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PERFORM SHORTENING AND REMOVAL OF DRAINS

SHORTENING OF DRAINS

Shortening and removal of drains refers to the process of adjusting or cutting to an appropriate length and then removing medical devices that are used to drain fluids or provide access to specific areas within the body

A drain: A surgical implant that allows removal of fluid and/or gas from a wound or body cavity.

Examples of Drains

Nasogastric Tube (NG Tube): This is used to drain stomach contents or provide nutrition. Shortening and removal may be necessary when the tube is no longer needed or needs adjustment.
Catheters: Catheters can refer to various types, such as urinary catheters and central venous catheters. Shortening and removal may be needed when the catheter is ready to be taken out.
Ventriculoperitoneal Shunts (VP Shunts): These are used to manage excess cerebrospinal fluid in the brain. While they are typically removed in a surgical procedure, adjustments or revisions may be needed during a patient’s treatment.
Vascular Access Ports: These are used for long-term intravenous treatments. Ports are typically removed when they are no longer required, such as when a patient completes chemotherapy.
Jackson-Pratt Drain (JP Drain): Used to remove fluids that build up in surgical sites, such as after a mastectomy or abdominal surgery. They are typically removed when the drainage decreases to an acceptable level.
Hemovac Drain: Similar to the JP drain, the Hemovac drain is used to remove blood and fluids from surgical sites. It is also removed when drainage decreases.
Penrose Drain: A soft, flat rubber tube used to allow drainage from a wound. It may be removed when the wound has healed sufficiently.
Chest Tube: Inserted into the chest to remove air or fluids, often in cases of pneumothorax or pleural effusion. They can be removed when they are no longer needed.
Biliary Drainage Tube: Used to drain bile from the liver or gallbladder when there is a blockage. Removal depends on the patient’s condition and the resolution of the blockage.
Ureteral Stent: Placed in the ureter to promote urine flow, often after urological surgeries. They may need to be shortened or removed when they are no longer needed.
Gastrostomy Tube (G-tube): Used for long-term enteral feeding, often in patients who cannot eat normally. Removal may be considered when the patient can resume oral feeding.

Indications of Drains

Nasogastric Tube (NG Tube):

Gastric decompression: To remove stomach contents and gas to relieve abdominal distention.
Enteral feeding: To provide nutrition and medications when oral intake is not possible.
Gastric lavage
Medication administration

Foley Catheter (Indwelling Urinary Catheter):

Urinary retention: To relieve the inability to urinate.
Monitoring urinary output: In critically ill or surgical patients.
Post-operative use: For surgeries involving the urinary tract.
Bladder irrigation
Urologic procedures

Ventriculoperitoneal Shunt (VP Shunt):

Hydrocephalus: To divert excess cerebrospinal fluid (CSF) from the brain to the abdominal cavity.
Normal pressure hydrocephalus (NPH): To manage the accumulation of CSF in older adults.
Traumatic brain injury
Meningitis

Central Venous Catheter (CVC):

Intravenous medications and fluids: To administer chemotherapy, total parenteral nutrition (TPN), or other treatments.
Hemodialysis access: For patients with renal failure.
Frequent blood draws: In critically ill patients or those with challenging peripheral access.
Long-term parenteral nutrition (TPN)
Transfusion of blood products
Cardiac monitoring and pacing
Administration of chemotherapy
Emergency resuscitation

Thoracostomy Tube (Chest Tube):

Pneumothorax: To remove air from the pleural space.
Pleural effusion: To drain fluid or blood from the pleural cavity.
Post-surgical use: After thoracic surgery to prevent pneumothorax or pleural effusion.
Hemothorax
Empyema
Lung abscess
Trauma
Pulmonary embolism

Classifications of Drains

Drains are categorized based on various factors, including their functionality and design. Here, we discuss the classifications of drains:

Open vs. Closed Drains

Open Drains:

These drains include corrugated rubber or plastic sheets.
Drain fluid collects in a gauze pad or stoma bag.
Simpler design and less expensive: They are typically cheaper and easier to assemble compared to closed drains.
Can drain large volumes of fluid: They have a larger drainage capacity and can handle significant fluid buildup.
Easier to monitor: They allow visual inspection of the drainage, making it easier to assess the volume and type of fluid.
They increase the risk of infection.
Example: Penrose drain.

Closed Drains:

Consist of tubes draining into a bag or bottle.
Reduced risk of infection: They create a sealed system, minimizing the risk of contamination and infection.
More precise fluid measurement: They provide a more accurate measure of the volume of drainage.
Less risk of leakage: The closed system reduces the chance of drainage leaking out.
Can be connected to suction devices: They can be easily connected to suction devices for continuous drainage.
These drains include chest and abdominal drains.
The risk of infection is reduced.
Example: Jackson-Pratt drain.

Active vs. Passive Drains

Active Drains:

Active drains are maintained under suction, which can be low or high pressure.
Both open (e.g., Sump drain) and closed (e.g., Jackson-Pratt, Hemovac drain) drains can be active.

Advantages of Active Drains:

More efficient drainage: They provide continuous suction or pressure, leading to faster and more complete drainage.
Can handle larger volumes of fluid: They are designed to handle significant fluid buildup and can be more effective in removing blood clots.
Reduced risk of infection: The continuous drainage can help prevent bacterial growth and reduce the risk of infection.
Keep the wound dry.
Efficient fluid removal.
Can be placed in various locations.
Prevent bacterial ascension.
Allow evaluation of the volume and nature of fluid.

Disadvantages of Active Drains:

More complex and expensive: They require a power source or other components, which can increase the cost and complexity.
Higher risk of malfunction: They have a greater chance of malfunction or failure compared to passive drains.
More difficult to manage: They require more specialized knowledge and may necessitate frequent adjustments and monitoring.
High negative pressure may injure tissue.
Drains can be clogged by tissue.

Passive Drains:

Passive drains operate without suction and rely on pressure differentials, overflow, and gravity between body cavities and the exterior.
Passive drains include closed (e.g., NGT, Foley’s catheter, T-Tube) and open (e.g., Penrose drain, corrugated drain) drains.

Advantages of Passive Drains:

Simpler design and less expensive: They are typically less complex and cost-effective compared to active drains.
Less risk of complications: They generally have a lower risk of malfunction or infection compared to active drains.
Easier to manage: They require less maintenance and can be managed by nurses and other healthcare professionals.
Allow evaluation of volume and nature of fluid.
Prevent bacterial ascension.
Eliminate dead space.

Disadvantages of Passive Drains:

Less efficient drainage: They rely on gravity and may not drain fluids effectively, especially in large volumes.
Increased risk of infection: The open design increases the risk of contamination and infection.
Difficult to monitor drainage: The drainage volume may be difficult to measure accurately, leading to potential complications.
Gravity differences may affect the location of the drain.
Drains can easily become clogged.

Types of Drains:

Pigtail Drain:

Inserted under radiological guidance: This ensures precise placement and minimizes complications.
Used to remove unwanted body fluids from organs, ducts, or abscesses: This includes fluids like pus, bile, blood, or urine.
The tip forms a pigtail shape, facilitating drainage: This shape helps prevent the drain from getting clogged and ensures efficient removal of fluids.
Advantages:

Can be placed in difficult-to-reach areas.
Low risk of tissue damage due to its flexibility.
Effective in draining thick, viscous fluids.

Disadvantages:

May be prone to blockage.
Requires radiological expertise for insertion and maintenance.

Hemovac Drain:

A fine tube with multiple holes at the end: Allows for efficient collection of fluids from a larger area.
Attached to an evacuated glass bottle for suction: Provides continuous suction, promoting rapid drainage.
Drains blood under the skin: Often used for post-operative drainage following surgery or trauma.
Advantages:

Efficient in removing blood and other fluids.
Provides constant drainage, reducing the risk of blood clots forming.

Disadvantages:

Risk of suction malfunction or breakage.
May cause discomfort or pain if placed incorrectly.
Requires regular emptying and monitoring.

Penrose Drain (Open Drain):

A soft, flexible drain: Easy to insert and adapt to various anatomical structures.
Empties into absorptive dressing material passively: Relies on gravity and capillary action for drainage.
Prevents fluid from moving from areas of greater pressure to areas of lesser pressure: Helps control fluid accumulation and reduce swelling.
Advantages:

Simple design and low cost.
Can be used for short-term drainage.
Minimal risk of mechanical complications.

Disadvantages:

Less efficient drainage than closed systems.
Increased risk of infection due to the open design.
Not suitable for large volume drainage or high-risk areas.

T-Tube:

Placed into the common bile duct: Allows for drainage of bile after biliary surgery.
Connected to a small pouch (bile bag): Collects and allows for easy monitoring of bile drainage.
Used for temporary post-operative drainage of the common bile duct removed once the bile duct is healed.
Advantages:

Helps prevent bile duct obstruction.
Facilitates healing by allowing bile to drain.
Allows for monitoring of bile drainage.

Disadvantages:

Can cause discomfort or pain.
Requires regular emptying and monitoring.
May be prone to blockage or leakage.

Chest Tube (Closed Drain):

Used to drain hemothorax, pneumothorax, pleural effusion, chylothorax, and empyema: Effective for removing fluid and air from the chest cavity.
Inserted into the pleural space in the 4th intercostal space above the upper border of the rib below (4th to 6th): Requires careful placement to ensure effectiveness and minimize complications.
Advantages:

Efficient in removing fluids and air from the chest cavity.
Reduces pressure on the lungs, allowing for better breathing.
Minimizes the risk of infection due to the closed system.

Disadvantages:

Requires specialized training and equipment for insertion and management.
Can cause pain or discomfort.
May be prone to kinking or blockage.
Complications to assess for include arterial thrombosis, air embolism, hematoma, bleeding, and infection.

Nasogastric Tube (NG Tube):

Passed through the nostrils to the stomach: Allows for access to the stomach for various procedures.
Indications include gastric juice aspiration, lavage in cases of poisoning, overdose medication, and feeding: Versatile tool for managing stomach contents and providing nutritional support.
Advantages:

Provides access to the stomach for various procedures.
Relatively safe and easy to insert.
Can be used for short-term or long-term management.

Disadvantages:

Can cause discomfort or irritation.
May cause nausea or vomiting.
Complications include epistaxis, aspiration, and erosions in the nasal cavity and nasopharynx.

Urinary Catheters:

Hollow, flexible tubes used to collect urine from the bladder: Provides a way to drain urine from the bladder.
Indications include relieving urinary obstructions, managing bladder weakness or nerve damage, draining the bladder during and after surgery, and treating urinary incontinence: Essential for managing urinary issues and ensuring bladder health.
Catheter materials can include rubber, silicone, or latex
Advantages:

Allows for effective urine drainage.
Reduces urinary tract infections.
Provides a way to monitor urine output.

Disadvantages:
Can cause discomfort or pain.
Risk of infection if not properly maintained.
May be associated with bladder stones or urinary retention.

PROCEDURE FOR SHORTENING AND REMOVAL OF DRAINS

Requirements

Top Shelf	Bottom Shelf
Stitch removing pack containing	Bottle of antiseptic solution
– Stitch Scissors
– Non-toothed dissecting forceps
– 2 dressing forceps
– Cotton wool swabs
– Gauze
– Sterile gloves
– Sterile safety pin
– Sterile dressing towel
– Receiver

Procedure

Removal of a Drain

Steps	Action	Rationale
1.	First clean the wound as for surgical dressing.	To reduce the risk of spreading infections.
2.	Cut and remove the stitch between the drain and the skin.	To loosen the drain.
3.	Take out the drain and place it in a receiver.	To prevent cross-infection.
4.	Gently compress the area, clean the wound, and apply a dressing.	Compression is done to drain the wound.
5.	Finish up as for simple dressing.	To protect against inversion of microorganisms.
6.	Document procedure.	For follow-up care.

Shortening of a Drain

Steps	Action	Rationale
1.	Clean wound as for surgical dressing.	To prevent cross-infection.
2.	Pull the drainage tube with the dissecting forceps. If it is the first dressing post-operatively, there will be a need to cut the stitch between the drain and the skin before adjusting to the prescribed length.	To loosen the drainage.
3.	Use sterile forceps or gloves to insert the safety pin across the drain and to close the pin.	To secure the drain in position and to prevent infection.
4.	Dress the wound and finish as for a simple dressing.	To prevent inversion of microorganisms.
5.	Document the procedure.	For easy continuity of care.

Hospital Standards Procedures.

Emptying a Drain

Steps	Action	Rationale
1.	Perform hand hygiene.	Hand hygiene reduces the risk of infection.
2.	Collect necessary equipment.	Having the required supplies readily available, such as a drainage measurement container, non-sterile gloves, waterproof pad, and alcohol swab, ensures a smooth and efficient procedure.
3.	Apply non-sterile gloves and goggles or a face shield where necessary.	Personal protective equipment (PPE) reduces the transmission of microorganisms and protects against accidental exposure to body fluids.
4.	Maintaining principles of asepsis, remove the plug from the pouring spout as indicated on the drain.	Aseptic technique is crucial to prevent contamination. Opening the plug away from your face reduces the risk of accidental splashing of body fluid.
5.	Gently tilt the opening of the reservoir toward the measuring container and pour out the contents. Note the character of drainage: color, consistency, odor, and amount.	Pouring away from yourself prevents exposure to body fluids. Monitoring and documenting the characteristics of drainage are essential for patient care and record-keeping.
6.	Swab the surface of the pouring spout and plug with an alcohol swab. Place the drainage container on the bed or a hard surface, tilt it away from your face, and compress the drain to flatten it with one hand.	Swabbing with alcohol maintains cleanliness. Flattening the drain before closing helps expel air, ensuring efficient functioning of the drainage system.
7.	Place the plug back into the pour spout of the drainage system, maintaining asepsis.	Reinserting the plug while maintaining aseptic principles reestablishes the vacuum suction in the drainage system.
8.	Secure the device onto the patient’s gown using a safety pin; ensure the drain is functioning; make sure that enough slack is present on the tubing.	Securing the drain minimizes the risk of inadvertent removal. Providing adequate slack accommodates patient movement and prevents tension at the drain insertion site.
9.	Discard drainage according to agency policy.	Proper disposal procedures protect healthcare workers against exposure to blood and body fluids.
10.	Remove gloves and perform hand hygiene.	Hand hygiene should be performed after removing gloves, as gloves are not puncture-proof or leak-proof. Hands may become contaminated during glove removal.
11.	Document the procedure and findings accordingly. Report any unusual findings or concerns to the appropriate healthcare professional.	Documentation ensures accurate recording of drainage and any changes. If multiple drains are present, numbering and noting their locations in the chart is essential. Any significant changes or concerns must be reported to the healthcare provider per agency policy.

Removal of Drains

Steps	Action	Rationale
1.	Confirm that the prescriber’s order correlates with the amount of drainage in the past 24 hours.	Ensuring the prescriber’s order aligns with recent drainage amounts is crucial for safe removal. It helps avoid early removal if the drainage is not yet at an acceptable level.
2.	Explain the procedure to the patient; offer analgesia and a bathroom visit as required.	Patient education and offering analgesia reduce anxiety about the procedure. Preparing the patient for the sensation they might experience during removal promotes cooperation. Analgesia ensures comfort during the procedure.
3.	Assemble supplies at the patient’s bedside: dressing tray, sterile suture scissors or sterile blade, cleansing solution, tape, garbage bag, outer dressing.	Organizing supplies in advance ensures efficiency and readiness for the procedure, enhancing patient safety and comfort.
4.	Apply a waterproof drape or mackintosh for setting the drain onto once it has been removed.	This provides a designated place for the removed drain, preventing contamination and maintaining cleanliness.
5.	Perform hand hygiene.	Hand hygiene before the procedure reduces the risk of introducing microorganisms from other sources to the patient.
6.	Apply non-sterile gloves and PPE accordingly.	Wearing non-sterile gloves and appropriate PPE as assessed at the point of care reduces the risk of transmission of microorganisms and provides added protection against contamination.
7.	Release suction on the reservoir and empty; measure and record volumes greater than 10 ml. Remove the dressing.	Releasing suction ensures safe removal. Measuring and documenting the drainage volume is crucial for patient care and record-keeping.
8.	Clean and dry the incision and drain site following principles of asepsis.	Preparing the wound and surrounding area through aseptic cleaning minimizes the risk of infection.
9.	Carefully cut and remove the securing suture following principles of asepsis.	Removing the suture safely is essential to avoid complications and ensure smooth removal of the drain.
10.	While holding two to three 4 × 4 sterile gauze in the non-dominant hand, stabilize the skin.	Sterile gauze helps absorb any additional drainage during the removal process, reducing the risk of introducing microorganisms. Stabilizing the skin minimizes discomfort to the patient during the procedure.
11.	Ask the patient to take a deep breath and exhale slowly; remove the drain as the patient exhales. Firmly grasp the drainage tube close to the skin with the dominant hand, and with a swift and steady motion, withdraw the drain.	Patient cooperation, distraction, and timed removal reduce discomfort. The gentle resistance felt during removal is expected, but if resistance is strong, taking a pause and encouraging relaxation is essential.
12.	Place the drain and tubing onto a waterproof pad or into a garbage bag. Remove gloves.	Proper disposal prevents contamination of the environment and maintains hygiene.
13.	At this point, some nurses may clean and dry the wound.	The decision to clean the wound can vary based on the specific situation and healthcare provider’s preferences.
14.	Dress the wound with a sterile dressing.	Dressing the wound post-removal is essential as drain sites may continue to drain for a few days.
15.	Discard the drain and garbage.	Proper disposal follows agency policy and decreases the risk of exposure to blood and body fluids for others.
16.	Perform hand hygiene.	Hand hygiene after the procedure minimizes the risk of contamination.
17.	Assess the dressing 30 minutes after drain removal. Likewise, ask the patient to call if they notice any increased drainage from the site.	Monitoring for changes in drainage after removal is essential for patient safety and early detection of complications.
18.	Document the procedure (including drain removal, drain output and characteristics, how the patient tolerated the procedure, dressings applied) accordingly. Report any unusual findings or concerns to the appropriate healthcare professional.	Accurate and timely documentation and reporting are crucial for patient care and safety, ensuring that any concerns are addressed promptly.

CARE OF WOUNDS WITH DRAINAGE

Important Points in the Care of Closed Drainage

Step	Action	Rationale
1	Maintain the end of the tube from the wound below the water in the drainage bottle.	This prevents air from passing back up the tube into the wound.
2	Seal the tubing first with either clips or artery forceps before emptying the bottle.	To prevent air entry into the lungs.
3	Measure the amount of water or antiseptic in the drainage bottle and subtract this amount from the total when measuring the drainage.	To get the correct amount of fluid drained from the wound.
4	Observe for any abnormal deposits, colour, and odour.	To aid diagnosis and follow up/progress.
5	Keep a clip or artery forceps at the bedside incase of an accident to the tubing.	To be able to clip the tube immediately to prevent air going to the lungs in case of accident to the tubing.
6	Maintain sterility of the bottle and should never be lifted up to the bed level or above.	To maintain asepsis and also to prevent back flow of fluid from the drainage chamber to the pleural cavity.

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Administer drugs appropriately

Administer Prescribed Medicines Appropriately

A medicine is any chemical substance in a regulated dose intended for use in the medical diagnosis, cure, treatment, or prevention of disease or any substance that is prescribed and administered to patients to produce therapeutic effects in the body.

Rights Related to Medicine Administration

The rights that should be observed:

Right patient.
Right medicine.
Right dosage.
Right route.
Right time.
Right storage.
Right formulation.
Right disposal.
Right site.
Right equipment.

Routes Used in Administering Medicines

SYSTEMIC ROUTE

ENTERAL ROUTE

Oral: Drugs taken by mouth, including tablets, capsules, liquids, and suspensions, that are absorbed through the stomach or intestinal lining.
Sublingual: Drugs placed under the tongue that dissolve and are absorbed into the bloodstream via the tissues under the tongue, providing rapid onset of action.
Buccal: Drugs placed between the gums and cheek, where they dissolve and are absorbed into the bloodstream through the buccal mucosa.
Rectal: Suppositories or enemas administered into the rectum, where they are absorbed through the rectal mucosa.

PARENTERAL ROUTE

Injections:

Intravenous (IV): Direct injection into a vein for immediate systemic effect.
Intramuscular (IM): Injection into a muscle, where the drug is absorbed into the bloodstream.
Subcutaneous (SC): Injection into the fatty tissue under the skin.
Intra-arterial: Injection directly into an artery, typically used in specialized medical procedures.
Intra-articular: Injection into a joint space for local effect.
Intrathecal: Injection into the cerebrospinal fluid in the spinal canal.
Intradermal: Injection into the dermis layer just beneath the epidermis, often used for allergy testing and tuberculosis screening.
Epidural: Injection into the epidural space surrounding the spinal cord, commonly used for pain relief during labor and surgery.
Intraperitoneal: Injection into the peritoneal cavity in the abdomen, used in some chemotherapy treatments.
Intracardiac: Injection directly into the heart muscle, often used in emergencies.

LOCAL ROUTE

Skin topical: Application of creams, ointments, gels, or lotions to the skin for local treatment of skin conditions.
Intranasal: Sprays or drops administered through the nasal passages for local or systemic effect.
Ocular drops: Solutions or suspensions administered into the eyes to treat local conditions like infections or glaucoma.
Otic drops: Solutions administered into the ear canal to treat local ear conditions such as infections.
Intraosseous: Injection directly into the bone marrow, used in emergency situations when IV access is not available.
Intralymphatic: Injection into the lymphatic system, used in certain cancer treatments and vaccinations.
Intrapleural: Injection into the pleural space surrounding the lungs, used for treating pleural effusions and certain cancers.
Inhalation: Drugs administered through the respiratory tract, typically using inhalers or nebulizers, for rapid absorption into the bloodstream via the lungs.
Transdermal: Patches or gels applied to the skin that release the drug slowly for absorption over time.
Mucosal:

Throat: Lozenges, sprays, or gargles for local treatment of throat conditions.
Vaginal: Creams, tablets, or rings inserted into the vagina for local treatment of infections or hormonal therapy.
Rectal: Suppositories or enemas for local treatment of rectal or lower gastrointestinal conditions.

INHALATION

Inhalation is the breathing of air vapor or volatile medicine into the lungs.

Types

Dry inhalation: Oxygen Administration: this is given when the respiratory capacity is diminished as in chest injuries, pneumonia and cardiac failure.
Moist/steam inhalation: It is used in case of inflammation of air passages and the nasal sinuses. These are given to:

Warm and moisten the air breathed in and relieve irritation e.g. in bronchitis, after tracheotomy and other chest conditions.
To relieve inflammation and coughing e.g. in colds.
To relieve congestion and oedema e.g. in sinusitis and acute laryngitis.
Nebuliser: this produces vapors which is inhaled by the patient for example in asthma to relieve spasms of the bronchial tubes or for the relief of chest pain in angina pectoris. Other indications include Respiratory diseases eg asthma, pneumonia, Airway obstruction, Nasal congestion, Nasal bleeding, Chest injuries and Cardiac failure.

Forms of Medicines

Liquids:

Solutions: Medicine dissolved in water.
Syrups: Medicine dissolved in sugar and water.
Mixtures: Medicine mixed with liquid but not dissolved in it.
Milks: White medicine substances mixed with water.
Emulsions: Medicine mixed with oil and water.
Elixirs: Medicine dissolved in a sweetened flavored solution containing alcohol.
Tinctures: Medicine dissolved in alcohol or alcohol and water.
Fluidextracts: Medicine that has been boiled and evaporated to concentrate their strength and dissolve them in alcohol.
Liniments: Medicine mixed in oil, soap, or alcohol (for external use only).
Lotion: Mixed with water for external application.

Solids and Semisolids:

Capsules: Medicine enclosed in gelatine containers used for liquids, powders, and oils.
Powders: Medicine in powder form.
Pills: Medicines molded in a round shape coated with sugar.
Tablets: A solid dosage form of varying weight, size, and shape.
Enteric Coated Tablets: A tablet coated with a substance that blocks absorption of the medicine until it reaches the small intestines.
Lozenges: To be dissolved in the mouth for throat or oral treatment.
Ointment: Medicines mixed with oil or fat.
Pastes: Ointments with various powders added.
Suppositories: Medicines mixed with a firm base, which can be molded for insertion into a body cavity.
Ampoules: Sealed glass containers that contain a dose of powdered or liquid medicine.
Vials: Rubber-stoppered glass containers that may contain a single or several doses of medicines.

Time for Administering Medication

Four hourly: (eight times in 24 hours) 2 am., 6 a.m., 10 a.m., 2 p.m., 6pm, and 10 p.m.
Six hourly: (four times a day) 6 a.m., 12 p.m., 6pm, and 12 midnight.
Eight hourly: (three times a day) 6 a.m., 2 p.m., and 10 p.m.
Twelve hourly: (twice daily) 6 a.m. and 6 p.m.

Abbreviations Used in Prescriptions

Aa.: of each
Ad lib.: as much as desired
B.i.d. or b.d.: twice a day
t.d.s. or t.i.d.: three times a day
a.c.: before
P.c.: after
g.: gram
Gr.: grain
Gutt.: a drop
Mane: in the morning
Mist.: a mixture
Nocte: at night

q.h.: every hour
o.m.: every morning
o.n.: every night
p.r.n.: whenever necessary
q.4h: every 4 hours
s.o.s.: if necessary in an emergency
Stat: immediately
q.i.d.: 4 times a day/every 6 hours
o.d.: once a day

GENERAL RULES OF DRUG ADMINISTRATION

Read the instructions carefully and incase of any doubt ask the Doctor or ward in charge.
Never give a drug from a container or a bottle which is not clearly labeled.
Check the label against the instructions 3 times .The 1 st time before having the container, 2nd time before the drug is drawn, 3rd time before the drug is administered to the patient.
Give the drug following 10Rs i.e -right patient, right time, right dose, right route, right drug/medication, right formulation, right disposal, right storage, right equipment and right site.
Once a drug is drawn from its container it shouldn’t be returned.
Always identify the drug by reading its label on the container not by its color, smell, shape and size.
Do not transfer drugs to another container when the old label is still on.
Ask for clarification if any order regarding the dose is not readable.
Watch all patients for drug reactions, especially parental drugs.
If any drug changes its color, it should not be administered.
Liquid preparations should always be shaken before drawing from the bottles.
Never use a drug which has been left in an unlabeled container.
Always measure the dose of the drug in good light.
Observe strictly the time of administration of medication.

ORAL ADMINISTRATION

Requirements

Trolley

Top Shelf:

Bottles of mixtures
Bottle or boxes of tablets, capsules
Medicine cups
Teaspoons, mortar and pestle
Jug of drinking water, milk/fruit juice
Glasses
Medicine charts
Small medication tray
Scissors
Kidney dish

Bottom Shelf:

1 bowl of soapy water

Bedside:

Hand washing equipment

Procedure for Oral Administration

Steps	Action	Rationale
1.	Follow general rules of nursing procedures.	Ensures accuracy and prevents errors
2.	Observe the rules of medicine administration.	Ensures accuracy and prevents errors
3.	Arrange medication trolley in nurse’s station.	To save time and reduce error in medication administration
4.	Prepare medicine of one patient at a time, keeping medicine lists/charts together.	Ensures accuracy and prevents errors
5.	Verify the order for medication from the patient’s chart comparing with the medicine list and the label on the bottle.	Ensures accuracy
6.	Check the label on the medicine container three times (i.e. when taking it from the shelf, before pouring it into the medicine cup and before returning it to the shelf).	Ensures accuracy
7.	For tablets/capsules, pour required number from bottle into bottle cap and transfer to medication cup, for packaged tablet/capsule pour directly over the cup retain the strip.	Reduces errors in medication administration
8.	For liquid, hold medication cup to eye level and pour the prescribed amount.	Ensures accuracy
9.	For volume of less than 5ml, use a 5ml syringe without a needle to measure the amount prescribed.	Ensures accuracy
10.	Keep the label on the bottle uppermost against the palm of hand when pouring.	To avoid spilling liquid in place.
11.	Wipe the rim of the bottle before replacing the cork.	Prevents cap from sticking.
12.	Use only the dropper-supplied with liquids measured in drops.	Ensures accuracy
13.	Read the label again before replacing the container on the trolley.	Third check reduces errors.
14.	Place the measuring cup on the tray together with the drinking cup with water and then take it to the patient at the correct time.	Ensures timely administration
15.	Call the patient’s name, check the room or bed number against the medicine list before giving the medicine.	Confirms the patient’s identity
16.	Assess the patient’s condition including the level of consciousness and vital signs. For instance patients having digitalis the pulse rate should be checked before administering the medicine.	To rule out likely contraindications or side effects.
17.	Explain to the patient the medications to be given to the patient and clarify any questions or doubts.	Promotes the patient’s rights and compliance.
18.	Assist patient in sitting or side lying position.	Prevents aspiration
19.	Administer medicine properly, only one medicine at a time and offer a glass of water or milk.	Aids swallowing.
20.	If a patient has difficulty swallowing, grind the tablets in a mortar with pestle, crush it to fine powder and mix it with a small amount of water.	To ease swallowing.
21.	Prepare powdered medication at the bedside and give it to the patient.	Increases compliance.
22.	Give effervescent tablets immediately after dissolving.	It helps to improve the taste of medicine.
23.	If the patient is unable to hold medication in hand; assist to place the cup to the lip and slowly transfer medicine into the mouth using a spoon.	To support the patient.
24.	If medicines fall on the floor, discard and replace them.	To avoid contaminated medicine
25.	Stay with the patient until the medicine has been swallowed; if the patient is confused or disoriented his/her mouth should be checked to confirm that the patient has swallowed the medicine. If the medicine is vomited within 5 minutes report to the In-charge or Doctor. Medicines must never be left on the bedside table.	Ensures that patient receives prescribed medication at the correct time
26.	Assist the patient to a comfortable position.	Maintains patient’s comfort
27.	Dispose of soiled supplies, clean work area and wash hands.	Reduces transmission of infection
28.	Document the administration of the medication with date, time and signature immediately after administration.	To avoid errors and promote proper accountability.
29	Reassess the patient’s response to the medicine within one hour after giving it and any ill effects reported.	To detect therapeutic/ side effects or adverse effects.
30	The medicine cups are washed and returned to their proper place.	Promote hygiene.

INHALATION

Inhalation is the breathing of air vapor or volatile medicine into the lungs.

Types

Dry inhalation: Oxygen Administration: this is given when the respiratory capacity is diminished as in chest injuries, pneumonia and cardiac failure.
Moist/steam inhalation: It is used in case of inflammation of air passages and the nasal sinuses. These are given to:

Warm and moisten the air breathed in and relieve irritation e.g. in bronchitis, after tracheotomy and other chest conditions.
To relieve inflammation and coughing e.g. in colds.
To relieve congestion and oedema e.g. in sinusitis and acute laryngitis.
Nebuliser: this produces vapors which is inhaled by the patient for example in asthma to relieve spasms of the bronchial tubes or for the relief of chest pain in angina pectoris. Other indications include Respiratory diseases eg asthma, pneumonia, Airway obstruction, Nasal congestion, Nasal bleeding, Chest injuries and Cardiac failure.

DRY INHALATION (Oxygen administration)

It is given when the respiratory tract is diminished as in chest injuries, cardiac failure and pneumonia.

REQUIREMENTS FOR OXYGEN ADMINISTRATION

Clean tray

Rubber tubing.
BLB oxygen mask.
Flowmeter.
Nasal catheter.
Gallipot with gauze pads.
Humidifier with distilled water

Bedside

Oxygen source.
Screen

PROCEDURE

Steps	Action	Rationale
1	Refer to the general rules	Keeps standard
2	Turn and test the oxygen cylinder before bringing everything to the bedside	Conserves time and energy
3	Determine need for oxygen therapy in patient and check physician’s order for rate, device used, concentration	Reduces risk of error in administration
4	Position patient in sitting up or one side	Promotes comfort
5	For nasal cannula use; connect nasal cannulae to oxygen set up with humidification, check if oxygen is flowing out of prongs	Humidification prevents dehydration of mucous membranes
6	Place prongs in the patient’s nostrils 2 inches, place tubing over and behind each ear with adjuster comfortably under the chin or place tubing around the patient’s head with the adjuster at the back or base of the head and place gauze pads at ear beneath the tubing as necessary	Facilitates oxygen administration and patient comfort. Pads reduce irritation and pressure
7	Encourage patient to breathe through the nose, with the mouth closed	Nose breathing provides for optimal delivery of oxygen to the patient
8	For B.L.B mask use; attach face mask to oxygen source start the flow of oxygen at the specified rate, for a mask with a reservoir allow oxygen to fill the bag before proceeding to the next step	The bag is the oxygen supplier to the patient
9	Position the face mask over the patient’s nose and mouth, adjust the elastic strap around patient’s head, adjust the flow rate	A loose or poorly fitting mask will result in oxygen loss
10	Apply padding behind ears as well as scalp where elastic band passes	Padding prevents skin irritation
11	Reassess patient’s respiratory status, including respiratory rate, effort, and lung sounds	Assesses effectiveness of oxygen therapy
12	Document relevant information in the patient’s record	Ensures accurate medical records

Parts of an Oxygen Flowmeter

PARENTERAL ROUTE (INJECTION)

Requirements

Trolley

Top shelf	Bottom shelf
Small Tray. Sterile syringes and needles of all capacities and appropriate size. Prescribed sterile medications in ampoules or vials. Patient’s charts and medicine lists. Gallipot with swabs. Antiseptic solution in a gallipot. Ampoule file Sterile water for injection Injection dishes Tourniquet. Cannula of appropriate gauge. Strapping Pair of scissors. Clean gloves	Sharps Safety Box. Receiver for used swabs. Receiver for used gloves. Small pillow for supporting the arm. Macintosh and towel
	Bedside
	Screen. Handwashing equipment.

Procedure

A. Intradermal or Intracutaneous Injection

Steps	Action	Rationale
1.	Refer to general and medicine administration rules for injections.
2.	A tuberculin syringe or 1 ml syringe is used and needles.
3.	Identify the patient, put in a comfortable position.
4.	Clean the skin with an antiseptic swab and allow the site to dry.	Exposes the selected site.
5.	If it is a BCG vaccination, clean the site with water.
6.	Stretch the patient’s skin, draw it tight and introduce the needle at an angle parallel to the skin.
7.	Gently and slowly inject the medicine while observing for a small wheal to appear.
8.	Carefully withdraw the needle.
9.	Do not massage the site after removing the needle.	This may alter the test results.
10.	Circle the area with a pen and record time, and request the patient not to wash the area until it is assessed for the intended outcome.	If it was for diagnostic purposes e.g., Mantoux test.
11.	Inspect for signs of reaction when the stated duration of time has reached.
12.	Report and record results.
13.	Clean away the used equipment.

B. Subcutaneous Injection or Hypodermic

Steps	Action	Rationale
14.	Help patient assume position depending on site selected.	Ensures free access to site.
15.	Choose a suitable needle gauge; take a 1 ml or 2 ml syringe depending on the dosage.
16.	Draw the medicine into the syringe.
17.	Expel the air by holding the syringe with the needle pointing up.
18.	Place the syringe in the injection dish.
19.	Explain the procedure to the patient, asking him/her not to move while the injection is being given.	Encourages cooperation and allays anxiety.
20.	Select the site and clean it with an antiseptic swab and let the area dry first.
21.	Grasp and pinch or squeeze the patient’s skin gently between the finger and thumb of your left hand and insert the needle at an angle of 45°.	Provides for easy and less painful entry into subcutaneous tissue.
22.	Pull back the (piston) plunger and inject the medicine slowly.	Determines if the needle is in a blood vessel.
23.	When the medicine has been injected completely, place a swab over the needle and withdraw the needle quickly and smoothly.	Reduces discomfort.
24.	If there is any bleeding at the site, apply firm gentle pressure with a swab until it stops.
25.	Make the patient comfortable and record the medicine given on the patient’s treatment sheet.
26.	Discard syringe, gloves, and swabs appropriately and clear away the equipment.	Promotes infection control measures.

C. Intramuscular Injection

Steps	Action	Rationale
27.	Observe the general nursing rules.
28.	Read the prescription carefully and check the medicine with the other nurse, including the amount to be given.
29.	Assemble syringe and needle, put on gloves.
30.	Break open the top of the ampoule (by using a gauze swab or a file) or remove the top of the rubber cap.
31.	Reconstitute powdered medicines according to the instructions on the bottle.
32.	Put on gloves and draw up the prescribed dose of the medicine.
33.	Expel the air and remember that with antibiotics and multi-dose vials, the air is expelled into the container.
34.	Position the patient depending on the site chosen.	Proper positioning ensures muscle relaxation of the patient.
35.	Select, locate, clean the site and allow it to dry.
36.	Inject the medication; grasp and pinch the area surrounding the injection site or spread skin at site as appropriate.	Aids needle penetration in patients with thick muscles.
37.	Hold the syringe between thumb and forefinger and pierce skin at a 90° angle and insert the needle.
38.	Aspirate by holding the barrel steady with a non-dominant hand.	Helps to check if a needle is in a blood vessel.
39.	If the blood does not appear in the syringe, inject the medication slowly and steadily.	Helps to disperse medication into muscle tissue, thus decreasing a patient’s discomfort.
40	Withdraw the needle slowly and steadily while supporting at the hub of the syringe and needle. With non-dominant hand support the skin surface using cotton swab for applying counter traction at the site	Helps to reduce discomfort and prevent pulling of tissues when needle is withdrawn
41	Apply gentle pressure at the site with a dry cotton swab but do not massage.	Massaging irritates tissues at the injection site.
42	Discard the un capped needle and syringe appropriately.	Promotes infection prevention and control.
43	Clear away, remove gloves and wash hands.
44	Record procedure including the name of medication, dose, site and response of the patient.	Reduces chances of medication errors

D. Intravenous Injection

Steps	Action	Rationale
45.	Prepare the injection tray and take it to the patient’s bedside.	Ensures all necessary items are available for the procedure.
46.	Identify the patient and explain the procedure to the patient.	Alleys anxiety.
47.	Screen the bed and put on gloves.	Provides privacy.
48.	Place a small pillow and a protective sheet under the patient’s arm.	Promotes comfort and protects the beddings.
49.	Expose the patient’s forearm and anterior surface of the elbow.	Ensures easy access to the injection site.
50.	Inspect the selected vein, if it is visible and clear; apply a tourniquet or a sphygmomanometer cuff around the patient’s upper arm and inflate sufficiently about 8 to 10 cm above the site.	Helps to distend and enlarge the vein.
51.	Request the patient to close and open the fist for a minute.	Promotes venous filling and visibility.
52.	Clean the area with an antiseptic and dry with a sterile swab.	Reduces microorganisms.
53.	Expel air from the syringe.	Ensures accurate dosing and prevents air embolism.
54.	Hold the patient’s arm and with your left thumb exert pressure about 3 cm below the chosen site and make the skin tight.	Stabilizes the vein and reduces movement.
55.	Insert the needle at an angle of 15-45 degrees with its bevel up then quickly and steadily insert into the vein. Pull back the piston slightly if blood is aspirated.	Ensures that the needle is in the vein.
56.	Remove the tourniquet or deflate the cuff and inject the medicine slowly.	Prevents excessive pressure in the vein and ensures proper delivery of medication.
57.	When the medicine is injected, put a swab over the site and withdraw the needle.	Minimizes bleeding and ensures cleanliness.
58.	Apply pressure at the site with a swab for some seconds to make sure there is no bleeding. If oozing continues, apply a swab and a piece of strapping.	Prevents bleeding.
59.	Record the medicine in the patient’s chart and clear away.	Ensures accurate medical records and maintains order.

SOME OF THE RECOMMENDED VEINS FOR INTRAVENOUS INFUSION

BACK OF THE HAND

FOREARM

LOWER EXTREMITY

Dorsal metacarpal veins

Basilic vein
Cephalic vein

Basilica vein and Cephalic

Femoral and saphenous vein in the thigh

Dorsal venous plexus, medial and lateral marginal veins in the foot

Femoral and saphenous vein in the thigh

COMPLICATIONS OF INTRAVENOUS INJECTIONS

Incorrect IV Site Placement: Inserting the IV into the wrong vessel (e.g., artery instead of vein) can lead to severe consequences.
Medication Errors: Misidentification of medications, incorrect dosages, or incompatible mixing can result in serious adverse reactions.
Rapid Administration and Undesired Effects: Delivering medications too quickly can lead to undesirable effects like hypotension, cardiac arrhythmias, allergic reactions, and fluid overload.
Thrombophlebitis: Inflammation of a vein, often with a blood clot, can occur due to frequent IV injections, improper technique, or certain medications.
Circulatory Overload: Infusing too much fluid too quickly can overwhelm the circulatory system, leading to fluid buildup and strain on the heart and lungs.
Embolism: A blood clot, air bubble, or foreign matter blocking a blood vessel can occur due to thrombophlebitis, improper IV line placement, or air entering the line.
Shock: Severe allergic reactions, blood loss, or sepsis can lead to a life-threatening decrease in blood flow to vital organs.
Infiltration/Extravasation: When IV fluids leak out of the vein into the surrounding tissues, it can cause pain, swelling, and tissue damage.
Phlebitis: Inflammation of a vein without a clot, often caused by irritation from the IV catheter or medication.
Air Embolism: Air entering the bloodstream through the IV line can travel to the heart or lungs, causing blockage and potentially leading to respiratory distress or cardiac arrest.
Catheter-Related Bloodstream Infection (CRBSI): A serious complication where bacteria enter the bloodstream through the IV catheter, leading to fever, chills, and potentially sepsis.
Nerve Damage: Incorrect placement of the IV catheter can damage nerves in the area, resulting in pain, numbness, or weakness.
Hematoma: Bleeding into the surrounding tissues from the IV puncture site, appearing as a bruise.
Phlebosclerosis: Hardening of the vein due to repeated IV punctures or irritation from the catheter.

Common Sites for Intramuscular Injections

Gluteal Muscle: The outer upper quadrant of the buttock is the safest site, as it avoids the sciatic nerve.
Thigh Muscles: The upper outer third of the thigh muscles.
Deltoid Muscle: Used for small injections (up to 2 ml) if the patient has enough muscle mass, but this site should be avoided whenever possible.

COMPLICATIONS OF INTRAMUSCULAR INJECTIONS

1. Abscess Formation: This occurs when unsterile needles and syringes are used, or when oily substances are not injected deep enough. The injection site becomes inflamed and filled with pus.

Prevention: Strict adherence to aseptic technique, proper needle selection, and injecting oily substances deep into the muscle tissue are crucial.

2. Nerve Injury: Incorrectly positioning the needle can damage nearby nerves, causing pain, numbness, weakness, or paralysis.

Prevention: Thorough anatomical knowledge, correct landmark identification, and careful needle insertion are essential.

3. Tissue Damage/Necrosis: Injecting too much medication, using irritating substances, or repeated injections in the same site can lead to tissue damage and cell death.

Prevention: Administering the correct dosage, choosing less irritating medications, and rotating injection sites regularly can minimize this risk.

4. Hematoma: A hematoma forms when blood leaks into the surrounding tissue after the injection, causing a bruise or swelling.

Prevention: Applying pressure to the injection site after the injection can help prevent hematoma formation.

5. Pain and Discomfort: Intramuscular injections can be painful, especially if the medication is irritating or the injection technique is not correct.

Prevention: Using proper injection technique, choosing a suitable needle size, and warming the medication to room temperature can reduce pain.

6. Allergic Reactions: Some individuals may have an allergic reaction to the medication or the ingredients in the solution.

Prevention: Thorough patient history, allergy testing, and careful observation for signs of allergic reactions are crucial.

7. Injection into a Blood Vessel: The needle may unintentionally enter a blood vessel, leading to potential complications like drug overdose or embolism.

Prevention: Aspirating (drawing back on the plunger) before injecting helps to ensure the needle is not in a blood vessel.

8. Delayed-Onset Muscle Soreness: Some medications can cause muscle soreness or stiffness that may not appear until several hours or days after the injection.

Prevention: No specific prevention, but staying hydrated and avoiding strenuous activity after the injection may help.

9. Infection: Improper sterile technique can lead to infection at the injection site.

Prevention: Strict adherence to aseptic technique is essential.

10. Air Embolism: Although rare, air can be injected into the bloodstream, leading to complications like respiratory distress or cardiac arrest.

Prevention: Using proper technique to ensure no air is introduced into the syringe or needle.

Intravenous infusion equipment and the superficial veins of the forearm that may be cannulated

Formula for Calculating the Drop Rate

To calculate the drop rate, use the following formula:

Example:

The doctor has prescribed 1000 mls of 5% dextrose infusion to run in 10 hours. How many drops per minute will you regulate if the infusion set has a drop factor of 20?

Factors that May Affect the Flow Rate

Height of the Infusion Bottle: Raising the infusion bottle higher will increase the rate of flow, and lowering it will decrease the rate.
Patency of Infusion Set and Needle: A blood clot in the needle may stop the infusion. This may occur when there is a delay in changing the emptied infusion bottle.
Kinking of the Tubing or Faulty Position of the Needle: When the needle is against or away from the vein wall, it may affect the flow.
Tight Splint: A tight splint on or above the infusion needle will restrict the flow rate.
Blocked Air Vent: A blocked air vent will cause the infusion to stop running.

Care of the Patient While on Intravenous Infusion

Accurate Record Keeping: Keep an accurate record, including the time of starting the infusion, type of fluid, amount, and the prescribed rate of flow.
Frequent Assessment: Assess the patient at frequent intervals for signs of abnormal reactions such as pain, sweating, restlessness, or change of color.
Regular Site Inspection: Inspect the site at regular intervals for signs of infiltration.
Condition Monitoring: Take and record the patient’s condition regularly.
Daily Cleansing: If the infusion is running for some days, cleanse the area around the injection site with sterile gauze daily.

INSTILLING MEDICATION INTO EAR

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ADMINISTERING MEDICATION THROUGH NASO-GASTRIC TUBE

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ADMINISTERING RECTAL AND VAGINAL MEDICATION.

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Nursing Process

NURSING PROCESS

The Nursing process is an organized, systematic, dynamic method of giving individualized nursing care that focuses on identifying and treating unique responses of individuals or groups, to actual or potential alterations in health. (Nursing procedure Manual, 2015)

OR:

The nursing process is defined as a systematic, rational method of planning that guides all nursing actions in delivering holistic and patient–focused care.

Outline the CHARACTERISTICS of the nursing process

Cyclic and Dynamic: – it is an ongoing continuous process throughout the stages of illness and treatment and ends with the cease of the illness.
Goal directed and Client oriented: The nursing process is intended to treat the patient and is in the best interest of the patient.
Interpersonal and Collaborative: This goes to explain the amount of interaction that might be necessary between nurses, patients of similar illnesses and the medical team.
Universally applicable: This process is universally standard and no matter what the institution it may be, the process remains the same.
Scientific and Systematic: Every symptom or sign is a result of a scientific fact which leads to scientific methods of treatment and follow-ups. It is systematic and goes from step to step as in the phases mentioned below.
Requires critical thinking: The use of the nursing process requires critical thinking which is a vital skill required for nurses in identifying client problems and implementing interventions to promote effective care outcomes.

Explain the components of the nursing process
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

ASSESSMENT PHASE

The first phase of the nursing process is assessment.
It involves collecting, organizing, validating, and documenting the clients’ health status. Assessment involves data collection which is the process of gathering information regarding a client’s health status. The main methods used to collect data are health interviews and physical examination.

Types of data collected

Subjective data or symptoms: This is information obtained from the patient through an interview. It also includes symptoms felt by the patient only. It is only the patient who can tell you information e.g. present complaints, past medical history, past surgical history etc
Objective data or signs: This is the information that is measurable, tangible data collected via the senses, such as sight, touch, smell, or hearing e.g. vomiting, distended abdomen, presence of edema, lung sounds, crying, skin color, and presence of diaphoresis.

NURSING DIAGNOSIS PHASE.

A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability to that response, by an
individual, family, group, or community.
NB: Medical diagnosis is different from a nursing diagnosis because nursing diagnosis refers to human response to health conditions whereas the medical diagnosis focuses on health conditions.

Types of the nursing diagnosis:

1. Actual nursing diagnosis

These are presenting response to current health condition
The actual nursing diagnosis has three parts i.e. Diagnosis, relation to (pathophysiology) and evidence.

Scenario A: A patient complaining of fevers, on thermometer reading it indicates 38°C.
From NANDA 2021 – 2023 fevers have hyperthermia i.e.
Hyperthermia related to increased leukocyte activity evidenced by the thermometer reading of 38°C.

Scenario B: A patient complained of headache of the forehead since the last 2 days after a minor head injury following a fight. On examination the pain was at 3 on a 0 – 5 pain scale.
From NANDA 2021 – 2023 headache is described as Acute pain since it has been present less than 3 months.
-Acute pain related to trauma to the head evidenced by the patient’s verbalization of feeling headache of 3 on a 0 – 5 pain scale.

2. Potential Nursing diagnosis:

This is an issue that could occur incase the current symptoms is not properly managed.
The potential nursing diagnosis has two parts that is the nursing diagnosis and the relation (pathophysiology) only.

Scenario: A patient reported vomiting for 1 day after ingesting chips and chicken. On examination the patient had no signs of dehydration.
From NANDA 2021 – 2023 vomiting does not have an actual nursing diagnosis it only has a potential nursing diagnosis which is risk for fluid volume deficit.
–Risk for fluid volume deficit related to vomiting.

PLANNING PHASE

The planning stage is where goals and outcomes are formulated that directly impact patient care.
Planning phase is divided into
1. Goals
2. Expected outcomes

Goals

These are the aims of the nursing interventions to be provided.
Therefore they should be smart

Goals should be:

Specific or on point
Measurable or Meaningful
Attainable or Action-Oriented
Realistic: it should represent things in a way that is accurate and true to life
Timely or Time-Oriented

Goals are divided into 3 categories i.e.
1. Short term goals: these are goals having time limit ranging from minutes to 5 days.
2. Intermediate goals: these are goals having time limit ranging from 5 days to 30 days.
3. Long term goals: these are goals having time limit ranging from 30 days to years.

Expected Outcome

This what a nurse expects the patient to present after provision of the nursing interventions
Its divided into 2 i.e. short term and long term outcomes.

IMPLEMENTATION PHASE

The implementation phase of the nursing process is when the nurse puts the treatment plan into effect.

It involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care.
The implementation phase is divided into two parts

Nursing Interventions
Rationale

EVALUATION

Evaluating is the fifth step of the nursing process. This final phase of the nursing process is vital to a positive patient outcome. Once all nursing intervention actions have taken place, the team now learns what works and what doesn’t by evaluating what was done beforehand. This is the past tense of the outcome if they have been
achieved.

Explain the importance of using a nursing process

The nursing process allows the nurse to provide effective care by prioritizing meaningful interventions based on their assessments and clinical diagnosis of the patient.
At the end of the nursing process, the nurse evaluates the success of their care to ensure that effective care is being prioritized.
It creates a standard of care where the nurse develops a nursing diagnosis and care plan based on their assessment of the patient.
The nursing process provides care that is centered around the individual patient which reduces the time the client spends in the health care facility, and optimizes their health by minimizing complications in care.
By setting defined goals with a clear timeline in the nursing process, the nurse can evaluate the effectiveness of the care they are providing and make changes to the care plan as needed.

SO IN BRIEF

Assessment:

Subjective Data (Symptoms): Patient complaining of fevers.
Objective Data (Signs): Thermometer reading indicates 38°C.

Diagnosis:

Actual Nursing Diagnosis: Hyperthermia related to increased leukocyte activity evidenced by the thermometer reading of 38°C.
Potential Nursing Diagnosis: Risk for fluid volume deficit related to vomiting.

Planning (Goals/Expected Outcomes):

Goals:

Short Term: Reduce temperature to between 36.0°C to 37.4°C within 30 minutes.
Intermediate Term: [Specify a goal if needed]
Long Term: [Specify a goal if needed]

Expected Outcomes:

The patient will verbalize that he no longer feels feverish. Thermometer reading will be between 36.0°C to 37.4°C.

Implementation:

[Specify nursing interventions here, e.g., tepid sponging.]

Rationale:

[Explain why you did the intervention, e.g., To allow evaporative cooling.]

Evaluation:

Patient verbalized that he no longer feels feverish, and the thermometer reading was 36.7 degrees Celsius after 30 minutes

Sample Care Plan

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Sample Nursing Care Plan for s patient with Malaria

Assessment	Diagnosis	Planning (Goals Expected Outcomes)	Implementation/ine	Rationale	Evaluation
Fever	Hyperthermia related to leucocyte activity as evidenced by an elevated temperature of 39° C.	Reduce fever to 37° C within 30 minutes.	– Administer antipyretic medication as prescribed. – Encourage adequate fluid intake. – Apply cooling measures (e.g., tepid sponging).	– Antipyretic medication helps lower the fever. Adequate fluid intake prevents dehydration. Cooling measures aid in reducing body temperature.	Fever reduced to 37° C
Headache	Acute Pain related to malarial infection evidenced by patient verbalizing headache.	Alleviate headache within 40 minutes.	– Administer analgesic medication as prescribed. – Provide a quiet and dimly lit environment. – Encourage relaxation techniques (e.g., deep breathing).	– Analgesic medication helps relieve pain. – A quiet environment reduces stimuli that may exacerbate the headache. – Relaxation techniques promote comfort.	Headache Alleviated with In 40 minutes With a pain Scale reading Of 1/10.
Myalgias	Impaired Physical Mobility related to muscle pain and weakness as evidenced by difficult in movement.	Improve mobility and reduce muscle pain within 5 days.	– Encourage gentle stretching exercises. Administer analgesic medication as prescribed. – Provide warm compresses to affected areas.	– Gentle stretching improves flexibility and reduces muscle pain – Analgesic medication helps relieve pain. – Warm compresses promote muscle relaxation.	Improved mobility and reduced muscle pain After 5 days.
Nausea	Nausea related to changes in eating habits as evidenced by patient complaints and increased salivation	Alleviate nausea within 1 hour.	– Administer antiemetic medication as prescribed. – Encourage small, frequent meals. – Provide oral hygiene measures after vomiting episodes.	– Antiemetic medication helps alleviate nausea. – Small, frequent meals are easier to tolerate. – Oral hygiene measures prevent discomfort and promote a sense of well-being.	Patient vebalised That no nausea After 1 hour..
Vomiting	Imbalanced Nutrition related unpleasant sensory stimuli as evidenced by vomiting	Patient will demonstrate bowel sounds within normal limits.	– Administer antiemetic medication as prescribed. – Monitor and record intake and output. – Provide oral rehydration solutions as needed.	– Antiemetic medication helps control vomiting. – Monitoring intake and output prevents dehydration. – Oral rehydration solutions restore fluid balance.	Patient demons trated normal Bowel sounds
Diarrhea	Risk for Imbalanced Nutrition: Less Than Body Requirements related to less food intake as evidenced by watery stool.	Achieve optimal nutritional intake.	– Administer antidiarrheal medication as prescribed. – Encourage a bland and easily digestible diet. – Monitor and record bowel movements.	– Antidiarrheal medication helps control diarrhea. – A bland diet is easier on the digestive system. – Monitoring bowel movements informs about the effectiveness of interventions.	Achieved optimal nutritio nal intake.
Dehydration	Risk for deficient fluid volume related to diarrjoea, nausea and vomiting.	Patient will maintain hydration as evidenced by adequate intake and output, vital signs, and skin turgor	Administer fluids intravenously as indicated. Offer high-water content foods like soups Administer antiemetics as indicated.	Fluids for fluid replacement To encourage rehydration and motility of the bowel. To reduce vomiting episoded

Summary NANDA

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Expected outcomes:

Patients will demonstrate bowel sounds within normal limits.
Patients will exhibit normal eating habits without experiencing nausea, vomiting, abdominal discomfort, dyspepsia, bloating, and early satiety.
Patient will exhibit balanced nutrition as evidenced by the absence of malnutrition
Patient will regain and maintain adequate body weight for age and gender
Patient will verbalize two strategies to reduce nausea and improve comfort.
Patient will express improved comfort as evidenced by improved sleep and mood.
Patient will verbalize relief from nausea
Patient will be able to demonstrate strategies that prevent nausea
Patient will maintain hydration as evidenced by adequate intake and output, vital signs, and skin turgor

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