDOCRINE SYSTEM

Hormonal changes:
The placenta produces several hormones which cause a number of physiological changes.
Successful physiological adaptation of pregnancy is due to alterations in hormone production by
the maternal endocrine system and the trophoblast.
Human chorionic gonadotrophic hormone.
It is produced by the trophoblast. H.C.G levels increase rapidly in early pregnancy, maximum
levels being attained at 8-10 weeksof gestation. The main function of HCG is to maintain the
corpus luteum in order to ensure secretion of progesterone and Oestrogen until placental
production is adequate after 10-12 weeks after which concentration of HCG gradually decreases
until it has completely disappeared 2 weeks after birth.
Progesterone hormone;
This is produced mainly in the corpus luteum. Its function is to thicken the decidua in order to
receive a fertilized ovum. It helps to increase the glandular tissue, ducts of the breasts and muscle
fibres of the uterus.
Oestrogen;
It causes growth of the uterus and duct system of the breasts in pregnancy. It is excreted in urine
and amount present indicates fetal wellbeing.
Relaxin hormone;
During the last weeks of pregnancy, it acts on ligaments and joints producing the “give” of the pelvis. It is also produced by decidua and the trophoblast to promote myometrium relaxation and
may play a role in cervical ripening and rapture of membranes.
HPL ( human placental lactogen): It stimulates the growth of breasts and has lactogenic properties that affect a number of metabolic changes. These changes brought about by HPL ensure that glucose is readily available for body and brain growth in the developing fetus, and protects against nutritional deficiencies.
Pituitary hormones: The follicle stimulating hormone and L.H are suppressed by the high levels of Oestrogen and progesterone. The adrenal gland increases only slightly in size during pregnancy due to hypertrophy and widening in glucocorticoid area which suggests increased secretion of hormones.
Thyroid function: In normal pregnancy, the thyroid gland increases due to hyperplasia of glandular tissue and increased vascularity. There is normally an increased uptake of iodine during pregnancy which may be to compensate for renal clearance of iodine leading to reduced level of plasma iodine.

CHANGES IN THE REPRODUCTIVE SYSTEM

CHANGES IN THE UTERUS:

It stretches and expands to accommodate and nurture the growing fetus. This occurs in the
myometrium. The body grows to provide a nutritive and protective environment in which the fetus will develop and grow.

Uterine muscle layers;
1. Endometrium;
– Menstruation stops.
-It becomes the decidua during pregnancy.
-It becomes thick, soft, spongy and readily supplied with blood.

2 . Myometrium.

The enlargement of the body of the uterus is due to 2 factors.
1. The actual muscle fibres enlarge increasing in length about 10 times and in width about 3 times.
This process is called hypertrophy (increase in size).
2. The new muscle cells make their appearance and grow alongside the original muscle cells. This process is called hyperplasia (increase in number).
The size; as pregnancy advances, the uterus grows from its normal size. The length being 7.5cm,
width 5cm and thickness 2.5cm. So it becomes 30cm in length, 23cm in width and 20 cm in
thickness. The weight increases from 60g to 960g.
The shape; Health growth of the uterus requires adequate space to accommodate the growing fetus, increasing amount of liquor and placental tissue. After conception, the uterus enlarges
because of Oestrogen. At the beginning of pregnancy, it is pear shaped organ, at the end of 12 weeks, it is globular, from 12-38weeks its oval shaped and when lightening takes place after 38weeks, it turns back to globular.

Muscle layers of the myometrium;

Outer most longitudinal layer,
This layer begins in the anterior wall of the upper uterine segment, passes over the fundus and down the posterior wall. It is by contraction and retraction of this muscle layer that the fetus is expelled from the uterus during labour.
Middle oblique layer,
In this case, muscles are arranged in criss cross manner; the muscle cells surround the blood vessels in the figure of 8 pattern. After separation and expulsion of the placenta, they compress the blood vessels and help to prevent PPH. They are sometimes referred to as living ligatures.
Inner circular layer,
This is the weakest of the 3 layers, the muscle fibres pass transversely around the uterus. They are more developed around the cervix, lower uterine segment and the fallopian tubes. They help in cervical dilatation.

3. The perimetrium;
This is the layer of the peritoneum which does not totally cover the uterus, its deflexed over the bladder anteriorly to form the utero vesicle pouch and posteriorly forming pouch of Douglas. After 12 weeks, the uterus rises out of pelvis and becomes an abdominal organ. It loses its ante-version and ante flexed position and becomes erect and leans on its axis on the right.

CLINICAL OBSERVATIONS OF THE GROWING UTERUS

At 12 weeks

The uterus is out of the pelvis and becomes upright; it is no longer anteverted and ante flexed. The uterus is palpable just above the symphysis pubis and is about the size of a grape fruit.

At 16 weeks

Between 12 and 16 weeks, the fundus becomes dome shaped. As it rises, it rotates to the right (dextrorotation) due to the recto sigmoid colon in the left side of the pelvis and exerts tension on the broad and round ligaments.
The conceptus has grown enough to put pressure on the isthmus causing it to open out so that the uterus becomes more globular in shape.

At 20 weeks

The fundus of the uterus may be palpated at the level of the umbilicus. The uterus becomes more rounded around the fundus.

At 30 weeks

The fundus may be palpated midway between the umbilicus and ximphoid sternum. Enlarging uterus displaces the intestines laterally and superiorly. Abdominal wall supports the uterus and maintains the relationship btn the long axis of the uterus and axis of the pelvic inlet.
In supine position, the uterus falls back to the vertebral column, aorta and inferior venacava.

At 36 weeks

By the end of 36 weeks, the enlarged uterus fills the abdominal cavity. The fundus is at the tip of the ximphoid cartilage.

At 38 weeks

Between 38 and 40 weeks, there is increase in smoothening and softening of the lower uterine segment. Uterus becomes more rounded with a decrease in fundal height. The reduction in fundal height is known as lightening.

Changes in blood supply: The uterine blood vessels increase in diameter and new vessels develop under the influence of Oestrogen. Blood supply to the uterine and ovarian arteries increases to about 750ml/ min at term to keep pace with its growth and meet the needs of the functioning placenta.

Changes in the fallopian tubes: On either side are more stretched out and are more vascular in pregnancy. Uterine end of the tube is usually closed and fimbriated end remains open.

Changes in the isthmus;
It softens and elongates from 7mm to23mm and forms the lower uterine segment during late pregnancy.

Changes in the ovaries:
The follicle- stimulating hormone {FSH} ceases its activity due to the increased levels of estrogen and progesterone secreted by the ovaries and corpus luteum .This prevents ovulation and menstruation. As the uterus enlarges, the ovaries are raised out of the pelvis. Also both ovaries are enlarged due to increased vascularity and become edematous particularly that containing the corpus luteum.
The corpus luteum enlarges during early pregnancy and may even form a cyst on the ovary. The corpus luteum produces progesterone to help maintain the lining of the endometrium in early pregnancy. It functions until about the 10th and 12th week of pregnancy when the placenta is capable of producing adequate amounts of progesterone and estrogen. It slowly decreases in size and function after the 10th to 12th week.

Changes in the cervix:
It remains tightly closed during pregnancy, providing protection to the fetus and resistance to pressure from above when the woman is in standing position. There is slight growth on the cervix during pregnancy, it becomes softer and this is due to increased vascularity and relaxing effects of hormones.
Under the influence of progesterone racemose glands secrete thicker and more viscous mucus which fills the cervical canal and prevents entry of infection in the uterus. The plug of mucous is called opeculum
Towards the end of pregnancy or at the onset of labour the cervix becomes part of the lower
uterine segment, this is called effacement of the cervix. The external os of the cervix also admits a finger. A short softened cervix or os which admits the
tip of a figure at term is referred to as ripe cervix.

Changes in the vagina:
The muscle layer hypertrophies and capacity of vagina increases and it becomes more elastic
allowing it to dilate during 2 nd stage.
The epithelium becomes thicker with increased desquamation of the superficial cells which
increase the amount of normal white virginal discharge known as leucorrhea. The epithelial cells have high glycogen content. The cells interact with Do-derlein’s bacillus and produce a more acidic environment providing extra degree of protection against some organism and increasing susceptibility to others such as candida albicans. The vagina is more vascular and appears violet in colour.

Changes in the vulva:
The vulva appears bluish in colour due to increased vascularity and pelvic congestion.

Breast changes:
-In early pregnancy, breasts may feel full or tingle and increase in size as pregnancy progresses.
-The nipples become more erectile.
– The areolar of the nipples darken and the diameter increases.
– The sebaceous glands become the Montgomery’s tubercles which enlarge and tend to
protrude.They secrete sebum to lubricate the breast throughout pregnancy and breast feeding.
– The surface vessels of the breast become visible due to increased circulation and turns to bluish
tint on the breasts.
-A little clear, sticky fluid(colostrum) may be expressed from the nipples after the 1 st trimester
which later becomes yellowish in colour.

Changes in the cardiovascular system:

The heart
Due to increased work load, the heart hypertrophies particularly in the left ventricle. The uterus pushes the heart upwards and to the left. Heart sounds are changed and murmurs are common.
The cardiac output is increased by 40%. The heart rate increases by an average of 15 beats per minute. The stroke volume increases from 64 to about 71mls.

Effect on blood pressure
During the first trimester, blood pressure remains almost constant. BP drops in 2 nd trimester due to hormone progesterone which causes vasodilation. It reaches its lowest level at 16-20 weeks and towards term, it returns to the level of the first trimester. The decrease may lead to fainting.
Supine position should be avoided in pregnancy as it leads to supine hypotensive syndrome due to compression of the inferior venacava thus reducing venous return. Poor venous return in late pregnancy may lead to oedema in lower limbs, varicose veins and hemorrhoids.

Blood flow
Blood flow increases to uterus, kidneys, breasts and skin but not to liver and brain. Utero
placental blood flow increases by 10-15% about 75mls per minute at term. Renal blood flow increases by 70-80%.

Blood volume
Increase in blood volume varies according to the size of the woman, number of pregnancies she has had, parity and whether the pregnancy is singleton or multiple.
The total blood volume increases steadily from early pregnancy to reach a maximum of 35 to 45% above the non- pregnant level. A higher circulating volume is required for the following;
-To provide extra blood flow for placental circulation.
-To supply the extra metabolic needs of the fetus.
-To provide extra perfusion of kidneys and other organs.
-To compensate for blood loss at delivery.
-To counterbalance the effects of increased venous and arterial capacity.

Plasma volume
Increases by 40% where the red cell mass decreases by 20%leading to haemodilution (physiological anaemia). These changes begin at 6-8weeks of pregnancy. The acceptable Hb level in pregnancy is 11-12g/dl.

Iron metabolism
Iron of about 1000g is needed. 500g is to increase the red cell mass, 300g to fetus and 200g for daily iron compensation.

In normal pregnancy, only 20% of ingested iron is absorbed. The purpose of iron supplementation is to prevent iron deficiency anaemia not to raise Hb level.

Plasma protein
During the 1st 20 weeks of pregnancy, plasma protein concentration reduces due to increased plasma volume. This leads to lowered osmotic pressure leading to oedema of lower limbs seen in late pregnancy. In absence of disease, moderate oedema is termed as physiological oedema.

Clotting factors
Fibrinogen 7,8,9 and 10 increase leading to a change in coagulation time from 12 to 8 minutes.
The capacity of clotting is increased in preparation to prevent PPH after separation of the placenta.

White blood cells.
These are slightly increased during pregnancy, from 700mm to 10500mm during pregnancy and up to 1600mm during labour. The total count cells rises from 8 weeks and reaches a peak at 30 weeks of gestation. This is mainly because of the increase in the number of neutrophils, polymorphs, nucleus, leucocytes, monocytes and granulocytes are active and efficient phagocytes.

Erythrocytes.
They decrease during pregnancy from 4.5million to 3.7million.

HB.
HB concentration falls from 14g/dl; a falling HB is a physiological. The total iron requirements of pregnancy where as a high HB level can be assign of pathology. The total requirements of
pregnancy is averagely 1000g ,about 500gare required to increase the red cells mass and about 300g are transported to the fetus mainly in the last weeks of pregnancy . The remaining 200g are needed to compensate for insensible loss in skin, stool and urine.

RESPIRATORY SYSTEM.
The basal metabolism rate is increased and the volume of air which enters and leaves the lungs during the normal respiration becomes slightly increased. This is because of increased oxygen consumption by the fetus and the work of maternal heart and lungs.
In the late pregnancy the ribs flare out inhibiting the capacity of the thoracic cavity to expand, the enlarging uterus elevates the diaphragm up wards and compresses the lower lobes of the lungs

CHANGES IN THE URINARY SYSTEM
Renal blood flow and glomerular filtration rate increases by 50%.
There is frequency of micturition in early and late pregnancy. Ureters become elongated and kinked due to progesterone hormone and this results into urine stagnation hence increased favor to UTI in pregnancy.

CHANGES IN THE GIT
-The gums become edematous, soft and spongy and may bleed.
-Increased salivation(ptyalism) is common.
-Nausea and vomiting is common in 70% of the cases.
-Changes in taste becoming metallic.
-Craving for abnormal things like soil or plaster known as pica.
-Increased appetite in most women.
-Heart burn due to of stomach content from decreased space by growing uterus.
-There is reduced GIT motility leading to constipation.

Changes in metabolism
– There is increased metabolism to provide nutrients for the mother and fetus.
-Maternal weight, There is continuing weight increase in pregnancy which is an indication of
fetal growth.
Weight gain in pregnancy is as follows;-
4kg in the 1 st 20 weeks(0.2kg/week)
8.5kg in the last 20 weeks(0.4kg/week)
12.5kg approximate total.

Maternal weight gain
Content weight
Uterus 1kg
Breasts 0.4kg
Fat 3.5kg
Blood volume 1.5kg
Extra cellular fluid 1.5kg
Total7.9kg
Fetal weight gain
Fetus 3.4kg
Placenta 0.6kg
Amniotic fluid 0.6kg
Total4.6kg
GRAND TOTAL12.5kg

The following factors influence weight gain.
Maternal oedema.
Maternal metabolic rate.
Dietary intake.
Vomiting or diarrhea.
Amount of amniotic fluid.
Size of the fetus.

CHANGES IN THE MUSCULO-SKELETAL SYSTEM
Progesterone and Relaxin lead to relaxation of pelvic ligaments, joints and muscles. The relaxation allows the pelvis to increase its capacity in readiness to accommodate the presenting part towards term and also during labour. The symphysis pubis and sacroiliac joints soften, the gait of the mother changes as the balance of the body is altered by the weight of the
uterus. Allowing the pelvis to increase its capacity towards term is a process known as a give.

SKIN CHANGES
Increased activity of melanin-stimulating hormone from the pituitary causes varying degrees of pigmentation in pregnant women from the end of 2 nd month until term.The areas that are commonly affected are; areolar of the breasts, abdominal mid line, perineum and axilla. This is because of increased sensitivity of the melanocytes to the hormone or because of greater number of melanocytes in these areas.
-Linea nigra. This is a dark line that runs from the umbilicus to the symphysis pubis and may
extend as high as the sternum. It is hormone induced pigmentation. After delivery, the line begins to fade though it may not ever completely disappear.
-Mask of pregnancy(Cloasma). This is the brownish hyper pigmentation of the skin over the face, fore head, nose, cheeks and neck. It gives a bronze look especially in black complexioned
women.
-Striae gravidurum(stretch marks).
-Sweat glands. Activity of the sweat glands usually increases throughout the body which causes the woman to perspire more profusely during pregnancy.
– A rise in body temperature of 0.5 and increase in blood supply causes vasodilation and makes
woman feel hotter.

MINOR DISORDERS OF PREGNANCY

These are referred to as minor because they are not life threatening.
The causes can be;-

Hormonal changes
Accommodation changes
Metabolic changes and
Postural changes

DIGESTIVE SYSTEM
Nausea and vomiting (morning sickness)
This is due to hormonal changes progesterone and Oestrogen and high level of HCG, it occurs from 4-16 weeks. This decreases when the placenta fully takes over.
Management
-Light snacks
-Carbohydratesnack like cassava, a hard crackers
-Avoid sweet things
-Coming out of the bed slowly.
Heart burn
Burning sensation in the media sternal region progesterone relaxes the cardiac sphincter and allows reflux of gastric contents into esophagus most troublesome between 30-40 weeks, because of pressure on stomach from growing uterus.
Management
-Avoid bending

-Small frequent meals
-Sleeping with more pillows
-Persistent heart burn antiacids like magnesium triscilicate.
Excessive salivation (ptyalism)
From 8 weeks, hormones are thought to be the cause. It may accompany heart burn. Counseling is helpful.
Constipation
Progesterone cause relaxation of the plain muscles and decreased peristalsis of the gut.
Management
-Increased intake of water, fresh fruit, vegetables and whole meal foods in diet.
-Glass of warm water in the morning, before tea and breakfast may activate the gut.
– Exercise can be helpful especially walking.
Aperients are only considered as a last resort.
Pica
This is when a mother craves for certain foods or unnatural substances.
The cause is unknown but hormones and changes in metabolism are attributed to it.

MUSCULO SKELETAL SYSTEM
This can be due to hormones Relaxin. Discuss with woman and let her be aware, it will
disappear after delivery.
Leg cramps
Cause of leg cramp in pregnancy is unknown may be due to ischemia or a result from changes in PH or electrolyte status.
Management
-Mother to dorsiflex the foot and raise foot of bed.
-Gentle leg movement before sleeping at night.
-Others-use of vit B complements and calcium.

Backache
The weight of the pregnant uterus and altered posture increase susceptibility which is exacerbated by progesterone and Relaxin causing relaxation and softening of ligaments of the pelvis.
Management
-Avoid high heeled shoes.
-Sit on a comfortable chair or support the back on a wall while seated.
-Have extra rest during the day.

CIRCULATORY SYSTEM
Fainting
In early pregnancy, it may occur due to vasodilation under the influence of progesterone before there has been a compensatory increase in the blood volume.
Management
-Avoid long standing periods.
-Quickly sit or lie down if feels slightly faint,
-Mother should avoid lying on her back except during abdominal examination.
Vericose veins
-Progesterone relaxes smooth muscles of veins and results in sluggish circulation. Varicose veins
may occur in legs, anus and vulva.
Management
During pregnancy
-Support tights increase comfort eg stockings.
-Avoid constipation.
-A sanitary pad may give support.
-Use a crepe bandage on affected leg from below upwards before getting out of bed in the
morning and remove it at night.
-The affected leg should be elevated when resting.

-advise mother to see the doctor if varicose veins appear on the vulva.
-In case of severity, book mother for hospital deliverysince they can easily rapture and cause
severe bleeding.
During labour
-Inform doctor.
-Take off blood for Hb, grouping and x-matching.
-Be careful when shaving the vulva and when performing an episiotomy.
-Sedatives are given to prevent premature pushing.
Hemorrhoids
These are veins of the vulva or rectum and they usually occur due to constipation. They can be painful, edematous and ulcerative.
Management
-Advise mother on diet to avoid constipation.
-Use cold compress gently on the area.
-Doctor may order analgesic like anusol.

Heart palpitations
This occurs due to increased functioning of the heart to meet the demands of the growing fetus
and mother.

NERVOUS SYSTEM
Carpal tunnel syndrome
The mother complains of numbness, pins and needles in her fingers and hands.
It’s caused by fluid retention which causes oedema and pressure on the median nerve by compressing it.
Management
-Wearing a splint at night and rising hands on a pillow at night.

-If it persists, refer to doctor who will give diuretics.
Insomnia
This is failure to get sleep and may be caused by worries, anxietyand it shouldn’t be taken
lightly.
Emotional instability
Hating, irritation,loving i.e. willing to stay closer to partner.

GENITAL URINARY SYSTEM
Leucorrhoea
This is increased, non- irritant, vaginal discharge.
Management
-Ensure hygiene if distressing.
-Wear cotton under pants for easy absorption.
Frequency of micturition
This occurs in early pregnancy when the growing fetus is still in the pelvic cavity and late pregnancy when the PP descends and competes for space needed by bladder.

INTEGUMENTARY SYSTEM
Itching of the skin
This can be due to Striae gravidurum, poor hygiene, heat rash and minor skin rashes.
Management
-Wear cotton clothes which are non-irritating.
-Advise on personal hygiene.
-Apply calamine lotion in case of skin rash.

Disorders which require immediate action

Vaginal bleeding.
Reduced fetal movements.
Frontal or recurrent headache.
Sudden swelling or oedema.
Early rapture of membranes.
Premature onset of contractions
Maternal exhaustion at whatever extent.
Fits.
Excessive nausea and vomiting.
Epigastric pain.

Normal Pregnancy Read More »

Terminologies

TERMS USED IN MIDWIFERY

Midwifery: It is profession of providing assistance and medical care to women undergoing labour and child birth during antenatal, pre-natal and postnatal period.

Obstetrics: This is abranch of medicine dealing with pregnancy, labour and puerperium.

Caesarian section: Is an incision made on the uterus through the anterior abdominal wall to remove products of gestation after 28weeks of gestation.

Cephalic: Means head.

Cervix: Is the neck of the uterus

Colostrum: This is afluid found in the breast from the 16 th week of pregnancy up to 2 nd and 3 rd day after delivery.

Crowning: This is wherethe largest transverse diameter of the fetal skull escapes under the sub pubic arch and does not recede back between contractions.

Gestation: Pregnancy or maternal condition of having a developing fetus in the body.

Fetus: Human conceptus from the 9 th week to delivery.

Viability: Capability of living usually accepted 24weeks-28 weeks although survival is rare.

Gravida: Woman who is or has been pregnant regardless of pregnancy outcome.

Prime gravida: Woman pregnant for the first time.

Multi gravida: Woman who has been pregnant more than once.

Nuli Para: Woman who is not now and has never been pregnant.

Parity: Is number of children born alive or dead after 28weeks of gestation.

Vernix caseosa: Is a greasy substance that covers the baby’s skin at birth.

Meconium: This is stool of the neonate that is present in the lower bowel at 16weeks of
gestation and is passed within 3 days following birth, its greenish black in colour.

Lightening: This is drop in fundal height.

Show: The bloody stained mucoid discharge seen at the onset of labour

Terminologies Read More »

Parkinson’s Disease

Parkinson’s Disease is a slowly progressive degenerative neurologic disorder affecting the brain centers that are responsible for control and regulation of movement where there is loss of brain cells that produce dopamine that leads to insufficient production of dopamine.

Parkinsonism disease is called shaking disease or shaking palsy or paralysis agitans. It’s a degenerative disease of the nervous system related to cerebral atherosclerosis. This extrapyramidal disorder was named after James Parkinson in 1817 who describe it as a movement disorder.

Predisposing factors

The cause of the disease is mostly unknown (idiopathic) but research suggests several causative factors;

(i) Postencephalitic Parkinsonism (encephalitis lethergica): feature may develop 20 years later and may include oculogyric crisis
ii) Drug may induce Parkinsonism such as haloperidol, metoclopramide, phenothiazine and lithium
iii) Hypoxia due excess carbon monoxide
iv) Toxic substances like manganese
v) Vascular abnormalities like atherosclerosis

Genetics,
Atherosclerosis,
Viral infections e.g. viral encephalitis,
Head trauma,
Exposure to industrial pollutant,
chemical toxin such as manganese,
Herbicides,
Chemical solvents or poly chlorinated biphenyls.,
Antipsychotic drug
Age
Sex

Pathophysiology of Parkinsonism

Parkinson’s disease is associated with the degeneration of dopamine producing neurons in the substantia nigra of neurum an area in basal ganglia (deep in cerebral hemisphere). Dopamine is a neurotransmitter responsible for controlling and refining motor movement as an inhibitor co-paired to acetylcholine which is muscle exciters like coordination and posture.

When excitory activity of acetylcholine is not balanced by dopamine difficulty in controlling and initiating voluntary movements occur and acetylcholine effects are exaggerated. Cellular degeneration in Parkinson’s disease leads to impairment in the extrapyramidal tracts that control semiautomatic and coordinated movements. The exact cause is unknown though it can be caused by drugs, genetical and environmental factors.

Clinical Manifestations of Parkinson’s Disease

Cardinal Signs and Symptoms of Parkinson’s Disease

Tremors: Tremor present at rest but not during sleep characterized by rhythmic movements of 4 – 5 cycles a second and can occur in the head, facial muscles, limbs, jaw and lips. Micrographic (tiny hand writing) pill rolling character due to movement of the thumb across the palm also occur. Tremors are increased by emotions.
Rigidity: Rigidity: muscles are stiff with pain in severe cases; rigidity may be continuous or intermittent. Fine limb movements are difficult to perform.
Akinesia: Loss or impairment in power of voluntary movement. Bradykinesia (slowness in walking) and hypokinesia (loss of movement): rising from a chair
becomes difficult and takes several attempts of falling back.
Posture and Balance: Change in gait: tendency to walk forward on toes with small steps may be accelerated. Fascination (work with short steep with no arm swinging) propels patient either forward or back ward propulsively until falling is inevitable
Changes in balance ie stooped over posture when up right, difficult in entertaining balance
when sited erect and semi flexed arms.

Other signs and symptoms include;

The patient walks backwards if pulled from the back (pull test)
Speech is soft monotonous and slurred with difficulty in starting speech.
Slowness in thought and disinterest
Autonomic symptoms like constipation, dysuria, postural hypotension
Sensory function and tendon reflexes are normal

Differential Diagnosis

Essential tremor
Dementia with Lewy bodies
Multiple system atrophy
Alzheimer’s disease
Drug induced parkinsonism
CBD cortical basal degeneration and PSP progressive supranuclear palsy

Management of Parkinson’s Disease

Medical Management

There is no cure treatment for Parkinsonism disease; the victims can be helped with drugs that improve akinesia, rigidity and tremors.

Dopaminergic Agents e.g. Levodopa – it’s a chemical that is converted to dopamine in the brain.
Dopamine antagonistic e.g. bromopride. Butaclamol can mimic natural dopamine in the brain.
Dopamine agonists reduce bradykinesia tremor and rigidity such as bromocriptine merylate, levodopa, carbidopa, pramipexole etc
MAO-B inhibitor e.g. phenelzine and tranylcypromine, help reduce breakdown of dopamine in the brain. These drugs led to nausea, hypotension. Palpitation, dry mouth and sleep disturbance
Anti-cholinergics; e.g. chlorpromazine (Thorazine) to help reduce tremor, acetylcholine in CNS e.g. cycrimine, procyclidine, benztropine, biperiden and Benzhexol (aten) also relieves tremors
As a nurse avoid drug with similar effects like antihistamine, antispasmodics and tricyclic antidepressants. Monitor side effects such as delirium, blurred vision, constipation, agitation, hallucination anxiety and confusion
Amantadine help to improve muscle control and relief stiffness

Surgical Management of Parkinson’s disease.

Deep Brain Stimulation (D.B.S):

Is a surgical procedure in which electrodes are placed in specific areas of the brain, electrodes are connected to a generator which is programed to send electrical pulses to the brain.
The procedure may help to alleviate the following symptoms; tremor, rigidity, stiffness & slowed movement

Facial Nerve Decompression Surgery

Management of acute facial paralysis may involve facial nerve decompression surgery in cases of virally-induced facial paralysis (Bell’s palsy, Ramsay-Hunt syndrome) or primary facial nerve repair/grafting in cases of resection or transection of the facial nerve

Nursing Care

Perform motion exercises to all joints 3 time a day, massage skeletal muscles to relieve stiffness and use a broad base support when ambulating.
Advise patient care givers to avoid pyridoxine protein food and alcohol when using levodopa
Modify home environment to remove hazards and alert the patient on effects of stress, heat and excitement
Avoid staying in one position for a long time and try walking with hand clasped behind.
Motor patient weight weekly, follow plans for small frequent meals and avoid eating high protein meals at medication time. Ensure adequate fiber and fluid intake.
Perform exercise voice regulation by singing or reading loud.
Monitor sleep pattern, thought disorders and hallucination.
Respond promptly to the urge of urination, defecation and ensure emptiness. Use stool softeners if needed, keep urinal at bedside and monitor bowel habits.
Avoid carpets and rugs on floor as a patient sticks on them, use walking aids and offer shoes that are easy to put with smooth soles on to the patient.
Alternative medicine ie massage, tai chi , yoga, pet therapy ,meditation
Joining support groups

Diagnosis

PET Scan (positron emission tomography)—decreased dopaminergic activity in the substantia nigra
Unified Parkinson’s Disease Rating Scale—cognitive interview
Normal CT
Normal MRI

Complications

Dysphagia (difficulty in chewing and swallowing)
Depression
Anxiety
Dementia
Constipation
Smell dysfunctions , sexual dysfunction ,orthostatic hypotension , bladder problems , constipation, sleep disorders

Parkinson’s Disease Read More »

BELL’S PALSY (FACIAL NERVE PALSY)

Bell’s Palsy is a disorder characterized by disruption of the motor branch of the facial nerve (CN vii) or paralysis of one side the face in absence of stroke

Sir Charles Bell, Scottish Surgeon, first described in early 1800’s based on trauma to facial nerves

Prevalence

It occurs at any age
But most often seen in adults between 20 and 60 years
The incidence is equal in men and women

Prognosis

80% of clients recover completely with in a few weeks to a few months
3-4% recover without any treatment
15% recover but have some permanent facial paralysis. These clients are usually older with other conditions like DM

Causes

The exact cause is unknown but can be triggered by bacterial or viral infections like :

Herpes simplex
HIV
Sarcoidosis. growth of tiny collections of inflammatory cells in different parts of the body
Herpes zoster
Epstein-Ban
Lyme disease (bacterial infection caused by infected ticks)

It is also believed to occur due to localized inflammatory reaction of the facial nerve at the stylomastoid foramina.

Demyelination of the nerve can trigger bell’s palsy.

Pathophysiology

The facial nerve has motor nerves that innervate the muscles of expression on the face and sensory that supplies the tongue. Disruption of the nerve lead to rapid weakening or paralysis of the facial muscles on one side creating a mask like appearance (angry face)
Paralysis develops in 24-36 hours and eye of the affected side tears constantly.
The condition accompany outbreak of herpes vesicle around the ear.

Signs and symptoms of Bell’s palsy

Dribbling/drooling of saliva from the angle of the mouth affected and dropping of the face.
Difficult in closing the affected eye
Food collects between teeth and cheeks in the affected side
Nasal labial fold is effaced on the affected side when the patient is asked to show his/her teeth.
Absence of furrows on the affected side (like smooth forehead) when the patient looks up while the healthy side they
are present.
The patient fails to whistle.
Bell’s sign (failure of the eye to close and roll up ward on the affected side
Mouth deviates to normal side
Inability to perform facial expression like smiling.
Unilateral loss of taste
Pain behind the ear before paralysis with fever, tinnitus or hearing difficulty
Facial weakness
Muscle twitches
Dry eyes and mouth
Headaches
Sensitivity to sound

Differential Diagnosis

Lyme disease
Otitis media
Tumor
Multiple sclerosis

Complications of Bell’s Palsy

Malnutrition
Psychological withdrawal
Dehydration
Muscle stretching and facial spasms
Synkinesis -involuntary contraction of certain muscles when you’re trying to move others.
Excessive dryness in eyes which can lead to eye infections and blindness.
Psychological withdrawal changes in appearance, malnutrition or dehydration, mucous membrane trauma, corneal abrasion, muscle stretching, and facial spasms and contractures.

Investigations

Diagnosis made on basis of symptoms in the absence of other causes of paralysis such as stroke.
No definitive test
Electromyography (EMG) may determine nerve excitability or absence
MRI or CT scan to check the nerves in the face

Management of Bell’s Palsy

There is no specific treatment of the condition and hospitalization is not required;

MEDICAL MANAGEMENT

Corticosteroids- drug of choice
Prednisone may be started immediately!
Best if initiated before paralysis is complete
Taper off over 2 weeks(tapering is the process of stopping all opioids or reducing opioids quickly over a few days or weeks, decreasing the dose by 25% to 50% to 75% to 100%)
Decrease edema and pain
Analgesics e.g. ibruprofen may be needed for pain
Antivirals : Acyclovir (Zovirax) and Famvir because HSV is implicated in 70% of cases.
ABCs

NURSING CARE;

Warm moist sponge to relieve pain
Pad the dry eye
Nutrition
Physiotherapy and facial massage to stimulate facial muscles
Speech therapy
Alternative medicine ie massage, tai chi , yoga, pet therapy ,meditation
Joining support groups
If patient has corticosteroid therapy, aware of side effect like gastrointestinal distress and fluid retention.
If patient has diabetes condition, corticosteroid must be use carefully and monitor blood glucose
To reduce the pain, compress with warm compress on paralyzed face, but it should not burn the skin.
Use face strap to symmetrize the lip
Use of artificial tears
Ask patient to stay in warm circumstance, avoid dust and wind, and close the eye with dangerous exposure
To avoid complication in swallowing like aspiration and body weight decrease, ask patient to sit upright while he/she eats, chewing in non-paralyzed face side, chewing with small portion, consume balance nutrition foods, and avoid solid foods
Give patient privacy while patient has meal time, so the patient will not feel embarrassed
Perform mouth care and be careful since foods remain between lip and gingiva.
Give psychological support. Ensure the patient that the recovery needs 1-8 weeks
To maintain the muscle tonus, massage patient’s face with upward direction for 5-10 minutes, ask the patient to massage his face by his/her self.
If he/she is ready to do active exercise, ask the patient to smile in front of mirror.
Suggest the patient to close his/her eye with eye protector, especially if the patient is to go out.
Advice patient to close eyelids periodically and gently.

BELL’S PALSY (FACIAL NERVE PALSY) Read More »

Trigeminal Neuralgia

Trigeminal Neuralgia also known as Tic Douloreuv is a disorder that affects the 5th cranial nerve that causes intense paroxysmal pain in one or more trigeminal nerve branches.

Branches of the Trigeminal Nerve

The trigeminal nerve has 3 divisions i.e

The ophthalmic division that supplies the forehead, eyes, nose, meninges, paranasal sinuses and part of the nasal mucosa.
The maxillary division supplies the upper jaw, teeth, lip, cheeks, hard palate, maxillary sinus and part of the nasal mucosa.
The mandibular division supplies the lower jaw, teeth, lip, buccal mucosa, tongue, part of the external ear and the meninges. More about nerves

Classification of Facial Pain

Trigeminal neuralgia, type 1, (TN1): facial pain of spontaneous onset with greater than 50% limited to the duration of an episode of pain (temporary pain).
Trigeminal neuralgia, type 2, (TN2): facial pain of spontaneous onset with greater than 50% as a constant pain.
Trigeminal neuropathic pain, (TNP): facial pain resulting from unintentional injury to the trigeminal system from facial trauma, oral surgery, ear, nose and throat (ENT) surgery, root injury from posterior fossa or skull base surgery, stroke, etc.
Trigeminal deafferentation pain, (TDP): facial pain in a region of trigeminal numbness resulting from intentional injury to the trigeminal system from neurectomy, gangliolysis, rhizotomy, nucleotomy, tractotomy, or other denervating procedures.
Symptomatic trigeminal neuralgia, (STN): pain resulting from multiple sclerosis.
Post herpetic neuralgia, (PHN): pain resulting from trigeminal Herpes zoster outbreak.
Atypical facial pain, (AFP): pain predominantly having a psychological rather than a physiological origin.

Causes of Trigeminal Neuralgia:

Nerve Compression:
- Explanation:: Compression of the trigeminal nerve by nearby structures, often blood vessels, leading to irritation and pain signals.
- Example: Blood vessels impinging on the trigeminal nerve, causing compression and neuralgia.
Demyelinating Plaques:
- Explanation: Damage to the myelin sheath surrounding the trigeminal nerve, disrupting normal nerve function.
- Example: Demyelination seen in conditions like multiple sclerosis.
Herpes Virus Infection:
- Explanation: Activation or infection of the trigeminal nerve by the herpes virus, contributing to inflammation and pain.
- Example: Reactivation of the herpes simplex virus affecting the trigeminal nerve.
Infection of the Teeth and Jaw:
- Explanation: Infections in the teeth or jaw leading to inflammation and irritation of the trigeminal nerve.
- Example: Dental infections spreading to the trigeminal nerve branches.
Irritation from Flu-Like Illnesses:
- Explanation: Inflammatory response due to flu-like illnesses affecting the trigeminal nerve.
- Example: Increased sensitivity and irritation during or after a viral infection.
Trauma of the Teeth or Jaw:
- Explanation: Physical injury to the teeth or jaw causing irritation of the trigeminal nerve.
- Example: Dental trauma resulting in nerve irritation and subsequent neuralgia.
Aneurysm Causing Pressure on the Nerve:
- Explanation: Enlargement of an artery (aneurysm) putting pressure on the trigeminal nerve.
- Example: Compression of the nerve by an adjacent aneurysm.
Tumor:
- Explanation: Presence of a tumor near the trigeminal nerve leading to compression and irritation.
- Example: Tumor growth impacting the trigeminal nerve.
Arteriosclerotic Changes of an Artery Close to the Nerve:
- Explanation: Changes in artery walls close to the trigeminal nerve, potentially leading to compression.
- Example: Arteriosclerosis affecting vessels in proximity to the trigeminal nerve.

Precipitating Factors of Pain:

Light Touch:
- Explanation: Even gentle touch or breeze on the face triggers severe pain due to the hypersensitivity of the trigeminal nerve.
- Example: Brushing against the face lightly causing intense pain.
Eating:
- Explanation: Chewing and the mechanical process of eating can trigger neuralgic pain.
- Example: Pain occurring during or after meals.
Swallowing:
- Explanation: The act of swallowing, which involves movement and muscle engagement in the face, can trigger pain.
- Example: Pain associated with swallowing liquids or food.
Talking:
- Explanation: Articulating words and facial movements during speech may induce pain.
- Example: Pain occurring while engaging in conversation.
Sneezing:
- Explanation: The sudden and forceful nature of sneezing can trigger intense facial pain.
- Example: Pain experienced during or after sneezing.
Shaving:
- Explanation: The mechanical action of shaving involving contact with the face can lead to pain.
- Example: Pain triggered by shaving activities.
Chewing Gum:
- Explanation: Repetitive jaw movements during gum chewing can aggravate trigeminal neuralgia.
- Example: Pain associated with chewing gum.
Brushing the Teeth or Washing the Face:
- Explanation: Activities involving contact with the face, such as brushing teeth or washing, may cause pain.
- Example: Pain occurring during facial hygiene practices.
Exposure to Wind:
- Explanation: Sensitivity to environmental factors, such as wind, leading to pain.
- Example: Pain triggered by exposure to windy conditions.

Clinical Features of Trigeminal Neuralgia:

1. Nature of the Condition:

Trigeminal neuralgia is a chronic condition affecting the fifth cranial nerve.

2. Characteristics of Pain:

Characterized by unilateral paroxysms of shooting and stabbing pain.
Pain typically occurs in the area innervated by the trigeminal nerve branches (ophthalmic, maxillary, mandibular).
Most commonly affects the second and third branches.

3. Description of Pain:

Pain is often described as a burning, knife-like, or lightning-like shock.
Occurs in the lips, upper or lower gums, forehead, or side of the nose.

4. Facial Presentation:

Presents with severe facial pain.

5. Unilateral Nature:

The pain is unilateral, affecting one side of the face.

6. Muscular Involvement:

Associated with involuntary contraction of facial muscles.

7. Eye and Mouth Involvement:

Can cause sudden closing of the eye or twitching of the mouth.
Historically known as tic douloureux, referring to painful facial twitches.

8. Triggers for Pain Episodes:

Pain can be spontaneous or initiated by activities such as chewing, talking, or touching the affected side of the face.

9. Impact on Daily Activities:

Patients may alter behaviors, such as improper eating, neglect of hygiene, or wearing a cloth over the face.
Social withdrawal due to pain-related discomfort.

10 Coping Mechanisms:

Excessive sleeping may be adopted as a coping mechanism to deal with pain.

10. Risk of Suicide:

There is a risk of suicide due to the disruption of the patient’s lifestyle caused by the intensity of pain.

11. Unpredictable Recurrence:

Recurrences are unpredictable, varying in frequency and duration.
Episodes can recur for several days, weeks, or months apart.

Pathophysiology of Trigeminal Neuralgia

Classical (idiopathic) form: There is no known cause for the, however, studies point to an underlying vascular pathology as a cause by irritation over the trigeminal (Gasserian) ganglion. Although the cause is not certain, vascular compression and pressure are suggested causes. The disorder occurs more commonly in women and in people with multiple sclerosis (MS) compared with the general population.

Symptomatic (secondary) form: There are known common causes affecting the CN, Vascular compression of the trigeminal ganglion

Differential Diagnosis

Demyelinating (MS)
CPA tumors
Nasopharyngeal and Paranasal pathology
Dental Pathology
Herpes zoster
Unstable Angina

Medical Management of Trigeminal Neuralgia:

Pharmacologic Therapy:

Carbamazepine (Tegretol):
- Action: Reduces transmission of impulses at nerve terminals, relieving pain.
- Dosage: Typically prescribed at 100mg.
- Administration: Given with meals to minimize side effects.
Monitoring and Side Effects:
- Patients are observed for side effects, including nausea, dizziness, drowsiness, and potential aplastic anemia.
- Long-term therapy requires monitoring for bone marrow depression.
Alternative Medications:
- Gabapentin and baclofen are utilized for pain management.
- If pain control remains inadequate, phenytoin (Dilantin) may be added as adjunctive therapy.

Surgical Management:

Microvascular Decompression:
- Intracranial approach (craniotomy) to decompress the trigeminal nerve.
Percutaneous Radiofrequency:
- Produces a thermal lesion on the trigeminal nerve.
- Immediate pain relief may occur, but side effects may include facial dysesthesia and loss of the corneal reflex.
Gamma Knife Radiosurgery:
- Utilizes stereotactic magnetic resonance imaging (MRI) to identify the trigeminal nerve.
- Followed by gamma knife radiosurgery for precise intervention.
Balloon Micro-Compression:
- Percutaneous procedure disrupting large myelinated fibers in all three branches of the trigeminal nerve.

Nursing Management:

Identification of Triggers:
- Assist patients in recognizing triggers for facial pain (e.g., hot or cold stimuli, jarring motions).
- Teach strategies like using cotton pads and room temperature water for facial care.
Oral Hygiene:
- Instruct patients to rinse their mouths after eating when tooth brushing causes pain.
- Perform personal hygiene during pain-free intervals.
Dietary Guidance:
- Advise patients to consume food and fluids at room temperature.
- Suggest chewing on the unaffected side and opting for soft foods.
Emotional Well-being:
- Recognize and address anxiety, depression, and insomnia common in chronic pain conditions.
- Implement appropriate interventions and referrals.
Postoperative Care:
- Perform neurologic checks to assess facial motor and sensory deficits postoperatively.
Eye Care:
- Instruct patients not to rub the eye if sensory deficits occur post-surgery.
- Assess for eye irritation or redness and administer artificial tears if prescribed.
Eating and Swallowing:
- Observe patients for any difficulty in eating and swallowing foods of different consistencies.
Support Groups:
- Encourage patients to join support groups for emotional and informational support.

In General,

Trigeminal neuralgia poses a challenge as there is no specific cure. Management focuses on alleviating pain through medications like antiseizure drugs (e.g., carbamazepine, phenytoin, clonazepam) and analgesics during episodes. If conservative approaches prove ineffective, surgical interventions may be considered.

Medical Management:

Drug Therapy:
- Antiseizure medications, such as carbamazepine, phenytoin, or clonazepam, coupled with analgesics, are administered during pain episodes.
Surgical Options:
- When conservative measures fail, surgical interventions include:
  - Glycerol injection into trigeminal nerve branches.
  - Suboccipital craniotomy rhizotomy for comprehensive pain relief.
  - Gamma knife radiosurgery.
  - Percutaneous radiofrequency procedures.

Patient Assessment and Education:

Pain Assessment:
- Thoroughly assess the nature and character of the pain to tailor an effective management plan.
Patient Education:
- Educate the patient about the condition, its nature, and available treatment options.
- Emphasize the importance of preventive measures to mitigate the risk of suicide.

Patient Care:

Hygiene and Nutrition:
- Ensure optimal patient hygiene and nutrition status to support overall well-being.
Psychological Support:
- Provide psychological support to build patient confidence and aid in coping with the challenging situation.

Diagnostic Investigations:

Ordered Investigations:
- Ensure that ordered diagnostic investigations, including CT scans, MRIs, and CSF analyses, are completed to guide treatment decisions.

Trigeminal Neuralgia Read More »

Applied anatomy and Physiology of the nervous system

REVIEW OF THE ANATOMY AND PHYSIOLOGY OF NERVOUS SYSTEM

ANATOMY OF THE NERVOUS SYSTEM

The nervous system can be separated into parts based on structure and on function:
Structurally, it can be divided into the central nervous system (CNS) and the peripheral nervous system (PNS).
The CNS is composed of the brain and spinal cord, both of in the embryo
The PNS is composed of all nervous structures outside the CNS that connect the CNS to the body. Elements of this system develop from neural crest cells and as outgrowths of the CNS. It consists of the spinal and cranial nerves, visceral nerves and plexuses, and the enteric system
Functionally, it can be divided into somatic and visceral parts.

The somatic part “soma” in Greek for body) innervates structures (skin and most skeletal muscle) derived from somites and is mainly involved with receiving and responding to information from the external environment;
The visceral part (‘viscera’ from the Greek for guts) innervates organ systems in the body and other visceral elements, such as smooth muscle and glands, in peripheral regions of the body it is concerned mainly with detecting and responding to information from the internal environment
The neuron is the functional unit of the entire nervous system; its cell body and axon terminates
in the synapse

Structure of a neuron

FUNCTIONS OF NEURON STRUCTURES

Nucleus – controls the entire neuron.
Dendrite – receive stimulus and carries its impulses toward the cell body
Cell Body (soma) – has a nucleus & cytoplasm. It acts as a factory of the neuron. It produces all protein for the dendrites and neural transmitters
Axon – fiber which carries impulses away from cell body ie it forms conduction region for the neuron
Schwann Cells/ neurolemmocyte – cells which produce myelin or fat layer in the Peripheral Nervous System (axon maintenance and regeneration) It’s a glial cell that wrap the nerve fibre in PNS.
Myelin sheath – dense lipid layer which insulates the axon ( makes the axon look gray) It speeds-up nerve transmission.
Node of Ranvier – gaps or nodes in the myelin sheath. They speed up nerve transmission.
Axon terminals – form junctions with other cells

There are three types of Neurons

Sensory neurons – bring messages to CNS
Motor neurons – carry messages from CNS
Interneurons – between sensory & motor neurons in the CNS

Other cells of the nervous system

Satellite cells – surround cell bodies of neurons in ganglia. Their role is to maintain the micro-environment and provide insulation of the ganglion.
Ependymal cells: these cells line cavities in CNS i.e spinal canal and ventricles in the brain. They secrete cerebral spinal fluid and form choroid plexuses.
Oligodendrocytes: These cells wrap around CNS neurons to produce the myelin sheath. They function as Schwann Cells in CNS.
Astrocyte: these are neuroglia/ glial cell of the CNS they anchor the neuron to the blood vessels and for blood brain barrier. They are star shaped.
Microglia: These are monocytes in the nervous system they move to damaged brain tissue for phagocytosis.

CENTRAL NERVOUS SYSTEM

The Brain Anatomy

It consists of four main parts i.e

1) Cerebrum– largest brain structure with four lobes i.e frontal, temporal, parietal and occipital.
It is divided into hemispheres by a fissure called longitudinal cerebral fissure with corpus callosum (mass of white matter) deep connecting the. Its outer layer is the cerebral cortex made of gray
mater and area below is made of white matter.

2) Cerebellum– located behind the ponds below the occipital lobe of cerebrum occupying the posterior cranial fossa.
Its oval shaped with two hemisphere separated by vermis. It has grey matter and white mater as in cerebrum.

3) Brain stem (mid brain and hind brain{Pons & medulla oblongata})
Mid brain is located around cerebral aqueduct with cerebrum above and Pons below. It has nuclei and group of nerve fibers with lower parts of the brain and with the spinal cord.
Pons is located in front of the Cerebellum nuclei and nerve fibers. Medulla oblongata extents from the Pons and is continuous with the spinal cord. It has central grey matter and white matter which passes from the spinal cord and brain on outer aspect

4) Diencephalon (Thalamus, Hypothalamus) – part of the brain that connect cerebrum and mid brain made of structure located around the third ventricle. Peneal gland and optic chiasma is also located here. Thalamus has two masses of grey and white mater just below corpus callosum, one on either side of the ventricle and hypothalamus is below in front of the thalamus connected to pituitary gland with number of nuclei.

Physiology of the Brain

Cerebral cortex:

For mental processes like memory,
For sensory perception i.e pain, temperature, touch sight, hearing, taste and smell
Initiation and control of skeletal muscle contractions

Cerebellum:

Coordination of voluntary muscle movement
Posture and balance
Learning and language processing

Thalamus:

Relays and distributes impulses from the most parts of the brain to the cerebral cortex
Play role in memory

Hypothalamus

Control autonomic nervous system
Controls appetite, thirst, body temperature, water balance, emotional reaction and sexual
behavior
Sleeping and waking cycles due to melatonin hormone from pineal gland in the epithalamus
Secrete ADH and oxytocin

Brain stem

Mid brain has nuclei that act as relay station for ascending and descending nerve fibers
(connects cerebrum with lower brain fibers and spinal cord)
Pons works with medulla to control respiration and acts as relay station with some cranial nerves

Medulla oblongata

Control respiration center, cardiovascular center, and reflex center for vomiting, coughing, sneezing and swallowing. It is also a site of decussation pyramidal tracts (corticospinal) from motor area in the cerebrum to spinal cord crossing to opposite site

Anatomy of the Spinal Cord

It is roughly cylindrical in shape, and is circular to oval in cross-section with a central canal.

Made up of 31 pairs of spinal nerves
• Each spinal nerve has two components or roots
– Sensory fiber (dorsal root) — Brings information into the CNS from the periphery
– Motor fiber (ventral root) — Causes movement or reaction
The spinal cord extends from the foramen magnum to approximately the level of the disc between vertebrae LI and LII in adults, although it can end as high as vertebra T12 or as low as the disc between vertebrae LII and LIII. In neonates, the spinal cord extends approximately to vertebra LIII, but can reach as low as vertebra LIV.

The distal end of the cord (the conus medullaris) is cone shaped. A fine filament of connective tissue (filum terminale) continues inferiorly from the apex of the conus medullaris

It has two major swellings or enlargements in regions associated with the origin of spinal nerves that innervate the upper and lower limbs. A cervical enlargement occurs in the region associated with the origins of spinal nerves C5 to T1, which innervate the upper limbs. A lumbosacral enlargement occurs in the region associated with the origins of spinal nerves L1 to
S3, which innervate the lower limbs.

Internally, the cord has a small central canal surrounded by gray and white matter: the gray
matter is rich in nerve cell bodies and white matter surrounds the gray matter and is rich in nerve cell processes, which form large bundles or tracts that ascend and descend in the cord to other spinal cord levels or carry information to and from the brain.

Physiology of the Spinal Cord

Spinal cord provides communication between brain and the peripheral nerves. Tracts of white matter of the spinal cord carry sensory impulses to the brain and motor impulses from the brain to the skeletal muscles.

The grey matter of the spinal cord is a site of integration of reflexes which is rapid involuntary action in relation to a particular stimulus.

The meninges

They are three connective tissue coverings that surround, protect, and suspend the brain and spinal cord within the cranial cavity and vertebral canal, respectively:

The dura mater is the thickest and most external of the coverings;
The spinal dura mater is continuous with the cranial dura mater at the foramen magnum of the skull and is the outermost meningeal membrane. In the cranial cavity, one layer of the dura mater is fused to the bone and represents the periosteum, but the spinal dura mater is separated from the bones of the vertebral canal by an extradural space. Inferiorly, the Dural sac dramatically narrows at the level of the lower border of vertebra SII and forms an investing sheath for the pial part of the filum terminale of the spinal cord. The dural part of the filum terminale attaches to the posterior surface of the vertebral bodies of the coccyx.
The arachnoid mater is against the internal surface of the dura mater;
This is a thin delicate membrane against, but not adherent to, the deep surface of the dura mater. It is separated from the pia mater by the subarachnoid space. The arachnoid mater ends at the
level of vertebra SII. The sub-arachnoid space contain CSF.
The pia mater is adherent to the brain and spinal cord. It extends into the anterior median fissure and reflects as sleeve-like coating onto posterior and anterior rootlets and roots as they cross the subarachnoid space. As the roots exit the space, the sleeve-like coatings reflect onto the arachnoid mater. On each side of the spinal cord, a longitudinally oriented sheet of pia mater (the denticulate ligament) extends laterally from the cord toward the arachnoid and dura mater. Because the subarachnoid space can be accessed in the lower lumbar region without endangering the spinal cord, it is important to be able to identify the position of the lumbar vertebral spinous processes. The LIV vertebral spinous process is level with a horizontal line between the highest points on the iliac crests. In the lumbar region, the palpable ends of the vertebral spinous processes lie opposite their corresponding vertebral bodies. The subarachnoid space can be accessed between vertebral levels LIII and LIV and between LIV and LV without endangering the spinal cord

PERIPHERAL NERVOUS SYSTEM

CRANIAL NERVES

In a clinical practice, it’s very important for the nurse to know the basic cranial nerves, there location and function. Below are the major cranial nerves in the body

Olfactory nerve (CN I): this nerve arises from the olfactory (smell) receptors within the nasal mucosa. Loss of smell (Anosmia) is caused by head injury and tumors of the olfactory groove
e.g. meningioma, frontalglioma). The nerve is assessed by applying different odious substances in each nose. FIND THE REST OF THE NERVES BY CLICKING HERE

SPINAL NERVES

Spinal nerves contain both sensory and motor fibers, as do most nerves. Spinal nerves are given numbers which indicate the portion of the vertebral column in which they arise. There are 8 cervical nerves (C1-C8), 12 thoracic nerves (T1 – T12), 5 lumbar nerves (L1 – L5), 5 sacral nerves (S1-S5), and 1 coccygeal nerve. Nerve C1 arises between the cranium and atlas. All the others arise below the respective vertebra or former vertebra in the case of the sacrum.
A plexus is an interconnection of fibers which form new combinations as the “named” or
peripheral nerves.
Dermatomes are somatic or musculocutaneous areas served by fibers from specific spinal
nerves.

The map of the dermatomes is shown by Figure below . The map is useful in diagnosing origin of certain somatic pain, numbness, tingling, when symptoms are caused by pressure or inflammation of the spinal cord or nerve roots.

Referred pain is caused when the sensory fibers from an internal organ enter the spinal cord in the same root as fibers from a dermatome. The brain is poor at interpreting visceral pain and instead interprets it as pain from the somatic area of the dermatome.

So pain in the heart is often interpreted as pain in the left arm or shoulder, pain in the diaphragm is interpreted as along the left clavicle and neck, and the “stitch in your side” you sometimes feel when running is pain in the liver as its vessels constrict.

Myotome is that region of skeletal muscle innervated by a single nerve or spinal cord level.
Most individual muscles of the body are innervated by more than one spinal cord level so the evaluation of myotomes is usually accomplished by testing movements of joints or muscle groups.

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Orthopedic Nursing Care

Orthopedic Care

Orthopedic care is concerned with preventing, recognizing, and treating injuries, diseases, and ailments that afflict the musculoskeletal system of the body.

This system consists
of muscles, tendons, ligaments, and other connective tissues that enable a human being to perform physical activity.

Orthopedic care involves treating common problems such as;

Musculoskeletal trauma
Sports injuries
Degenerative diseases
Infections
Tumors
Congenital disorder

Some of the techniques used to treat musculoskeletal ailments through orthopedic care include but are not limited to the following:

Bandaging
Traction
Splints
Non-surgical procedures
Surgical procedures (such as ligament repair)

Bandaging

Purpose of Bandages

To cover retain dressings and splints in place,
To protect a wound,
To support as in sprain,
To compress,
To secure dressing,
To immobilize in fracture plaster of Paris cast,
To Control bleeding from wounds,
To restrict movement.

Types of Bandage

Triangular Bandages: This type of Bandages is used in emergency treatment and first aid,
> Head bandage,
> Sling
Roller Bandage: >Circular
> Spiral, Recurrent.
Plaster : It is made from plaster of Paris, it immobilizes fractures of bones.
Adhesive: It used for fracture at Clavicle bone.
Gauze Bandages
Crepe Bandages: These bandages are elastic and a degree to which they are stretched when applied
determines the amount of pressure they exert. They are widely used.

General rules of bandaging

Use a tightly rolled bandage of suitable width and material.
Face the patient when bandaging limbs.
Hold the head of the bandage uppermost.
Bandage the limb well aligned in an anatomical position.
Hold the bandage in the right hand when bandaging a left limb and vice versa
Bandage the limb from inside outwards and from below upwards, keeping the bandage even
throughout.
Ensure that the bandage is neither too tight nor too loose.
Finish off the bandage with a straight turn, fold in the end and secure avoiding joints and the site of injury.
Fasten with safety pins or with the provided fastener.
Apply tape in psychiatric, mentally handicapped or paediatric patients instead of pins or other
sharp appliances.

Bandaging patterns

Figure of eight

Observe general rules of all nursing procedures.
Put patient to comfortable position exposing the affected part.
Hold bandage with the drum facing upwards.
Wrap bandage around the limb twice below the joint.
Use alternating ascending and descending turns to form figure of eight; overlap each turn of the
bandage by one half to two-thirds the width of the strip.
Wrap bandage around the limb twice, above the joint to anchor it and secure end with a clip or
safety pin.
Elevate the bandaged extremity for 15 to 30 minutes after application of bandage.
Assess the skin for color, integrity pain and temperature.
Leave patient comfortable and clear away.

Spiral bandaging (e.g. bandaging the ear)

Make a fixing turn around the head
Bring the bandage under the ear and straight over the head and down the back, leaving the other
ear un-bandaged.
Repeat these turn three or four times until the affected ear is gradually covered.
Finish with a fixing turn and secure the bandage at the centre of the forehead using a safety pin
clip or tape.
Divergent Spica (pattern used to cover a dressing wound at a fixed joint e.g. Knee, heel or elbow).
Make two turns over the centre of the joint.
Now make alternate turns above and below these turns forming a pattern at each side of the
joint

Triangular Bandaging Arm sling

Place the injured arm across the patient’s chest so that the fingers almost touch the opposite
shoulder.
Place one corner of the bandage over the uninjured part with the right angled corner just above
the level of the elbow of the injured side.
Tuck the other upper half of the base of the bandage well beneath the forearm and elbow.
Carry the corner ends across the back and tie the ends with a reef knot, which lies in the hollow
above the clavicle on the un-injured side.
The right angle is folded and pinned to enclose the elbow.
Place a pad under the knot if it seems likely to cause pressure.

Bandaging the Eye

Facing the patient; hold the eye pad in position until the bandage covers it.
Begin from the affected side to the normal across the forehead and round the head in a fixing
turn, then from the back of the head the bandage comes under the ear, across the eye covering
the nasal side of the pad and straight over the head and down the back.
The next turn comes under the ear, overlaps the eye turn, crosses the fixing turn at the same
point as the other, then overlaps it crosses the head and comes round to the front.
Fix a pin should be in the centre of the forehead.

Capeline Bandage (Use a double headed roller bandage) Position patient in sitting up position and stand behind the patient)

Place the centre of the outer surface of the of the bandage in the centre of the fore head
Bring the head of the bandage around over the temples and above the ears to the nape of the
neck when the ends are crossed
Bring the upper bandage around the head and the other head of the bandage over the centre of
the top of the scalp and then to the root and nose
Bring the bandage which circles the victims head over the fore head covering and fixing the
bandage which crosses the scalp.
The bandage is then brought back over the scalp.
Ensure that each turn of the bandage covers 2/3 of the previous turn
Cross it again at the back and fix it using encircling bandage and turn back over the scalp to the
opposite side at the central line now covering the other margin of its original turn
Repeat the back word and forward turns to alternate side of the centre, each one begin in turn
fixed by the encircling bandage until the whole scalp is covered
Take two circular turns around the head, secure bandage with safety pin

Recurrent bandaging

Overlap each layer of bandage by half to two thirds the width of the strip; wrap firmly but not
tightly as you work ask the patient if it feels comfortable. Loosen the bandage if there is tingling,
itching, numbness or pain.
Stand facing the patient and take a fixing turn.
Carry the bandage upward across the front of the limb at 450 rounds behind it at the same level
and downwards over the front to cross the first turn at a right angle.
Repeat these turns until the limb has been sufficiently covered.

Splints

Injuries that result in instability require immobilization, decreasing the likelihood of further damage, protecting soft tissues, alleviating pain, and accelerating healing. Instability may result from direct injury to the bones (fracture), joints (dislocation), or the soft tissues such as the muscles (strain) or ligaments (sprain).

Following the diagnosis of an unstable injury, a splint may be the best treatment option and is defined as an external device used to immobilize an injury or joint and is most often made out of plaster.

A splint must be differentiated from a cast, to determine the best form of immobilization based on the clinical scenario. Contrary to a splint, a cast is a circumferential application of plaster that rigidly immobilizes a particular joint or fracture. Because of their circumferential restrictive nature, casts are not placed in the acute post-injury setting as they do not accommodate for soft tissue swelling.

Indications

Splints are placed to immobilize musculoskeletal injuries, support healing, and to prevent further
damage. The indications for splinting are broad, but commonly include:

Temporary stabilization of acute fractures, sprains, or strains before further evaluation or definitive operative management
Immobilization of a suspected occult fracture (such as a scaphoid fracture)
Severe soft tissue injuries requiring immobilization and protection from further injury
Definitive management of specific stable fracture patterns
Peripheral neuropathy requiring extremity protection
Partial immobilization for minor soft tissue injuries
Treatment of joint instability, including dislocation.

Equipment
Obtain and organize all equipment before splint application. The necessary equipment for a plaster or
fiberglass splint includes:

Sheet or towel to protect patient clothing
Stockinette (a soft, loosely knitted stretch fabric) or fabric under padding
Under cast padding, which is typically made out of cotton.
Plaster (8-10 sheets thick) or padded fiberglass. In general, forearm splints require smaller width,
and upper arm and leg splints require larger width rolls of material.
Water bucket filled with cool water.
Elastic bandage
Sling for upper extremity injuries
If fracture reduction is attempted, a C-arm X-ray should be used for the evaluation of the fracture
reduction.

General steps may be applied when placing a splint

Ensure adequate analgesia before splint application. This will ensure muscle relaxation and facilitate fracture reduction, if necessary.
Ensure that any soft-tissue injuries are addressed before splint placement.
Apply a stockinette circumferentially to the injured area. This should span both proximally and distal to the injured area, protecting the skin from irritation by the plaster or fiberglass.
Pad bony prominences such as the elbow, knee, or calcaneus with at least 1 cm to 2 cm of soft cast padding. Soft tissue protection is essential to prevent future skin irritation or necrosis. The thickness of this padding will depend on body habit.
Apply 2-3 layers of cast padding (0.25 cm to 0.5 cm) circumferentially to the remaining area of
immobilization.
Reduce any fracture by restoring the bone length, rotation, and alignment. This may require radiographic confirmation before support material application.
Activate the supportive plaster or fiberglass layers by saturating them in the water bucket. Laminate the sheets by pressing them together before application, as this increases the strength and adhesion between the layers.
Mold the supportive material around the area of injury. The specific molding approach will depend on the type of injury; however, as a general rule, the splint should be molded to resist any deforming angulation.
Ensure the supportive material does not circumferentially encase the injured area to accommodate any soft-tissue swelling. If there is circumferential overlap, this should be addressed by cutting the splint once the supportive material has set.
Fold the stockinette over the plaster or fiberglass to protect the patient’s skin from its sharp edges.
Circumferentially apply an elastic bandage around the splint. This aids in the molding of the splint material to the injured area and holds the support material in place until it has hardened. Direct placement on the skin should be avoided and is a commonly observed mistake.
Repeat the physical exam to ensure that there is no significant change in the patient’s neurovascular status. Any change in the physical exam should prompt the rapid removal of the splint and reassessment.
Counsel the patient on proper splint care and follow-up instructions.

Common upper extremity splints include:
1. Coaptation splint
2. Sugar tong splint
3. Posterior long arm elbow splint
4. Ulnar gutter splint
5. Radial gutter splint
6. Volar or dorsal short arm splint,
7. Thumb spica splint
Common lower extremity splints include:
1. Posterior long leg splint, posterior short leg splint
2. Posterior short leg splint with stirrups

Complications of Splints

Loss of fracture reduction
Skin irritation or breakdown
Joint stiffness.
Thermal injury
Neurovascular compromise – acute carpal turnel syndrome
Compartment syndrome – Excessive compression may occur through splint placement, mainly if a splint is circumferential, becoming a cast.

Traction

This is a system in fracture management in which a continuous pull is applied and maintained on a limb or other parts of the body by the use of cords and weights.

Indications
➢ To correct joint deformities
➢ To separate joint surfaces and so prevent further spread of infection e.g TB of the joints like hips, knees.
➢ To prevent muscle spasms
➢ To prevent and overriding of bones since it keeps/maintains bones in the right position during the healing process.

Types of traction

Skeletal traction
Skin traction
a) Hamilton Russel traction
b) Gallows traction
Pulp traction
Halo traction
Skull tongs traction
Fixators
a) Internal
b) External

SKELETAL TRACTION

This is the type of traction in which a pin, nail or wire is passed through a bone.
This type of traction is mainly used for the treatment of fractures and works better for well-built strong persons.

Common sites for introducing the pins include;
1. The condyles of the femur
2. The tubercles of the tibia
3. Calcaneus at the heels of the foot.

Metallic equipment used in skeletal traction

Steinmann’s pins: This is a rigid steel pin passed through a bone and attached to a special stirrup. Because of the presence of the stirrup, the surgeon is able alter the line of the pull without moving the pin.
Kirschner wire: This is a narrow steel wire which is not rigid unless pulled on by a stirrup when the stirrup is rotated. It can move the wire and so possibility for infection is high hence this is not commonly used compared to the Steinmann’s pin.

Preparation of the patient for skeletal traction
➢ Explain the procedure to the patient and provide reassurance to allay anxiety
➢ Do shaving if the patient is hairy.
➢ Do premedication if prescribed.
➢ Institute an intravenous line.
After the preparation, the patient s taken to the theater with the leg in Thomas splint with skin traction
applied, then an operation is done under general anesthesia in order to insert the Steinmann’s pin
through the bone. A stirrup is then attached to the pin and the patient returned to the ward.

Requirements for making a skeletal traction.

Trolley:
Top shelf:
➢ Extension cord
➢ 6-8 metal pulleys
➢ Cotton wool in a gallipot
➢ Receiver of forceps and scissors
➢ Gallipot of gauze
➢ Antiseptic lotion e.g. iodine in gallipot
Bottom shelf:
➢ Thomas splint
➢ Knee piece
➢ Foot piece for Thomas splint

➢ Strong slings, safety pins

➢ Weights e.g. sandbags of required weight by the doctor

➢ Bed elevators e.g. bed blocks

➢ Strapping.
At the bed side.
➢ Balkan bean
➢ Fracture boards.

Specific care for a patient on skeletal traction.
1. Pin:
Report any sign of inflammation, discharge or movement of the pin.
2. Traction.
➢ Cords and pulleys must be free and smooth running
➢ Cords must be long enough and must not touch the toes.
➢ The cord must not be knotted or kinked
➢ Weights should be secure and hanging freely

SKIN TRACTION

It involves applying splints, bandages, or adhesive tapes to the skin directly below the fracture. Once the material has been applied, weights are fastened to it. The affected body part is then pulled into the right position using a pulley system attached to the hospital bed.

Preparation of the patient for a skin traction

Relevant explanation is given to the patient to ensure cooperation. Explanation should also be given to the relatives who may consider that apparatus cruel.
Ensure firm base on the bed and comfortable mattress.
Ensure privacy, wash the leg and dry thoroughly observing any abrasions, which should be
reported immediately.
Shave the leg if necessary taking particular care not to cause any skin damage.
Paint the skin with tincture of benzoin compound, which eliminates allergic reaction to strapping
and assists adhesive properties.
Protect the bony prominences with adhesive felt or latex foam or orthopaedic wool.
Bed:
This should have a firm base, use fracture boards if necessary
Soft mattress
The bedclothes should be arranged in separate packs for the trunk and limb not in traction.
The patient must be kept warm and bed tidy at all times (this is important for patients morale.)
Bed cradle should be used if both legs are in traction to ensure that the bedclothes do not hamper the efficiency of the traction.
If there is an overhead beam, a trapeze should be applied to enable the patient lift himself up, thus help prevent formation of pressure sores and hypostatic pneumonia.
Bedclothes are necessary if the patients own weight is a counter traction.

Management of a patient with skin tractions

Acute management
1. Ensure Order for Skin traction is documented by the Orthopaedic Team-(including weight to be applied in kgs)
2. Preparation of equipment

Top Shelf

Shaving tray
Receiver containing: A
pair of dressing forceps, 21
dissecting forceps
Bowl containing swabs
Extension plaster
A pair of Scissors
Crepe bandages
Tape measure
Skin pencil

Bottom Shelf

Receiver for used swabs
Spreader
Cordiallv, Brown wool or
sorbo pads
Tincture of benzoin co.
Dressing mackintosh and
towel
A small blanket to cover the limb
Balkan Beam
Bed blocks

Bed Side

Hand washing equipment
Screens
Bucket for used
equipment
Weights in various
kilograms
On the bed
Pulleys
Fracture board

3. Pain relief: A femoral nerve block is the preferred pain management strategy and should be administered in the emergency department prior to being admitted to the ward.
– Diazepam and Oxycodone should always be charted and used in conjunction with the femoral nerve block.
4. Distraction and education: Explain the procedure to the parents and patient before commencing.
– Plan appropriate distraction from play therapy, parents or other nursing staff.
5. Application of traction: Ensure the correct amount of water has been added to the traction weight bag as per medical orders.
– Fold foam stirrup around the heel, ankle and lower leg of affected limb. Apply bandage, starting at the ankle, up the lower leg using a figure 8 technique, secure with sleek tape.
– Place rope over the pulley and attach traction weight bag. If necessary trim rope to ensure traction weigh bag is suspended in air and does not sit on the floor.
Ongoing management
6. Maintain skin integrity: Patient’s legs, heels, elbows and buttocks may develop pressure areas due to remaining in the
same position and the bandages.
– Position a rolled up towel/pillow under the heel to relieve potential pressure.
– Encourage the patient to reposition themselves or complete pressure area care four hourly.
– Remove the foam stirrup and bandage once per shift, to relieve potential pressure and observe condition patients skin.
– Keep the sheets dry.
– Document the condition of skin throughout care in the progress notes and care plan
– Ensure that the pressure injury prevention score and plan is assessed and documented.
7. Traction care: Ensure that the traction weight bag is hanging freely, the bag must not rest on the bed or thenfloor
– If the rope becomes frayed replace them
– The rope must be in the pulley tracks
– Ensure the bandages are free from wrinkles
– Tilt the bed to maintain counter traction
8. Observations: Check the patient’s neurovascular observations hourly and record in the medical record.
– If the bandage is too tight it can cause blood circulation to be slowed.
– Monitoring of swelling of the femur should also occur to monitor for compartment syndrome.
– If neurovascular compromise is detected remove the bandage and reapply bandage not as tight. If circulation does not improve notify the orthopaedic team.
9. Pain Assessment and Management: Assessment of pain is essential to ensure that the correct analgesic is administered for the desired effect
– Paracetamol, Diazepam and Oxycodone should all be charted and administered as necessary.
– Pre-emptive analgesia ensures that the patient’s pain is sufficiently managed and should be considered prior to pressure area care.
– Assess and document outcomes of pain management strategies employed.
10. Activity: The patient is able to sit up in bed and participate in quiet activities such as craft, board games and watching TV. Play therapy will be beneficial for patients in traction long term.
– Non-pharmacological distraction and activity will improve patient comfort.
– The patient is able to move in bed as tolerated for hygiene to be completed.
– Patients who are in traction for a number of weeks may require a referral to the education
department.
11. Theatre time
The patient should be transported to theatre in traction to reduce pain and maintain alignment.
Special considerations
The foam stirrup, bandage and rope are single patient use only.

Potential complications

Skin breakdown/pressure areas
Neurovascular impairment (assessment of circulation, oxygenation and nerve function of limbs within the body)
Compartment syndrome (Increased pressure within one of the bodies compartments which contain muscles and nerves. )
Joint contractures
Constipation from immobility and analgesics

PULP TRACTION

This is the type of traction used for management of displaced phalanges, metacarpals and metatarsal fractures. A structure is put through the pulp of the fingers and fastened to an extension wire which is incorporated in the plaster.

SKULL TONGS TRACTION.

This kind of traction is used to immobilize the cervical spine in the treatment of unstable fractures or dislocation of a cervical spine.
Types of skull tongs traction.
➢ Crutchfield tongs
➢ Gardner wells tongs
NB: Gardner wells tongs is widely used by most experts because it is believed that its less likely to pull out compared to the Crutch field tongs.

Procedure.
In either type of tongs, the patient is prepared psychologically, physically and made to consent. This process may be done in theater under anesthesia. The tongs are surgically inserted into the bony cranium and a connector half halo brace is attached to a hook from which traction can be applied.

After procedure:
➢ After the procedure the patient is put on a special bed with a special mattress and therapeutic frames.
➢ The position used is complete supine with a small pillow under the head.
➢ Since patients remain in this type of traction for long, the same precautions taken in other types of skeletal traction must also be observed.
➢ The head of the bed is elevated to provide counter traction.
➢ Castors are placed on this bed to allow easy wheeling in case of any movement to the x-ray etc.

Points to remember
➢ Perform activities of daily living for the patient because this patient has difficulties doing it for himself.
➢ Prevent infection at the tong sites by regular cleaning
➢ Suggest recreational or occupational activities since restlessness and boredom are common concerns.
➢ Teach the patient range of motion exercises.
➢ Provide good nutrition.

HALO TRACTION

This is quite similar to the skull tongs traction. It serves the purpose of providing stabilization and support for fractured cervical vertebrae.
The pin is inserted into the skull, but the difference is that its got a vertical frame piece that extends to the rest of the patient and allows movement out of bed without intervening its function.
This frame cannot be removed because any movement of the vertebrae could injure the spinal cord.

FIXATORS

These are metallic rods passed through a bone to ensure stability.

Types;

External fixation devices
This is a frame of metal rods that connect skeletal pins. These rods extend and provide tractions between the pin sites. They can be simple with two to three connecting rods but can also be complexed with many rods arranged at different angles to maintain the position of fractured bone fragments.
Advantages
➢ Can be used when many bone fragments are to be immobilized.
➢ Used when open wounds are present externally to prevent the possible risk for infection especially
seen in casts.
Internal fixator Metallic devices used either to replace certain bones or treat certain fractures. Can be temporal or permanent especially if it were put for the purpose of replacing a dead bone like missing head of the femur.

GENERAL NURSING CARE OF A PATIENT ON TRACTION

Traction should be put at day time preferably
The patient is nursed with fracture boards on the bed so as to keep firm
The foot or head of the bed is kept elevated at all times depending on the site of traction(skull or limbs).
Do not lift, move or remove weights unless asked to do so by the doctor. Make sure the cords are always pulling and the weights not resting on the bed. The beds are elevated using bed blocks and the traction is maintained throughout the 24 hours per day because sudden cessation irritates diseased joints, causes displacement in a fracture and its very painful for the patient.
The cords must run freely over the pulleys oiled regularly.
Watch the color of the toes to ensure circulation is satisfactory.
In case of skeletal traction: –
➢ The puncture site must be kept clean and dry.
➢ Use tincture benzoin-co. to seal the wound.
➢ Observe the screws on either side of the pin to ensure free movement, lubricate the screw of oil if necessary.
➢ Keep a cork on the sharp point of the pin to prevent injury and pulling off.
➢ Provide the patients bed with an overhead lifting pole and chain to help the patient lift himself.
➢ When giving a bed pan ask the patient to lift himself or ask for assistance and do it if the patient is unable.
➢ Change bottom sheet from head to toe.
Assist patient with bathing where he or she cannot wash for himself eg the back, legs. bathing is done daily. Keep care full attention to pressure areas especially around the ring of the Thomas splint.
Patient is kept on full diet. Encourage foods with extra vitamins, minerals eg iron, milk, liver.
Teach patients muscle exercises to be done daily and to move the joints eg knee and ankles.
Give psychological care by regular re assurance.
Provide indoor games to occupy patient.

Care of P.O.P

Elevate the limb on a pillow
Elevate the foot of the bed.
Wash the plaster powder off the toes
Expose the P.O.P to room temperature
Observe the toes for good blood supply.
Ask the patient to move with toes from time to time
Half hourly pressure check for pressure on the nerves
Check the color of the toes
Check the temperature of the toes by the back of your hands
Observe any swelling of the toes
Check the pain which shows pressure
Check for loss of sensation or movement of the toes
Check for numbness or tingling due to nerve pressure.
Check for any blood stains on P.O.P meaning there is bleeding.
Physiotherapy;
Ensure deep breathing exercise
Ensure limb movement of an affected site.

Orthopedic Nursing Care Read More »

Peri-Operative care

Peri-Operative care is the care rendered to a patient before, during and after the surgery.

Peri-Operative care is composed of the following

Pre-operative care: The period of time before surgery.
Intra-operative care: The period of time during surgery.
Post-operative care: The period of time after surgery.

Reasons For Surgery

1. Curative: To completely eliminate the underlying disease or condition.

Examples:

Appendectomy: Removal of a diseased appendix.
Tumor removal: Excision of cancerous growths.
Cholecystectomy: Removal of the gallbladder.

2. Diagnostic: To obtain information about a suspected condition.

Examples:

Exploratory Laparotomy: Surgical exploration of the abdominal cavity to diagnose the cause of symptoms.
Biopsy: Removal of a tissue sample for examination under a microscope.
Endoscopy: Insertion of a flexible tube with a camera to visualize internal organs.

3. Reconstructive: To restore function, appearance, or both to a damaged body part.

Examples:

Plastic Surgery: To repair facial defects, burns, or other disfigurements.
Hand Surgery: To repair damaged tendons, ligaments, or bones in the hand.
Orthopedic Surgery: To repair broken bones, joint replacements, or spinal deformities.

4. Palliative: To alleviate symptoms and improve quality of life when a cure is not possible.

Examples:

Gastrostomy: Surgical creation of an opening in the stomach for feeding in patients with esophageal cancer.
Stent placement: Insertion of a tube to open a blocked artery or airway.
Pain management procedures: Nerve blocks or other interventions to reduce pain.

Types of Surgery

1. Major Surgery: Complex procedures involving extensive tissue manipulation, often requiring prolonged operating time, general anesthesia, a large surgical team, and advanced equipment.

Characteristics:

Time: Longer procedure duration, often several hours.
Anesthesia: General anesthesia is typically required.
Team: Large team of surgeons, nurses, and support staff.
Equipment: Sophisticated equipment and instrumentation.
Recovery: Extended hospital stay and a longer recovery period.

Examples:

Open heart surgery: Repairing heart valves or coronary arteries.
Organ transplantation: Replacing a failing organ with a donor organ.
Major abdominal surgery: Removal of a large tumor or extensive bowel resection.
Complex orthopedic procedures: Joint replacements, spinal fusion, major bone reconstruction.

2. Elective/Planned Surgery: Surgery that is scheduled in advance, with no immediate threat to life. The condition is not life-threatening, and the patient can prepare for the procedure.

Characteristics:

Urgency: Non-urgent, allowing for thorough pre-operative evaluation and preparation.
Timing: Scheduled at the patient’s convenience or when medically appropriate.

Examples:

Cataract surgery: Removal of cloudy lens in the eye.
Cosmetic surgery: Procedures for aesthetic enhancement.
Joint replacement surgery: Replacing a worn-out joint with an artificial one.
Laparoscopic cholecystectomy: Removal of the gallbladder through small incisions.

3. Minor Surgery: Procedures that are less complex and invasive, requiring shorter operating time, local anesthesia, and a smaller surgical team.

Characteristics:

Time: Shorter procedure duration, often less than an hour.
Anesthesia: Local anesthesia or sedation may be used.
Team: Smaller surgical team, often a single surgeon and nurse.
Equipment: Simpler instrumentation and equipment.
Recovery: Shorter hospital stay or even outpatient procedure.

Examples:

Incision and Drainage (I&D): Draining an abscess or other fluid collection.
Biopsy: Removal of a small tissue sample for diagnostic testing.
Skin lesion removal: Excision of a mole, cyst, or other skin growth.
Tooth extraction: Removal of a tooth.

4. Emergency Surgery: Surgery performed immediately to address a life-threatening condition or a severe injury.

Characteristics:

Urgency: Immediate, often requiring immediate action to prevent serious complications or death.
Preparation: Minimal preoperative evaluation, often conducted simultaneously with the surgical procedure.

Examples:

Trauma surgery: Repair of severe injuries due to accidents or assault.
Appendicitis surgery: Removal of an inflamed appendix.
Hemorrhagic stroke surgery: Surgery to stop bleeding in the brain.
Cardiac arrest surgery: Emergency procedures to restore heart function.

PRE-OPERATIVE CARE OF PATIENTS

Objectives

Identify the requirements for pre and post operative care.
Prepare requirements for pre and post operative care.
Perform pre and post operative care.

Preparation for surgery should begin as soon as the doctor makes a diagnosis and decides that an operation is necessary. From that moment on, the patient and relatives are faced with the decision of accepting this treatment and its consequences or not.
The doctor should tell the patient and family why an operation must happen, what will be done and what the probable outcome will be.
An appointment for admission is now arranged depending on the acuteness of the illness, period of preoperative care and the amount of time the patient requires to make necessary arrangements regarding his family, financial matters and work.

1. Admission: patient may be admitted a day before or several weeks or days in a surgical ward for a planned surgery, depending on the extent of the pre-operative treatment, e.g., alcoholics, wasted cancer patients, so that their nutritional and electrolyte status and underlying conditions are treated before
surgery.

2. Rapport: Patient and significant others are received by the nurse, given seats, greeted, and introduction of names done by the nurse. Patient is showed a bed, and he is introduced to the ward or room-mates, he is showed the ward environment, i.e. the latrines, shelters, stores, kitchen, sluice room and other
departments within the hospital that are necessary for him to know, visiting hours, meal times.

3. Physical preparations and History: History of the disease is taken, starting from the present main complaint, and other associated complaints presently, history of previous illness, or operation done is noted, any drugs taken by the patient, any allergy to any drug, any dietary restrictions, patient’s occupation, religion, marriage status, etc.

4. Vital Observations are taken and recorded to provide a baseline for future comparisons, weighing is done and the surgeon is informed to come and review the patient.

5. Psychological preparation: There is need to prepare the patient before surgery psychologically because patients always have fears when faced with the fact of undergoing an operation, and this depends on the individual basic personalities, habitual reactions to stress over the years, general state of mental health, and the preconceptions that they have concerning surgery and anesthesia. These fears include; fear of unknown, post-operative pain, discovery of cancer, the loss of organs that have special meaning
for them, the hazard of death or fear of what other friends have been telling them about surgery, hazards of anesthesia, vulnerability while unconscious, threat of loss of job and financial security, loss of social and familial roles, and the problem of being separated from family members and former activities.
These fears cause anxiety in patients going for surgery and these can be expressed in a variety of behaviors such as: becoming silent and withdrawn, hopeless and helpless, childish, aggressive and disobedient, evasive, tearful.

Measures to alley the patient’s anxiety

Information and Orientation: Patient is given explanations or printed information about hospital routines, visiting hours, meal times, specific locations and general orientation to the hospital environment.
Procedure Explanations: Give full explanations of all procedures the patient may undergo, covering the pre-operative, intra-operative, and postoperative phases.
Reasoning and Discomfort: Patient is made aware of the reasons for the various procedures to be done on him and any discomfort that may be experienced, ensuring the patient understands the reasons for the intervention.
Collaborative Communication: There must be prior consultation between a nurse and the doctor in order to maintain the uniformity and accuracy of the information to be given to the patient.
Questioning and Clarification: Patient should be given a chance to ask questions concerning the operation and the postoperative period, providing reassurance and addressing any concerns.
Information Management: Give only as much information as the patient wishes to know, as too much information given in a short time may create more anxiety or when given at a wrong time, like some few hours to operation.
Peer Support: Patients going for major surgery like mastectomy, colostomy, may benefit from being introduced to people who have successfully recovered from these operations.
Occupational Therapy: Occupational therapy can be arranged for patients who are facing an extended preoperative period, e.g. games, handicrafts, television to distract the patient and ease the fear and loneliness.
Family and Friends: Encourage visits from family members and friends to have time with the patient, to provide companionship and emotional support.
Religious Support: Ascertain the patient’s religious preference and arrange for a priest, minister, or rabbi to visit if the patient so desires.
Age-Appropriate Language: A child should be told in simple language appropriate to his age and level of development what to expect before and after surgery.
Honesty and Clarity: The child should never be told lies. Be honest when telling him about surgery, tests, pain, stitches, etc.
Socialization: Let the child be with other hospitalized children for easy adjustment.

Note: handling fears in this way can smooth the patient’s operative course. Studies show that the calm,emotionally prepared pre-operative patient is able to withstand the induction of anesthesia better and also experiences less postoperative nausea and vomiting and fewer postoperative complications.

Consent Form

A consent form is a document with important information about a medical procedure or treatment, a clinical trial, or genetic testing. It also includes information on possible risks and benefits. If a person chooses to take part in the treatment, procedure, trial, or testing, he or she signs the form to give official consent. Any patient undergoing a surgical procedure, however minor, must sign a consent form.

Indications of Consent form

Avoiding Unwanted Procedures: Safeguards the patient from undergoing surgery they are unaware of or do not consent to.It protects the patient against submitting to operations that she or he does not know about or does not want.
Ensures the patient understands the nature of the proposed procedure, including its risks, benefits, and potential complications, empowering them to make an informed and voluntary decision.
Legal protection: Protects healthcare providers, including surgeons and hospital staff, from liability in cases where a patient or their family alleges that surgery was performed without consent.
Respect for Autonomy: Acknowledges and respects the patient’s right to self-determination and bodily integrity.
Open Dialogue: Encourages open communication between the patient and healthcare providers, allowing for any questions, concerns, or anxieties to be addressed before proceeding with the procedure.
Family Involvement: Facilitates the involvement of family members or loved ones in the decision-making process, particularly when the patient desires their input or support. Sometimes the patient wishes to talk to a close relative before signing the form

Factors to be considered before signing the consent form

Clear Explanation: The patient must have the full explanation of the operation before signing the consent form and pictures and diagrams may be necessary.
Potential Complications: The patient must be told about any possible complications and the disfigurements that may arise from the surgery.
Procedure and Investigations: Explain about procedures and investigations and let him understand before accepting the operation.
Anesthesia: Explain about the administration of anesthesia, addressing any concerns or questions the patient may have.
Pain Management: The patient should be reassured about pain management strategies during and after the surgery.
Disfigurement: If the surgery involves the possibility of disfigurement, such as amputation, mastectomy, or hysterectomy, this should be openly discussed with the patient, acknowledging the potential impact on their body image and self-esteem.
Social and Economic Background: The patient’s social and economic background should be considered, understanding potential challenges or concerns related to recovery, finances, and daily life.Encourage the patient to talk about his social, economic background, and talk to him about spiritual life.
Spiritual Life: The patient’s spiritual beliefs and practices should be acknowledged and addressed, offering appropriate support or resources if desired.
Organ or Body Part Removal: If any organ or body part is to be removed, the patient should be informed of this in a clear and sensitive manner.
Simple Explanations are given in terms that the patient can understand- the patient needs an honest and fair statement of what may be faced both in surgery and following the operation.
Signature: Adults sign their consent forms unless unconscious or mentally incompetent, thus making a relative or a guardian to sign on his behalf. Children under 18 years must be signed for by an adult and preferably a relative. If a child’s parents can not be present, permission be got by telephone or letter or the surgeon may sign the form personally, depending on the laws of the state or court order may have to be obtained permitting the operation.
Make sure this accompanies other medical forms to the operation room.
After all the above details, a patient is asked to sign the consent form which indicates that he consents to have the operative procedure performed. This implies that he has been provided with the knowledge necessary to understand the nature of the procedure to be carried out as well as the known and possible consequences of the operation.

6. Investigations: Most of these investigations are done to make sure that the patient’s physical status is at maximum fitness and to ensure that coexisting diseases that might alter the patient’s response to surgery or his recovery are treated.

Routine radiographs of the chest are taken, including sputum examinations: to be sure that the patient does not have any lung problem that would complicate anesthesia or recovery after surgery, especially difficulties with inadequate oxygen supply through the lungs and cardiac function. Signs of upper respiratory infections are noted and reported.
Urinalysis is done: to detect urinary tract infection or any other disease that may become a serious problem especially when it comes to drug elimination after anesthesia or presence of sugar or proteins or acetone which may indicate the presence of diabetes mellitus, chronic kidney disease, starvation or dehydration respectively: for any of these may alter the treatment that is
needed before, during and after surgery.
Blood tests such as, complete blood count, hemoglobin, blood grouping and cross matching bleeding and clotting time: these will help to make sure that the patient has a chronic infection, anaemia or any blood problems, which may bring problems during surgery, or interfere with wound healing and prolong a period of recovery. If Hb is low, shock may ensure intra-operatively,
or bleeding problems may cause problems intra or post-operatively.
Specific investigations like ECG, Plain abdominal radiographs: are done to assess the cardiac functions so as to influence the care to be given to the patient preoperatively or for his condition to stabilize first before surgery.

7. Treatment: Antibiotics are given according to the results of the investigations and pre-existing conditions. Any other condition discovered is treated appropriately before the patient is considered ready for surgery: heart conditions, blood conditions, respiratory, urinary, digestive, etc.
8. Nutrition: The patient should be in the best possible state nutritionally before undergoing anesthesia and surgery. This is because;

Dehydration and poor nutrition affects the prognosis post-operatively, particularly in infants and elderly especially if caused by excessive vomiting or diarrhea and this may cause electrolyte imbalance, coupled with chronic illness and poor appetite
Protein deficiency leads to slow wound healing and low resistance to infection
Lack of vitamin C retards wound healing.
Interventions
Balanced Diet: A well-balanced diet tailored to the individual patient’s needs should be provided, including adequate protein, carbohydrates, fats, vitamins, roughages, and plenty of fluids.
Monitoring and Reporting: Nurses play a role in monitoring the patient’s food intake and reporting any concerns to the surgeon or dietician.
Individualized Approach: The patient’s likes and dislikes should be considered when planning meals to encourage food intake and ensure optimal nutrition.
Appropriate Feeding Routes: Feeding methods should be chosen based on the patient’s condition and needs, ensuring they receive adequate nutrition through the most appropriate route.

9. Exercises: Patients need to be instructed pre-operatively concerning the proper way to cough, deep breathe, turn and move their extremities during the postoperative period. Such instructions, given in sufficient detail and at the correct time, greatly reduce operative and post-operative complications.

Deep breathing exercise: this is done by inhaling slowly through the nose, distending the abdomen and exhaling slowly through the mouth, pulling the abdomen in until all air has been expelled. This should be done at least 5-10 times every hour. This is important for effective aeration of the lungs and the tissues to allow full lung expansion in thoracic surgery, to expel secretions, to prevent pneumonia and Atelectasis.
Coughing exercise: patient is instructed to sit or lie, take a deep breath, exhale through the mouth and then follow with a short breath while coughing from deep in the lungs. Deep breathing exercise should be done before coughing exercise to stimulate coughing reflex. Patients who will go for thoracic or abdominal surgery should be showed how to splint their incision before
coughing in order to minimize pressure on the sutures and to control pain. A small pillow or rolled towel may be held against the incision to facilitate splinting.
Turning exercises: the patient will need to practice turning from side to side using the side rails if available. This prevents venous stasis and pooling of secretions in the lower lobes of the lungs, predisposing to pulmonary complications. This should be done every 1-2 hours post-operatively.
Extremity exercises: range of movement exercises of all the joints, flexing and extending the joints and to move each foot in a circular motion. These help to prevent circulatory problems, such as deep venous thrombosis, prevent muscle wasting and disuse, and encourage wound healing due to sufficient blood supply.

10. Treatment of existing abnormalities/infections: Abnormalities that have been detected are treated according to the diagnostic findings, e.g. mouth infections, dental caries, skin lesions, constipation, respiratory and cardiac conditions. Antibiotics, fluids, blood transfusions, painkillers are given as per the patient’s condition.
11. Hygiene: Hygiene ensures cleanliness of the skin, nails, umbilicus in case of abdominal surgery, oral care since this is the entrance to the respiratory system and digestive. It is aimed at minimizing the number of microbes that will be carried into the deeper tissues from the skin when the surgeon makes the incision. Patient’s gowns, bed linen, utensils and equipment of care are made clean including the tables, bed, etc.
12. Pre-operative visits: Visits from theater nurses and team are important to know the patient, and what he knows about the operation, to tell him the approximate length of surgery, to tell him what he will see , hear, and smell before he goes to sleep and what to expect in the recovery room.
13. Rest and sleep: Physical exhaustion deteriorates the general health and hinders many body activities and mental exhaustion aggravates shock. Patients may not relax due to fear of the forthcoming operation.

Prepare a comfortable freshly made bed and in a well-ventilated room.
Nurse avoids talking to a tired patient.
Visitors are restricted from always disturbing the patient.
Noise of any kind is avoided, i.e., using rubber-soled shoes, talking loudly is not allowed, radio sounds put at low tones, banging doors and using trolleys that make a lot of noise are avoided.
Sedation may be necessary to induce sleep or to reduce the pain that may interfere with sleep,

Preparation of the patient on the eve of surgery (12 hours to operation)

Skin care of the area to be operated: The skin site preparation preoperatively is aimed at removing dirt, oils and microorganisms, to prevent the growth of microorganisms that remained and to leave the skin undamaged with no
irritation from the cleansing and shaving procedure, and the area depends on the type of surgery to be done.

Principles of skin preparation

The areas to be prepared should always be larger and wider and longer than the area of the proposed incision, because the surgeon may unexpectedly widen or extend the incision line.
First wash the area with soap and water and start shaving when you are sure of the cleanliness.
Use a strong, light, well-focused and sterile safety razor or blade.
Shave against the direction of the hair shaft to ensure clean, close shave.
Check the skin for nicks, irritations, and cuts since these are all potential sites for infection.
Use skin antiseptics after shaving to clean the site, like chlorhexidine, iodine and others.

Specific preoperative preparations;

1. Abdominal operation: The patient’s gastrointestinal tract needs special preparation on the evening before surgery in order to reduce the possibility of vomiting and aspiration during anesthesia and to prevent contamination from fecal material during bowel surgery. The measures taken are:

restriction of foods and fluids to prevent vomiting during surgery, the aspiration of any vomitus and the resultant development of aspiration pneumonia. Solid food must be withheld 7-10 hours before operation, most patients receive nothing by mouth (NPO) after midnight; tea, water may be given up to 4 hours before surgery. When the surgery is scheduled until late afternoon, the patient may eat a light breakfast in the morning. When the patient is on NPO, the nurse should tell the patient not to eat and why; removes food and water from the patient’s bedside; places NPO-sign on the door and gives the report to the incoming nursing staff; extremely malnourished and debilitated patients are given intravenous infusions of glucose, amino acids or plasma up to the moment of surgery.
two or three enemas may be given in the evening to prevent contamination of the peritoneal cavity from the spillage of fecal content during surgery; in some cases, laxatives are given 2-3 days pre-operatively; nasogastric tubes for suction, drainage may be inserted in the evening or morning of surgery in order to remove gastric and intestinal contents; flatus tubes may as well be inserted to relieve gaseous distension;
catheterization is done to drain urine and to relieve urine retention postoperatively and intra-operatively to prevent accidental injury to the urinary bladder if it is full with urine during abdominal surgery.

2. Genito-urinary system: The renal functions are often impaired by diseases of the kidneys, prostate, urethra, bladder or ureter. The patient should be instructed to take plenty of oral fluids at least 2 liters per day and the fluid balance chart be strictly charted; an indwelling catheter be inserted for continuous bladder irrigation, washout , drainage post-operatively; intravenous fluids be run to irrigate the bladder so as to avoid urine stasis which predispose to calculi formation and bladder wall infection; urine sample
is removed aseptically for urinalysis; patient is encouraged to pass urine frequently and any abnormalities are treated appropriately.

3. Rectal operation/haemorrhoidectomy: This requires special preparations because it is not easy to render the rectum a sterile or aseptic and it is also difficult to control the passage of stool. The bowel may be emptied by an aperient’s administration given in the evening before operation and also repeated in the morning and 8 hours before operation. Simple enema of soap and water is given followed by washing of the rectum and shaving the perineum.

4. Gynaecological surgery: All patients going for this operation should have antiseptic douche done and no spirit or ether are applied on the genital mucosa. Urinary catheter is passed in situ before surgery and should continue post-operatively.

5. Respiratory operation: All patients for respiratory need close respiratory observations and any respiratory infections should be treated before surgery and respiratory exercises are taught preoperatively.
Paired organs: The affected organ of the pair like the eye, ear, limb, breast, should be marked with a tag or an adhesive tape to prevent the removal of the normal side.

On the morning of surgery the nurse usually awakens the patient about an hour before preoperative medications are scheduled. During that hour, the nurse does the following tasks:

She records the patient’s vital signs as baseline for future observations and comparison, to detect abnormalities which may entail postponement of operation, e.g., pyrexia, tachycardia (120b/m over), or bradycardia (pulse rate below 60 b/m), urine results and weight for future comparison and for drug calculation.
She checks for the skin preparation if done well or there is need to be repeated in a thorough manner.
She asks the patient to void before going to theater to avoid bladder injury in the lower abdominal and pelvic surgery, incontinence during operation (due to anesthesia), restlessness during the early post-operative period, or if the catheter is in situ, the output is emptied and
recorded.
She carries out special orders like giving enemas, insertion of catheters if not done in the evening, NGT, putting infusion lines if not done before and hanging fluids prescribed before anesthesia (1 liter of normal saline), or checking if the line is patent and the surrounding tissues are not infiltrated.
She gives the patient oral hygiene and removes any dentures and safely keeps them.
She gathers all the necessary documents like form 5, admission and observation charts, laboratory forms, x-ray radiographs, consent form, fluid balance chart, etc, and puts them together ready for theater.
She checks if the consent form is signed for and helps the patient if not done.
In privacy, she asks the patient to remove his or her own personal clothing which are safely to be kept, she removes and keeps the patient’s jewelry, earrings, but the wedding ring is usually left insitu and strapped with an adhesive tape; necklaces, bangles, plastic rings or rubber are too removed and kept together with other things.
She dresses the patient in a theatre gown which is clean and perhaps supports stockings. If the patient has long hair, braid them into 2 braids, all hair pins are removed to prevent scalp injury during and after surgery, and the head is covered with a protective cap.
Colored nail polish is removed with the nail file to help in easy assessment of cyanosis from the nail bed. Anything that is difficult to remove can be strapped off.
She questions the patient to make sure that food has not been eaten for the last 8 hours, or fluids taken during the preceding 4 hours, and report immediately if the patient has eaten so that surgery is postponed.
She makes the patient’s identification band containing his name, age ward, type of surgery to be undertaken and attaches it to the patient. She makes sure the information is accurate.
She gives preoperative medications: this is usually a combination of sedatives and analgesics opiates, e.g., morphine 10-15mg, or pethidine 50-100mgs, temazepam 10-20mg, tranquilizers such as diazepam 5-10mgs. These drugs are meant to reduce apprehension so as to reduce shock, to ensure sleep, and to reduce the amount of anesthetic drugs to be used, and to create amnesia for the events that precede surgery
Other drugs sometimes may be prescribed to be given before the patient is transported to theatre, such as antibiotics like Metronidazole i.v, + ampicillin gentamicin or chloramphenicol in some abdominal conditions, gynaecological conditions, head injury, gun shot wounds, etc. give according to the prescription.
Anti-secretions like atropine 0.6-1 mg is given to dry up secretions or to prevent overproduction when inhalation anesthetics are used especially ether; it improves the heart action and suppresses vagal influence on the heart. These drugs must be given half to 45 minutes preoperatively to ensure the above effects. The time of administration should be recorded accurately. If omitted or delayed, the anesthetist should be informed. Do not give under the
maxim “better late than never”.
When all the preparations are ready, and the time of surgery has come, the patient is transported to the operating theater on a couch, rolled by 2 nurses. Minimal noise should be made as hearing is very acute after pre-medications. All movements to theater should be gentle, steady and unhurried. The nurse should carry all documents to the theater with the patient.
A full report is given to the theater nurse, or anesthetist concerning the patient.
A post-operative bed is then made with clean linen. The specific bed depends on the type of surgery, e.g., divided bed, fracture bed with traction appliances, etc. bedside accessories like bed cradles, infusion stands, vital observations tray, mouth care tray, infusion trays, oxygen apparatus and cylinder, suction apparatus and suction machines, bed elevators, mosquito nets, etc. this are
the items necessary for resuscitation immediately post-operatively. The bed should be warm, without overheating to prevent shock.

Preparation for pre-operative care

Steps	Action	Rationale
1.	Refer to general rules and ensure understanding of the type of operation to be done.	To gain confidence in the nurse and for an informed consent to be given.
2.	Carry out preoperative nursing assessment.	To collect baseline data from the patient and the family.
3.	Ensure that diagnostic tests are done and results are ready before operation i.e. urinalysis, chest x-ray, blood test e.g. ABO group and rhesus factor, and HB, CBC, ECG.	To clarify pathological conditions and be able to manage them before surgery.
4.	Obtain consent from the patient for operation or if minor or unable to consent; next of kin consents on behalf of the patient.	To gain approval and protect the patient from unwanted procedures as well as preventing litigation related to unauthorized surgeries.
5.	Stop all solid foods and oral fluids 4-6 hours before operation.	To ensure empty stomach and prevent vomiting which may occur during the anaesthesia and cause respiratory failure or aspiration pneumonia.

PHYSIOTHERAPY:

Steps	Action	Rationale
6.	Deep breathing exercises:	To improve lung expansion and facilitate oxygenation of tissues before and after operation.
–	Position patient in an upright position.	To promote chest expansion.
–	Instruct patient to place palms of both hands along the lower anterior rib cage.	It allows the patient to feel the chest rise as the lungs expand.
–	Instruct the patient to exhale gently and completely.	To empty the lungs.
–	Instruct the patient to breathe in through the nose deeply and hold the breath for 3 seconds.	To promote lung expansion.
–	Instruct the patient to exhale through the mouth, pursing the lips like when whistling.	To empty the lungs.
–	Instruct the patient to do a return demonstration.	To check understanding.
7.	Coughing and splinting (Muscle support):	Coughing helps to remove retained mucus from the respiratory tract while splinting minimizes pain when coughing or moving.
8.	Leg exercises:	To prevent muscle weakness, promote venous return and decrease complications related to venous stasis i.e. deep venous thrombosis.
–	Request the patient to sit up.	For easy demonstration of the exercises.
–	Straighten the patient’s knees, raise the foot, extend the lower leg, hold this position for a few seconds. Lower the entire leg. Practice that exercise with the other leg (calf pumping).	To prevent weakness of the calf muscles and promote venous return. It contracts and relaxes calf muscle and gastrocnemius muscles.
–	Request the patient to point the toes of both legs towards the foot of the bed and then towards the chin.	To exercise muscles and joints of the toes.
–	Request the patient to keep legs extended and to make circles with both ankles. First circle to the right and second to the left. Ask the patient to perform a return demonstration.	To prevent pain and stiffness of the joints.

Requirements

Trolley

Top shelf	Bottom shelf	At the side
– Basin	– Receiver for used swabs	– Screen
– Soap in a dish	– Face cloth	– 2 chairs back to back
– Cotton swabs	– Draw mackintosh and draw sheet	– Hand washing equipment
– A small pair of scissors for trimming long hair	– Bucket for dirty water	–
– A jug of cold water		–
– Clean gloves		–
– A jug of hot water		–
– Antiseptic lotion		–

Procedure for Pre-operative care

Steps	Action	Rationale
Morning before Operation
1	Request the patient to bathe or offer the bath.	Promote hygiene.
2	Prepare the operation site.	–
3	Report any abnormalities detected.	For immediate intervention.
4	Give a clean gown and theater cap.	For decency and privacy.
5	Request the patient to empty the bladder if unable to catheterise before operation.	To minimize the risk of injury or complications during and after surgery, to promote hygiene.
6	The operation site is shaved on the morning of operation or 30 minutes before operation or in theater.	To promote infection prevention and control.
7	Provide preoperative medications if prescribed i.e. atropine, morphine, pethidine.	To reduce the incidence of surgical complications i.e. bronchial and salivary secretions and to allay anxiety.
8	Label and securely store the patient’s valuables such as money, jewelry, dentures and documents.	To prevent loss and legal purposes.
9	Put up intravenous infusion if prescribed.	To prevent postoperative shock.
10	Check the operation site for cleanliness, label the operation site and the patient.	To minimize infections. Right identification of the site of operation and the patient.
11	Check the surgical and safety (SSC) list (See SSC appendix).	Ensure pre-operative phase is completed.

Steps	Action	Rationale
Transportation to Theatre
12	Carry all notes i.e. X-ray forms; consent form, patient’s chart, and surgical and safety checklist with the patient to the theater.	To minimize errors and promote quality surgery.
13	Cover the patient with clean warm clothing during transportation to the theater.	To provide privacy and prevent chilling.
14	Two nurses transport the patient to the operating theater.	To safely hand-over the patient and give a report.
15	Hand-over the patient to in-theater nursing staff.	Ensure that it is the right patient and ready for surgery.

Intra-operative Nursing Care

Observing a client undergoing surgery may be a component of a nursing student’s experience.
Doing so will not only give the student a better idea of surgical procedures, but it will also help in understanding the client’s feelings and apprehensions. Special training mostly given in OR technique and anesthesia Nurses assist surgeons in the operating room.
The two basic categories of assistant are the sterile assistant and the circulating assistant. The sterile assistant (scrub nurse) is scrubbed, gowned and gloved. He/she functions within the sterile field. Duties include handling instruments to the surgeon, threading needles, cutting sutures, assisting with retraction and suction, and handling specimens.
The circulating nurse works outside the sterile field. Duties include opening sterile packs, delivering supplies and instruments to the sterile team, delivering medications to sterile nurse, labeling specimens, and keeping records during the surgical procedure. This person acts as a client advocate by monitoring the situation and maintaining safety in the operating room. In most
cases, the circulating nurse must be a registered nurse.

Post-Operative Nursing Care

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Peri-Operative care Read More »