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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

Parkinson’s disease is a neurodegenerative disorder characterized by the progressive loss of dopamine-producing cells in a specific region of the brain called the substantia nigra.

This loss of dopamine leads to abnormal brain activity and the manifestation of various motor and non-motor symptoms.

Cause of Parkinson’s Disease

The exact cause of Parkinson’s disease remains unclear, but it is believed to involve a combination of genetic and environmental factors. The exact cause of Parkinson’s Disease (PD) is unknown.

A combination of genetics and environmental factors is believed to trigger PD.

Factors that contribute to PD include:

Dopamine deficiency: Parkinson’s disease is characterized by the loss of dopamine-producing neurons in the brain. Dopamine is a neurotransmitter that plays a crucial role in movement control, so a deficiency leads to motor symptoms like tremors and rigidity.
Loss of norepinephrine: Norepinephrine is another neurotransmitter affected in Parkinson’s disease. It regulates various functions, including blood pressure, heart rate, and mood. Its loss can contribute to non-motor symptoms such as fatigue and changes in blood pressure.
The protein alpha-synuclein: This protein can form abnormal clumps called Lewy bodies in the brains of people with Parkinson’s disease. These clumps are thought to damage nerve cells and contribute to the development of the disease.
Genetics: While most cases of Parkinson’s disease are not directly inherited, certain genetic mutations can increase a person’s risk of developing the condition.
Environmental factors: Exposure to certain environmental toxins, such as pesticides and heavy metals, has been linked to an increased risk of Parkinson’s disease.
Mitochondria: Dysfunction of mitochondria (the energy-producing structures within cells) may play a role in Parkinson’s disease by leading to oxidative stress and cell damage in the brain.

Pathophysiology of Parkinson’s disease:

Parkinson’s disease is a progressive neurological disorder that affects movement. The disease is believed to be caused by the death of dopamine-producing cells in the substantia nigra, a part of the brain that helps control movement.

This leads to a depletion of dopamine, a neurotransmitter that helps regulate movement. The loss of dopamine causes problems with nerve signaling in the brain, which leads to the characteristic symptoms of Parkinson’s disease, such as tremors, rigidity, bradykinesia (slowness of movement), and postural instability. These symptoms arise due to the imbalance of excitatory and inhibitory neurotransmitters in the corpus striatum.

In details;

Initiating Factors: Antipsychotic drugs, encephalitis, and other causes can initiate the process.
Substantia Nigra Affected: These factors affect the substantia nigra (SN), a brain region critical for motor control.
Destruction of Dopaminergic Neurons: Leads to the destruction of dopaminergic neuronal cells within the substantia nigra, located in the basal ganglia.
Depletion of Dopamine: This destruction causes a depletion of dopamine stores, a key neurotransmitter involved in movement.
Degeneration of Nigrostriatal Pathway: The dopaminergic nigrostriatal pathway, which connects the substantia nigra to the corpus striatum, degenerates.
Neurotransmitter Imbalance: An imbalance occurs between excitatory (acetylcholine, Ach) and inhibitory neurotransmitters in the corpus striatum, disrupting normal signaling.
Motor Control Impairment: Results in difficulty controlling and initiating voluntary movements.
Parkinson’s Disease Manifestation: Ultimately leads to the manifestation of Parkinson’s disease, characterized by:

Tremors
Rigidity
Bradykinesia (slowness of movement)
Postural changes

The 5 Stages of Parkinson's Disease

1. Stage One: Mild Symptoms on One Side

In the beginning, symptoms are very mild and only affect one side of the body. You might notice a patient has a slight tremor (shaking) in one hand or leg, or some stiffness. One side of their face may also show less expression. At this stage, the person can usually continue with their daily activities without much trouble.

2. Stage Two: Symptoms on Both Sides

The stiffness and tremors now spread to affect both sides of the body. The person's posture may start to change, and they may walk more slowly. Their face might look more "mask-like" with less blinking, and their speech can become softer or slower. Balance is not yet a major problem, but everyday tasks will take longer to complete.

3. Stage Three: Balance Problems Begin

This is the middle stage where loss of balance becomes the main problem. The person's movements are much slower, and falls become more common. They can still be independent in many ways (like dressing and eating), but activities are now more difficult. They might need some help to stay safe.

4. Stage Four: Needing Help to Stand and Walk

At this stage, the symptoms are severe. The person needs help to stand up and walk, and may use a walker or other assistive device. They are no longer able to live alone safely and will need a lot of help with daily care. While they may still be able to stand or walk for short periods, it is very difficult.

5. Stage Five: Full-Time Care Needed

This is the most advanced stage. Severe stiffness in the legs may make it impossible to stand or walk, so the person may be in a wheelchair or bed-bound. They require 24-hour nursing care for all their needs. Some patients may also experience confusion, hallucinations (seeing things that are not there), or dementia.

Clinical Features of Parkinson’s Disease

1. Motor Symptoms:

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 handwriting) pill rolling character due to movement of the thumb across the palm also occurs. Tremors are increased by emotions.
Rigidity: Muscles are stiff with pain in severe cases; rigidity may be continuous or intermittent. Fine limb movements are difficult to perform. Stiffness or resistance in muscles, making movements less fluid and causing muscle pain or discomfort.
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.
Imbalance: 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 backward propulsively until falling is inevitable
Postural Instability: Changes in balance ie stooped over posture when up right, difficult in entertaining balance when sited erect and semi flexed arms. Impaired balance and coordination, resulting in a tendency to stoop, shuffle while walking, and increased risk of falls.
Bradykinesia: This means slowness of movement and speed (or progressive hesitations/halts) as movements are continued. It is one of the cardinal symptoms of Parkinson’s disease (PD). You must have bradykinesia plus at least either tremor or rigidity for a Parkinson’s diagnosis to be considered.

2. Non-Motor Symptoms:

Cognitive Changes: Some individuals with Parkinson’s disease may experience mild cognitive impairment, memory problems, difficulty with executive functions, and in later stages, dementia.
Sleep Disorders: Including insomnia, restless leg syndrome, excessive daytime sleepiness, and rapid eye movement sleep behavior disorder (acting out dreams during sleep).
Autonomic Dysfunction: Symptoms may include orthostatic hypotension (low blood pressure upon standing), constipation, urinary problems, excessive sweating, and sexual dysfunction.
Mood and Behavioral Changes: Depression, anxiety, apathy, and changes in mood or behavior are common in Parkinson’s disease.
Sensory Symptoms: Loss of sense of smell (anosmia) and visual disturbances such as blurred or double vision.
Speech and Swallowing Difficulties: Speaking softly, slurred speech, difficulty swallowing (dysphagia), and drooling may occur.
Pain and Fatigue: Some individuals with Parkinson’s disease may experience pain, muscle cramps, and fatigue.

Diagnosis of Parkinson’s Disease

1. Medical History: The doctor will begin by taking a detailed medical history, including asking about the patient’s symptoms, their duration, and any family history of Parkinson’s disease.

2. Physical Examination: A thorough physical examination will be conducted to assess motor symptoms such as tremors, rigidity, bradykinesia (slowness of movement), and postural instability. The doctor will also look for other possible causes of these symptoms.

3. Assessment of Symptoms: The doctor may use standardized rating scales, such as the Unified Parkinson’s Disease Rating Scale (UPDRS), to evaluate the severity of symptoms and track disease progression.

4. Response to Medication: Parkinson’s disease symptoms often respond positively to dopaminergic medications. The doctor may prescribe a trial of medication, such as levodopa, to observe if there is a significant improvement in symptoms. This can help support the diagnosis of Parkinson’s disease.

5. Neurological Examination: A neurological examination may be performed to evaluate other neurological signs and rule out alternative diagnoses.

6. Imaging Studies: While imaging studies are not mandatory for diagnosis, they can help exclude other conditions that mimic Parkinson’s disease. Imaging techniques such as magnetic resonance imaging (MRI) or computed tomography (CT) scans can be used to assess the brain structure and rule out other causes.

7. Laboratory Tests: There are no specific blood tests to diagnose Parkinson’s disease. However, blood tests may be performed to rule out other medical conditions that can present with similar symptoms.

Management of Parkinson’s Disease

Unfortunately, as of 2025, Parkinson’s disease can’t be cured, but medicines can help control the symptoms. Medicines often work very well. When medicine is no longer helping, Surgery may be considered.

Aims of Management

The primary goal in the management of PD is to treat the symptomatic motor and nonmotor features of the disorder, with the objective of improving the patient’s overall quality of life.
To relieve symptoms and maintain functioning to improve quality of life.

Medical Management

1. Levodopa (L-Dopa) – Class: Dopamine Precursor

Dosage: 50 – 125 mg three times daily immediately after meals.
Side Effects: Nausea, vomiting, orthostatic hypotension (low blood pressure upon standing), dyskinesias (involuntary movements), hallucinations, confusion, and sleep disturbances. – Contraindications: Use with caution in patients with a history of psychosis, glaucoma, or melanoma. Avoid concurrent use with non-selective monoamine oxidase inhibitors (MAOIs).

2. Carbidopa-Levodopa – Class: Dopamine Precursor with Decarboxylase Inhibitor

Dosage: The dosage is based on the ratio of carbidopa to levodopa, such as 25/100 8 hourly or 25/250 8 hourly.
Side Effects: Similar to levodopa alone, but carbidopa helps reduce the peripheral side effects of levodopa, such as nausea and vomiting.

3. Dopamine Agonists – Class: Dopamine Receptor Agonists

Examples: Pramipexole, Ropinirole, Rotigotine
Dosage: The dosage varies depending on the specific medication and individual needs. It is initiated at a low dose and gradually increased.
Side Effects: Nausea, dizziness, orthostatic hypotension, hallucinations, impulse control disorders (such as gambling or hypersexuality), and sleep disturbances.

4. MAO-B Inhibitors – Class: Monoamine Oxidase-B Inhibitors

Examples: Selegiline, Rasagiline
Dosage: The dosage varies depending on the specific medication. It is usually taken once or twice daily.
Side Effects: Nausea, headache, insomnia, and potential interactions with certain foods and other medications.
Contraindications: Use with caution in patients with a history of psychosis, cardiovascular disease, or peptic ulcer disease. Avoid concurrent use with non-selective MAOIs.

Specific Nursing Interventions for a patient with Parkinson’s disease:

1. Promote Safety:

– Assess the patient’s environment for potential hazards and remove obstacles to prevent falls.

– Encourage the use of assistive devices such as canes or walkers to improve stability and reduce the risk of falls.

– Provide education to the patient and their caregivers about fall prevention strategies and home safety modifications.

2. Assist with Mobility:

– Encourage regular physical exercise and activities tailored to the patient’s abilities to improve mobility, balance, and coordination.

– Collaborate with physical and occupational therapists to develop a personalized exercise and rehabilitation plan.

– Use appropriate techniques to assist the patient with transfers, ambulation, and maintaining proper body alignment.

3. Facilitate Communication:

– Encourage the patient to speak slowly and clearly, taking breaks between phrases to improve speech clarity.

– Use visual cues, gestures, or written communication aids to supplement verbal communication.

– Refer the patient to a speech therapist for evaluation and management of speech difficulties.

4. Support Swallowing:

– Provide the patient with a modified diet, including texture modifications or swallowing strategies as recommended by a speech therapist.

– Offer small, frequent meals to minimize fatigue and aid digestion.

– Encourage the patient to maintain an upright position while eating and drinking to facilitate swallowing.

5. Optimize Medication Management:

– Collaborate with the healthcare team to ensure timely administration of prescribed medications for symptom management.

– Monitor the patient’s response to medications and report any side effects or changes in symptoms.

– Educate the patient and caregivers about the importance of medication adherence and the proper administration of medications.

6. Manage Constipation:

– Encourage the patient to maintain a high-fiber diet and an adequate fluid intake.

– Recommend regular exercise and physical activity to promote bowel regularity.

– Discuss with the healthcare team the use of stool softeners or laxatives if necessary.

7. Provide Emotional Support:

– Offer empathetic and compassionate care to address the emotional and psychological impact of the disease.

– Encourage the patient to express their feelings and concerns, providing a supportive and non-judgmental environment.

– Refer the patient and their caregivers to support groups or counseling services to connect with others facing similar challenges.

8. Monitor Mental Health:

– Assess the patient for signs of depression, anxiety, or cognitive impairment.

– Collaborate with the healthcare team to manage and treat mental health symptoms.

– Encourage engagement in activities that promote mental stimulation, such as puzzles, reading, or social interactions.

9. Promote Sleep Hygiene:

– Educate the patient about good sleep hygiene practices, such as maintaining a regular sleep schedule, creating a comfortable sleep environment, and avoiding stimulants before bedtime.

10. Educate the Patient and Caregivers:

– Provide education on Parkinson’s disease, its symptoms, and expected progression.

– Teach self-management strategies, including medication management, exercise, and symptom recognition.

– Inform the patient and caregivers about available community resources and support services.

Possible Nursing Diagnosis

1. Impaired Physical Mobility related to bradykinesia and rigidity as evidenced by inability to initiate movement, staying in the same position for long and needing support to carry out voluntary movement.

– Explanation: The characteristic motor symptoms of Parkinson’s disease, such as bradykinesia, rigidity, and postural instability, can significantly impair the patient’s ability to move, walk, and perform daily activities independently. Observation of the patient’s gait abnormalities, reduced range of motion, and difficulty with motor tasks can provide evidence for this diagnosis.

2. Risk for Falls related to tremors and orthostatic hypotension:

– Explanation: Parkinson’s disease can increase the risk of falls due to postural instability, gait disturbances, and reduced coordination. The patient may exhibit shuffling gait, decreased arm swing, and a stooped posture. History of falls, presence of orthostatic hypotension, and environmental hazards in the patient’s living area can further support this diagnosis.

3. Impaired Swallowing related to muscle weakness involved in swallowing as evidenced by difficulty in swallowing, choking during eating, coughing and food sticking in the throat(verbalisation/facial grimace) :

– Explanation: Parkinson’s disease can lead to dysphagia (difficulty swallowing) due to muscle weakness, impaired coordination, and decreased mobility of the muscles involved in swallowing. The patient may exhibit prolonged meal times, coughing or choking during meals, or complaints of food sticking in the throat. Evaluation by a speech therapist and observations during meals can provide evidence for this diagnosis.

4. Risk for Impaired Verbal Communication related to speech muscle involvement:

– Explanation: Parkinson’s disease can affect the muscles involved in speech production, leading to reduced volume, slurred speech, and monotone voice. The patient may demonstrate difficulty in articulating words and expressing thoughts. Assessment by a speech therapist and observation of the patient’s speech patterns can support this diagnosis.

5. Risk for Impaired Skin Integrity related to immobility, incontinence:

– Explanation: The combination of bradykinesia, rigidity, and postural instability in Parkinson’s disease can lead to decreased mobility and changes in body alignment. These factors, along with sensory disturbances, can increase the risk of pressure ulcers and skin breakdown. Observation of the patient’s skin condition, areas of pressure, and assessment of skin integrity can provide evidence for this diagnosis.

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 i.e massage, tai chi , yoga, pet therapy ,meditation
Joining support groups

Diagnosis of Parkinson’s Disease

1. Medical History: The doctor will begin by taking a detailed medical history, including asking about the patient’s symptoms, their duration, and any family history of Parkinson’s disease.

5. Neurological Examination: A neurological examination may be performed to evaluate other neurological signs and rule out alternative diagnoses.

Complications of Parkinson’s Disease

1. Falls and Fall-related Injuries:

– Due to impaired balance, postural instability, and motor symptoms, individuals with Parkinson’s disease are at an increased risk of falls. Falls can result in injuries such as fractures, head trauma, and soft tissue damage.

2. Dysphagia and Aspiration Pneumonia:

– Parkinson’s disease can lead to difficulty swallowing (dysphagia), which increases the risk of food or liquid entering the airway (aspiration). Aspiration pneumonia, a lung infection caused by inhaling foreign material, is a potential complication of dysphagia.

3. Psychiatric and Mood Disorders:

– Depression, anxiety, and apathy are common psychiatric conditions that can occur in Parkinson’s disease. These mood disorders can significantly impact the patient’s quality of life and may require treatment and psychological support.

4. Cognitive Impairment and Dementia:

– As Parkinson’s disease progresses, some individuals may develop cognitive impairment, including problems with memory, attention, and executive functions. In some cases, this can progress to Parkinson’s disease dementia, which affects thinking, judgment, and daily functioning.

5. Sleep Disorders:

– Parkinson’s disease is associated with various sleep disturbances, such as insomnia, restless leg syndrome, and rapid eye movement (REM) sleep behavior disorder. These sleep disorders can lead to excessive daytime sleepiness, fatigue, and overall reduced quality of sleep.

6. Medication-related Complications:

– Long-term use of medications for Parkinson’s disease, such as levodopa, can lead to complications known as motor fluctuations and dyskinesias. Motor fluctuations are changes in the response to medication, resulting in periods of good symptom control (on periods) and periods of poor symptom control (off periods). Dyskinesias are involuntary, abnormal movements that can occur during certain periods.

Nursing Care Plan: Parkinson’s Disease

Assessment

Nursing Diagnosis

Goals/Expected Outcomes

Interventions

Rationale

Evaluation

Patient presents with resting tremors, bradykinesia, rigidity, and postural instability. Difficulty initiating voluntary movements.

Impaired Physical Mobility related to muscle rigidity and bradykinesia as evidenced by difficulty walking, shuffling gait, and tremors.

– Patient will demonstrate improved mobility and engage in physical activities with minimal assistance.

– Patient will perform range-of-motion (ROM) exercises daily.

– Patient will maintain safety while ambulating.

1. Encourage regular physical activity, including passive and active ROM exercises. 2. Provide assistive devices (walker, cane) as needed.

3. Teach the patient to use the “rocking” technique to initiate movement.

4. Educate on maintaining an upright posture and taking large, deliberate steps.

5. Collaborate with a physical therapist for mobility training.

1. Helps prevent stiffness and maintain joint flexibility.

2. Promotes independence and reduces fall risk.

3. Overcomes movement initiation difficulties.

4. Improves gait and reduces the risk of falls.

5. Enhances mobility and functional ability.

– Patient engages in physical activity with minimal assistance.

– Patient reports improved mobility.

– Patient remains free from falls and injuries.

Patient reports difficulty holding utensils, dressing, and writing. Increased time required for daily tasks. (Dressing, Eating, Grooming)

Decreased Self-Care Deficit syndrome related to bradykinesia and tremors as evidenced by inability to button clothes, feed self, or use utensils effectively.

– Patient will demonstrate improved ability to perform self-care activities with minimal assistance.

– Patient will use adaptive devices to enhance independence.

– Patient will maintain personal hygiene and grooming.

1. Encourage the use of adaptive utensils and clothing with Velcro fasteners.

2. Allow extra time for the patient to complete tasks.

3. Provide cues and step-by-step instructions for self-care activities.

4. Encourage family involvement in assisting the patient as needed.

5. Refer to an occupational therapist for fine motor skill training.

1. Facilitates independence despite motor difficulties.

2. Reduces frustration and promotes dignity.

3. Supports cognitive function and task completion.

4. Ensures patient receives necessary support while promoting autonomy.

5. Helps improve the patient’s ability to perform daily activities.

– Patient demonstrates improved ability to dress, eat, and groom.

– Patient uses adaptive devices effectively.

– Patient experiences less frustration with self-care.

Patient exhibits soft, monotone speech, masked facial expression, and difficulty swallowing.

Impaired Verbal Communication related to muscular rigidity and bradykinesia as evidenced by slow speech, decreased voice volume, and difficulty articulating words.

– Patient will use alternative communication methods as needed.

– Patient will engage in speech therapy exercises.

– Patient will demonstrate improved ability to express needs.

1. Encourage the patient to speak slowly and exaggerate pronunciation.

2. Suggest deep breathing exercises to strengthen vocal cords.

3. Use communication aids such as writing boards or voice amplifiers.

4. Encourage speech therapy to improve articulation and voice control.

5. Provide a calm, quiet environment to enhance communication.

1. Helps improve clarity of speech.

2. Strengthens respiratory muscles and voice projection.

3. Compensates for verbal communication difficulties.

4. Enhances the ability to communicate effectively.

5. Reduces frustration and improves comprehension.

– Patient reports improved ability to communicate.

– Patient uses communication aids effectively.

– Patient participates in speech therapy sessions.

Patient has difficulty swallowing, risk of aspiration, and reports choking episodes.

Inadequate nutritional intake related to impaired swallowing (dysphagia) as evidenced by coughing, drooling, and difficulty swallowing food and liquids.

– Patient will swallow safely without signs of aspiration.

– Patient will maintain adequate nutritional and hydration status.

– Patient will use modified diet strategies to prevent aspiration.

1. Assess swallowing ability and risk for aspiration.

2. Position patient upright (90-degree angle) during meals and for at least 30 minutes after eating.

3. Encourage small, frequent meals with thickened liquids if needed.

4. Teach patient to use the “chin tuck” technique while swallowing.

5. Refer to a speech therapist for swallowing evaluation and therapy.

1. Identifies patients at high risk for aspiration.

2. Promotes safe swallowing and reduces aspiration risk.

3. Prevents choking and maintains adequate nutrition.

4. Helps direct food away from the airway.

5. Enhances swallowing ability and safety.

– Patient swallows safely without choking or aspiration.

– Patient maintains adequate nutritional intake.

– Patient follows recommended swallowing techniques.

Patient expresses sadness, frustration, and social withdrawal due to disease progression.

Chronic confusion related to chronic illness and functional decline as evidenced by social isolation, low mood, and frustration with self-care difficulties.

– Patient will verbalize feelings and express emotions appropriately.

– Patient will participate in social activities as tolerated.

– Patient will demonstrate coping strategies to manage frustration.

1. Encourage the patient to express emotions and frustrations.

2. Provide emotional support and active listening.

3. Encourage participation in support groups or therapy.

4. Promote enjoyable activities that the patient can engage in despite limitations.

5. Monitor for signs of severe depression or suicidal thoughts and refer to a mental health professional if needed.

1. Helps the patient process emotions and reduce distress.

2. Provides reassurance and support.

3. Promotes socialization and reduces isolation.

4. Encourages engagement in life despite limitations.

5. Ensures early intervention for severe depression.

– Patient reports improved mood and emotional well-being.

– Patient engages in social activities.

– Patient verbalizes coping strategies effectively.

NANDA 2024-25

Nursing Concerns in Parkinson’s Disease:

Risk of Falls:

Concern for the patient’s increased risk of falls due to impaired balance and coordination.

Implementation of fall prevention strategies and regular assessments of gait and stability.

Functional Independence:

Concern for the preservation of the patient’s functional independence.

Promotion of activities that enhance independence in daily living.

Psychosocial Well-being:

Concern for the patient’s mental health and emotional well-being.

Regular assessment of mood, addressing any signs of depression or anxiety.

Communication Difficulties:

Concern for potential communication challenges.

Monitoring the patient’s ability to express needs and facilitating communication support as required.

Nutritional Status:

Concern for maintaining adequate nutrition.

Regular assessments of the patient’s nutritional intake and collaboration with dietitians to address any deficits.

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 of the face in absence of stroke.

Bell’s palsy is a type of facial paralysis that results in a temporary inability to control the facial muscles on the affected side of the face due to compression of the seventh cranial nerve.

The onset is mostly rapid and unilateral.

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

Causes of Bell’s Palsy

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

Herpes simplex, Herpes zoster and epstein barr virus.
HIV
Sarcoidosis, which is the growth of tiny collections of inflammatory cells in different parts of the body
Lyme disease (bacterial infection caused by infected ticks)

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

Demyelination of the nerve can trigger bell’s palsy.

Pathophysiology of Bell’s Palsy

The facial nerve has motor nerves that innervate/supply the muscles of expression on the face and sensory that supplies the tongue. Disruption of the nerve leads 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 the eye of the affected side tears constantly.
The condition accompanies an outbreak of herpes vesicles around the ear.

Etiology: The initial cause/factor is an inflammation of the facial nerve.
Compression and Occlusion: The inflamed and swollen nerve gets compressed, potentially leading to damage or blockage of its blood supply.
Ischemia: This compression results in reduced blood flow, causing ischemia (lack of oxygen and nutrients).
Necrosis: The lack of blood supply leads to nerve tissue death (necrosis).
Paralysis: The death of the facial nerve ultimately causes paralysis of the facial muscles.

Signs and symptoms of Bell’s palsy

Facial Weakness: Drooping of the face and difficulty in performing facial expressions like smiling.
Eye-related Issues: Inability to close the affected eye, leading to dry eyes, and the eye may fail to roll upward.
Drooling and Speech Difficulties: Dribbling of saliva from the affected mouth angle, and speech difficulties due to muscle weakness.
Challenges in Eating: Difficulty in closing the affected eye may result in food collecting between teeth and cheeks on the affected side.
Whistling Difficulty: Inability to whistle due to muscle weakness on the affected side.
Bell’s Sign: Failure of the eye to close and roll upward on the affected side.
Mouth Deviation: Deviation of the mouth toward the normal side.
Loss of Taste: Unilateral loss of taste sensation.
Pre-paralysis Symptoms: Pain behind the ear before facial paralysis, accompanied by fever, tinnitus, or hearing difficulty.
Muscle Twitches: Facial muscles may experience involuntary twitches.
Dry Eyes and Mouth: Reduced tear and saliva production leading to dry eyes and mouth.
Headaches: Individuals may experience headaches, possibly related to facial muscle tension.
Sensitivity to Sound: Increased sensitivity to sound may be observed.

Diagnostic Evaluation of Bell’s Palsy

Diagnosis is often based on symptoms, ruling out other causes of paralysis like a stroke.

No Definitive Test: No specific test confirms Bell’s Palsy; diagnosis relies on clinical evaluation.
History of Onset of Symptoms: The patient’s experience, including the timing and progression of symptoms, is a key factor in diagnosing Bell’s palsy.
Observation and Examination: Careful observation of the patient’s facial movements helps confirm the diagnosis. This includes assessing upper and lower facial weakness by observing actions like closing the eyes, lifting eyebrows, smiling, and frowning.
Neurological Examination: A thorough neurological examination is conducted to assess the patient’s facial motor capacity. This involves testing the ability to perform facial movements, such as closing the eyes, lifting the eyebrows, smiling, and frowning.
Blood Tests: Blood tests are needed only to rule out other conditions that might cause similar symptoms. These tests examine for viral infections or other risk factors known to be associated with Bell’s palsy.
Electromyography (EMG): This test measures the electrical activity of the facial muscles when stimulated. EMG helps to confirm the presence and severity of nerve damage. It also aids in differentiating Bell’s palsy from a stroke.
Imaging Studies (CT or MRI): Computed tomography (CT) or magnetic resonance imaging (MRI) are used to visualize the affected area and rule out any abnormalities or causes of pressure on the facial nerve. These studies are particularly helpful in excluding other potential causes, such as a brain tumor or a stroke.

Complications of Bell’s Palsy:

Malnutrition: Difficulty in eating and drinking due to facial muscle weakness can lead to malnutrition.
Psychological Withdrawal: Changes in facial appearance may cause psychological withdrawal and social challenges.
Dehydration: Reduced ability to close the affected eye can lead to excessive tear evaporation, contributing to dehydration.
Muscle Stretching and Facial Spasms: Prolonged muscle weakness may result in muscle stretching and facial spasms.
Synkinesis: Involuntary contraction of certain muscles while attempting to move others, leading to uncoordinated facial movements.
Excessive Dryness in Eyes: Inability to close the eye properly may cause excessive dryness, increasing the risk of eye infections and potential blindness.
Mucous Membrane Trauma: Difficulty in maintaining normal oral and nasal moisture can lead to mucous membrane trauma.
Corneal Abrasion: Insufficient eye protection may result in corneal abrasion, posing a risk to eye health.
Facial Spasms and Contractures: Persistent facial spasms and contractures can impact facial muscle function and appearance.
Changes in Appearance: Facial asymmetry and changes in appearance may contribute to psychological distress.
Speech Difficulties: Impaired muscle coordination may lead to difficulties in articulation and speech.
Chronic Eye Issues: Long-term complications may include chronic eye problems and discomfort.

Management of Bell’s Palsy

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

Aims of management.

Reduce Inflammation and Nerve Damage: This involves controlling the inflammation of the facial nerve, preventing further damage, and promoting nerve regeneration.
Preserve Facial Function: The goal is to minimize the severity and duration of facial paralysis and to prevent permanent facial muscle weakness.
Reduce Pain and Discomfort: Pain, especially in the ear or behind the ear, is common in Bell’s palsy. Pain management is important for the patient’s well-being.

MEDICAL MANAGEMENT

Medications:

1. Corticosteroids: The drugs of choice. Prednisone, a steroid medication, is often prescribed to reduce inflammation and swelling of the facial nerve.

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%)
Analgesics e.g. ibruprofen may be needed for pain

2. Antiviral Medications: Antiviral medications, such as Acyclovir (Zovirax) or famciclovir, because HSV is implicated in 70% of cases. They are sometimes prescribed, particularly if a viral infection is suspected.

3. Analgesics: Over-the-counter or prescription pain medications are used to manage pain and discomfort.

Facial Exercises: Facial exercises are an essential part of Bell’s palsy management, particularly after the initial inflammatory phase. These exercises aim to improve muscle strength and coordination, minimize muscle atrophy, and help regain facial function.

Examples of Conventional Exercises:

Eye Exercises: Closing the eye tightly, blinking repeatedly, and gently massaging the eyelids.
Brow Exercises: Raising the eyebrows, furrowing the brow, and moving the eyebrows from side to side.
Mouth Exercises: Smiling broadly, pursing the lips, puffing out the cheeks, and blowing air out of the mouth.
Chin Exercises: Moving the jaw side to side, clenching and unclenching the jaw.
Facial Massage: Gently massaging the affected side of the face to improve circulation and muscle tone.

Other Therapies:

Physical Therapy: A physical therapist can provide personalized facial exercise programs and teach techniques to improve facial muscle function.
Occupational Therapy: Occupational therapists can help with activities of daily living, such as eating, grooming, and communication, and can recommend adaptive strategies for coping with facial weakness.
Speech Therapy: Speech therapists can help address speech problems that may arise from facial paralysis, such as slurred speech or difficulty articulating words.

Surgery: Surgical intervention is rarely necessary for Bell’s palsy. In cases of persistent facial paralysis, nerve grafting or muscle transfers might be considered.

Physiotherapy:

Facial Massage: Regular facial massage is crucial for maintaining circulation and keeping the skin supple.Massage should be performed in an upward direction, avoiding downward strokes that can stretch the paralyzed muscles and worsen the condition.
Taping/Splinting: These methods help to reduce facial asymmetry by supporting the paralyzed side of the face and encouraging muscle balance. They can be customized by a physical therapist or occupational therapist.
Muscle Re-education: Faradic Re-education: This technique uses electrical stimulation to re-educate the facial muscles. It is only suitable for patients who can tolerate sensory stimulation.
Visual Feedback Exercises: Encouraging patients to perform facial exercises in front of a mirror allows them to observe their progress and improve their technique. This visual feedback can significantly aid in muscle re-education.

Conventional Exercises which include;

Elevate eyebrows, after brushing the forehead.
Elevate the corner of the lips (like saying “E”), after brushing the affected side of the face.
Close eyes slowly and alternately close one eye at a time.
Wrinkle and open the wings of the nose.
Open the mouth and say “a”, “o”, and alternate between “e”, “a”, “o”.
Smile with and without showing teeth.
Wind up the cheeks with closed lips.
Read and speak aloud.

Eye Care:

It is essential to protect the eye on the affected side. The patient should be advised to wash their eyes regularly with saline solution and wear protective goggles or eye patches to prevent dust, debris, or foreign particles from entering the eye.

Alternative Medicine: There is limited scientific evidence to support the effectiveness of alternative medicine for Bell’s palsy, but some individuals may find relief from:

Acupuncture: This involves inserting thin needles into specific points on the body, aiming to stimulate nerves and muscles.

SPECIFIC NURSING CARE;

Pain Relief: Apply a warm, moist sponge to alleviate pain.
Eye Care: Pad the dry eye to prevent excessive dryness and potential complications.
Nutrition: Monitor and support the patient’s nutrition, addressing challenges in eating and drinking.
Physiotherapy and Facial Massage: Implement physiotherapy and facial massage to stimulate facial muscles.
Speech Therapy: Provide speech therapy to address potential speech difficulties.
Support Groups: Encourage the patient to join support groups for emotional well-being.
Facial Symmetry: Utilize a face strap to help symmetrize the lips.
Eye Protection: Advise the patient to stay in warm environments, avoid dust and wind, and use eye protection in dangerous exposures.
Swallowing Precautions: Instruct the patient to sit upright while eating, chew on the non-paralyzed side, consume small portions, and maintain a balanced nutrition intake to prevent complications in swallowing.
Privacy during Meals: Respect the patient’s privacy during mealtime to avoid embarrassment.
Mouth Care: Perform careful mouth care, as food may accumulate between the lip and gingiva.
Muscle Tonus Maintenance: Massage the patient’s face with upward strokes for 5-10 minutes to maintain muscle tone, and encourage self-massage.
Active Exercise: If ready, ask the patient to perform active exercises, such as smiling in front of a mirror.
Eye Protection Outside: Suggest using eye protectors, especially when going outdoors. Sterile eyes

NURSING CARE PLAN FOR A PATIENT WITH BELL’S PALSY

Assessment	Nursing Diagnosis	Goals/Expected Outcomes	Interventions	Rationale	Evaluation
Facial asymmetry with drooping on one side, difficulty in closing the eye, and drooling from the mouth.	Post trauma syndrome related to inflammation of the facial nerve as evidenced by inability to close the eye and drooping of the mouth on one side.	Improve facial muscle strength and function, evidenced by the ability to close the eye and reduced drooling within 2 weeks.	– Teach facial exercises to stimulate muscle function. – Administer prescribed corticosteroids to reduce inflammation and swelling. – Encourage the use of assistive devices like eye patches to protect the eye.	– Facial exercises can help stimulate the muscles and improve function. – Corticosteroids reduce inflammation, which can relieve nerve compression. – Eye protection prevents corneal damage due to dryness.	Patient demonstrates improved ability to close the eye and reduced drooping, indicating improved muscle strength and function.
Patient reports difficulty swallowing and frequently chokes on liquids.	Impaired swallowing related to weakness of facial muscles as evidenced by frequent choking and difficulty swallowing.	Prevent aspiration and improve swallowing ability, evidenced by the ability to swallow liquids without choking.	– Instruct the patient on swallowing techniques, such as chin-tuck during swallowing. – Offer thickened liquids to reduce the risk of aspiration. – Position the patient upright during meals and for 30 minutes afterward.	Proper swallowing techniques and thickened liquids can reduce the risk of aspiration. – Upright positioning helps gravity assist in swallowing and reduces aspiration risk.	Patient swallows liquids without choking, indicating improved swallowing ability.
Patient reports difficulty in articulating words clearly and being understood by others.	Impaired verbal communication related to facial muscle paralysis as evidenced by difficulty articulating words.	Enhance communication ability, evidenced by the patient being understood by others.	– Provide alternative communication methods, such as writing or using communication boards. – Encourage the patient to speak slowly and clearly. – Refer to speech therapy if needed.	Alternative communication methods reduce frustration and improve understanding. – Speech therapy can help retrain muscles and improve articulation.	Patient is able to communicate effectively using alternative methods or improved speech clarity.
Patient complains of a dry and irritated eye.	Ineffective Dry eye self-management related to incomplete eyelid closure as evidenced by patient complaints of dryness and irritation.	Prevent corneal damage and reduce discomfort, evidenced by the patient reporting no eye irritation and maintaining eye moisture.	– Administer artificial tears or lubricating eye drops as prescribed. – Apply an eye patch during sleep to protect the eye. – Teach the patient to manually close the eyelid periodically.	Lubricating eye drops prevent dryness and irritation. An eye patch protects the cornea during sleep, reducing the risk of damage.	Patient reports no eye irritation and maintains eye moisture, indicating effective prevention of corneal damage.
Patient’s affected side of the face is sensitive, and they report discomfort.	Acute pain related to facial nerve inflammation as evidenced by patient complaints of pain on the affected side.	Reduce pain and discomfort, evidenced by the patient reporting a decrease in facial pain.	– Administer prescribed analgesics to manage pain. – Apply warm compresses to the affected area to alleviate discomfort. – Educate the patient on gentle facial massage techniques.	Analgesics relieve pain, warm compresses reduce discomfort, and facial massage can help stimulate circulation and reduce pain.	Patient reports reduced pain and discomfort, indicating effective pain management.
Patient expresses anxiety and emotional distress about their appearance and the sudden onset of facial paralysis.	Excessive Anxiety related to the sudden onset of facial paralysis as evidenced by patient verbalizing concerns about appearance, and presenting with emotional distress.	Reduce anxiety and improve emotional well-being, evidenced by the patient reporting reduced distress and improved coping.	– Provide emotional support and reassurance about the potential for recovery. – Encourage the patient to express feelings and concerns. – Refer to counseling or support groups if needed.	Emotional support and reassurance can help reduce anxiety. – Counseling or support groups provide a space for the patient to process emotions and learn coping strategies.	Patient reports reduced anxiety and improved emotional well-being, indicating effective emotional support.

NANDA 2024-26

Nursing Concerns for Bell’s Palsy

Risk for Aspiration: Facial weakness can affect swallowing, increasing the risk of aspiration.
Risk for Corneal Abrasion: The inability to close the eye completely can lead to corneal dryness and damage.
Impaired Communication: Facial weakness can make it difficult for the patient to speak clearly.
Disrupted Body Image: The facial paralysis can have a significant impact on the patient’s self-esteem.
Risk for Infection: The affected eye is more susceptible to infection due to dryness and decreased blinking.
Risk for Delayed Recovery: The patient may experience anxiety and frustration due to the slow recovery process.
Risk for Social Isolation: The facial paralysis can make the patient feel self-conscious and withdraw from social interactions.

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

Trigeminal Neuralgia

TRIGEMINAL NEURALGIA

Trigeminal Neuralgia also known as Tic Douloreuv is a disorder that affects the 5th cranial nerve that causes intense periodic pain in one or more trigeminal nerve branches. Normally affects the 2nd and 3rd branches.

Branches of the Trigeminal Nerve

The trigeminal nerve has 3 divisions i.e

The ophthalmic division(v1) that supplies the forehead, eyes, nose, meninges, paranasal sinuses and part of the nasal mucosa.
The maxillary division(v2) supplies the upper jaw, teeth, lip, cheeks, hard palate, maxillary sinus and part of the nasal mucosa.
The mandibular division(v3) supplies the lower jaw, teeth, lip, buccal mucosa, tongue, part of the external ear and the meninges.

Trigeminal neuralgia most commonly affects the second (V2) and third (V3) branches of the trigeminal nerve.

Causes of Trigeminal Neuralgia:

The exact cause of trigeminal neuralgia is not fully understood; however, factors depend on the subtype. The International Classification of Headache Disorders, Third Edition (ICHD-3) categorizes Trigeminal Neuralgia (TN) into three main types:

1. Classic Trigeminal Neuralgia (Classic TN):

This is the most common form of TN.
It is characterized by intense, sharp, electric-shock-like pain in the face, affecting the second (maxillary) or third (mandibular) branches of the trigeminal nerve.
The primary cause is believed to be compression of the trigeminal nerve by a nearby blood vessel, often an artery.

2. Secondary Trigeminal Neuralgia (Secondary TN):

This type of TN arises as a consequence of another underlying condition, such as:

Tumors: A tumor located along the trigeminal nerve can compress and irritate it.
Multiple Sclerosis (MS): The demyelination process in MS can damage the nerve fibers, leading to pain.
Other Neurological Disorders: Conditions like brainstem stroke or brain aneurysm can also contribute to secondary TN.

3. Idiopathic Trigeminal Neuralgia (Idiopathic TN):

This category refers to cases of TN where the underlying cause remains unknown.
Despite extensive investigations, no identifiable factor like a blood vessel compression or other neurological condition is found to be responsible.

General causative factors include

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

Trigeminal neuralgia (TN) is characterized by intense, stabbing, electric shock-like pain in the distribution of one or more branches of the trigeminal nerve (CN V). It is broadly classified into two main forms: classical (idiopathic) and symptomatic (secondary).

Classical (Idiopathic) Trigeminal Neuralgia: In the classical form, a definitive underlying cause is often not identified. However, microvascular compression of the trigeminal nerve near its exit from the brainstem is the most widely accepted etiological factor.

Vascular Compression: Aberrant arteries or veins (e.g., superior cerebellar artery) can compress the trigeminal nerve root, leading to demyelination of the nerve fibers. This demyelination disrupts normal nerve function and can cause ectopic impulse generation and aberrant cross-talk between different types of nerve fibers (Aβ, Aδ, and C fibers). The result is the paroxysmal pain characteristic of TN.
Gasserian Ganglion Irritation: Some studies suggest that irritation or compression of the Gasserian ganglion, where the three branches of the trigeminal nerve converge, can also contribute to classical TN.
Risk Factors: Classical TN is more prevalent in women and individuals over 50 years old.

Symptomatic (Secondary) Trigeminal Neuralgia: This form arises from an identifiable underlying condition that damages or compresses the trigeminal nerve.

Space-occupying lesions: Tumors in the cerebellopontine angle (CPA) such as acoustic neuromas, meningiomas, or epidermoid cysts can compress the trigeminal nerve.
Demyelination (Multiple Sclerosis): MS plaques in the brainstem can damage the trigeminal nerve, leading to TN. TN is more common in people with MS, and it often presents bilaterally in these individuals.
Other Structural Lesions: Aneurysms, arteriovenous malformations, or other vascular abnormalities can compress the nerve.

Differential Diagnosis

When evaluating a patient with suspected trigeminal neuralgia, it’s important to consider other conditions that can cause facial pain. The differential diagnosis includes:

Dental Pathology: Toothaches, abscesses, or temporomandibular joint (TMJ) disorders can mimic TN pain.
Herpes Zoster: Postherpetic neuralgia following a shingles outbreak can cause persistent facial pain.
Nasopharyngeal and Paranasal Pathology: Sinus infections or tumors in the nasal cavity or sinuses can cause facial pain.
Cervical Artery Dissection: Although rare, dissection of the internal carotid or vertebral artery can cause facial pain.
Giant Cell Arteritis: This inflammatory condition can cause facial pain, particularly in older adults.
Cluster Headaches and Migraines: These primary headache disorders can sometimes present with facial pain.
Unstable Angina: In rare cases, pain from unstable angina can radiate to the jaw and face, mimicking TN.
Trigeminal Neuropathy: Sensory loss or other neurological deficits may indicate a different underlying condition than TN

Investigations and Diagnosis of Trigeminal Neuralgia (TN)

Diagnosing TN primarily relies on a thorough medical history and physical examination, as there is no single definitive test.

1. Detailed Medical History:

Pain Description: Ask about the character, intensity, duration, frequency, and triggers of the pain.
Onset and Progression: Inquire about when the pain started, how it has changed over time, and whether it’s been getting worse.
Previous Medical History: Information on previous illnesses, neurological conditions, or surgeries is relevant. Ask about current medications and supplements.

2. Physical Examination:

Neurological Examination: Assess the patient’s reflexes, sensation, and motor function, particularly in the face and trigeminal nerve distribution.
Palpation: The doctor may palpate the jaw and face to identify any areas of tenderness or trigger points.

3. Imaging Studies:

Magnetic Resonance Imaging (MRI): An MRI scan can help rule out other neurological conditions that can cause facial pain, such as tumors, MS, or vascular malformations.
Computed Tomography (CT) Scan: A CT scan can also help visualize the anatomy of the trigeminal nerve and surrounding structures.

Medical Management of Trigeminal Neuralgia:

Aims of Management

Control Pain: Reduce the frequency and severity of pain attacks.
Improve Quality of Life: Enable individuals to engage in daily activities without significant pain interference.
Prevent Complications: Minimize the risk of potential complications such as depression, anxiety, and social isolation.

Pharmacologic Therapy:

1. Anticonvulsants: Carbamazepine (Tegretol) and oxcarbazepine (Trileptal) are the first-line medications for TN.

Carbamazepine (Tegretol): Reduces transmission of impulses at nerve terminals, relieving pain. Adult dose at 100mg. 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.

2. Antidepressants: Tricyclic antidepressants like amitriptyline (Elavil) can also be effective in pain management.

3. Pain Relievers: Over-the-counter pain relievers like acetaminophen (Tylenol) or ibuprofen (Advil) may provide temporary relief.

4. Alternative Medications: Gabapentin and baclofen are utilized for pain management. If pain control remains inadequate, phenytoin (Dilantin) may be added as adjunctive therapy. Baclofen: This muscle relaxant may help reduce muscle spasms and pain.

Surgical Management:

5. Microvascular Decompression: This surgical procedure involves moving the blood vessel that is compressing the trigeminal nerve away from the nerve.

6. Percutaneous Radiofrequency: This procedure uses heat to destroy the trigeminal nerve fibers responsible for pain.

7. Gamma Knife Radiosurgery: Utilizes stereotactic magnetic resonance imaging (MRI) to identify the trigeminal nerve. Followed by gamma knife radiosurgery for precise intervention.

8. Glycerol Injection: A glycerol solution is injected into the trigeminal nerve, interrupting pain signals.

Nursing Management:

9. 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.

10.Oral Hygiene: Instruct patients to rinse their mouths after eating when tooth brushing causes pain. Perform personal hygiene during pain-free intervals.

11. Dietary Guidance: Advise patients to consume food and fluids at room temperature. Suggest chewing on the unaffected side and opting for soft foods.

12. Emotional Well-being: Recognize and address anxiety, depression, and insomnia common in chronic pain conditions. Implement appropriate interventions and referrals.

13. Postoperative Care: Perform neurologic checks to assess facial motor and sensory deficits postoperatively.

14. 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.

15. Physical Therapy: Specific exercises and techniques can help reduce muscle tension and improve facial movement.

16. Eating and Swallowing: Observe patients for any difficulty in eating and swallowing foods of different consistencies.

17. Lifestyle Modifications: Avoiding triggers, maintaining a regular sleep schedule, and reducing stress can help manage TN.

18. Cognitive-Behavioral Therapy (CBT): CBT can teach coping skills for managing pain and stress.

19. Support Groups: Encourage patients to join support groups for emotional and informational support.

Nursing Interventions

Pain Management:

Assess the intensity, duration, and triggers of trigeminal neuralgia pain.
Administer prescribed medications and monitor their effectiveness.
Implement non-pharmacological pain relief strategies, such as cold packs or distraction techniques.
Monitor for side effects of pain medications.

Nutritional Support:

Assess the patient’s ability to chew and swallow comfortably.
Collaborate with a dietitian to develop a nutrition plan that accommodates the patient’s pain and dietary restrictions.
Monitor weight changes and signs of malnutrition.

Facial Mobility and Self-Care:

Evaluate the impact of pain on facial mobility and self-care activities.
Collaborate with occupational therapy to develop strategies for maintaining facial hygiene.
Provide assistance as needed for activities affected by pain.

Communication Challenges:

Assess the patient’s ability to articulate words during and after painful episodes.
Implement communication aids or alternative methods as necessary.
Provide emotional support to address potential frustrations related to communication difficulties.

Psychosocial Support:

Evaluate the patient’s emotional well-being and coping mechanisms.
Offer counseling or refer to support groups to address the psychological impact of chronic pain.
Encourage open communication about fears and concerns related to trigeminal neuralgia.

Patient Education:

Educate the patient about trigeminal neuralgia, including potential triggers and lifestyle modifications.
Provide information on prescribed medications, their purpose, and potential side effects.
Discuss strategies for managing pain at home and when to seek medical attention.

Social Interaction:

Assess the patient’s social activities and potential limitations due to pain.
Encourage social engagement while considering the patient’s comfort level.
Provide guidance on how to communicate the condition to friends and family.

Monitoring for Complications:

Monitor for signs of complications such as malnutrition, aspiration, or skin breakdown.
Collaborate with the healthcare team to address and prevent potential complications.
They include Depression, Anxiety, Weight Loss, Social isolation, Sleep disturbances, Decreased facial sensation.

Medication Adherence:

Assess the patient’s adherence to prescribed medications.
Identify and address any barriers to medication compliance.
Educate the patient on the importance of following the prescribed medication regimen.

Regular Follow-up:

Schedule regular follow-up appointments to assess the patient’s overall condition and adjust the care plan as needed.
Ensure continuity of care and collaboration among healthcare providers.

Nursing care plan for Trigeminal Neuralgia

Assessment

Nursing Diagnosis

Goals/Expected Outcomes

Intervention

Rationale

Evaluation

Patient reports difficulty chewing and swallowing; weight loss of 3 kg in the last month

Risk for imbalanced nutrition: less than body requirements related to difficulty chewing and swallowing

– Maintain adequate nutritional intake within 1 week.

– Patient reports improved ability to eat without pain.

– Assess a patient’s nutritional status (weight, dietary intake).

– Provide soft or pureed foods that are easier to chew and swallow.

– Consult with a dietitian to ensure nutritional needs are met.

– Painful episodes may lead to avoidance of certain foods, potentially resulting in inadequate nutrition.

– Soft foods reduce discomfort during eating.

– A dietitian can help design a nutritionally balanced meal plan.

Patient maintained adequate nutritional intake within 1 week.

Patient reported improved ability to eat without pain.

Difficulty swallowing, reports of choking during meals

Risk for Aspiration related to difficulty in swallowing.

– Prevent aspiration during meals within 24 hours.

– Patient swallows without difficulty or choking.

– Assess swallowing ability before each meal.

– Position the patient upright during meals and 30 minutes after.

– Provide thickened liquids to reduce the risk of aspiration.

– Facial pain may compromise the patient’s ability to swallow effectively, increasing the risk of aspiration.

– Upright positioning reduces the risk of aspiration.

– Thickened liquids are easier to control during swallowing.

Prevent aspiration during meals within 24 hours

Patient swallows without difficulty or choking

Patient remains alone and avoids social interactions

Social Isolation related to fear of pain during social interactions as evidenced by patients remaining alone and indoors.

– Reduce social isolation within 2 weeks.

– Patient participates in at least one social activity.

– Encourage the patient to express feelings about pain and social isolation.

– Refer the patient to a support group for individuals with chronic pain.

– Plan gradual exposure to social situations, starting with a trusted friend or family member.

– Anticipation of painful episodes may lead to withdrawal from social activities, increasing the risk of social isolation.

– Expressing feelings can help reduce the emotional burden of isolation.

– Support groups provide emotional support and understanding.

– Patient reports feeling less isolated.

– Participates in social activities without significant fear of pain.

Patient stutters and struggles to articulate words during conversation

Impaired Communication related to difficulty articulating words as evidenced by patient stuttering while talking.

– Improve communication within 1 week.

– Patient articulates words more clearly.

– Assess the extent of communication difficulties.

– Provide alternative communication methods (e.g., writing, gestures).

– Encourage the patient to speak slowly and take breaks when needed.

– Painful episodes may affect the patient’s ability to articulate words clearly, impacting communication.

– Alternative methods ensure communication needs are met.

– Speaking slowly and taking breaks can reduce frustration and pain.

– Patient articulates words more clearly.

– Uses alternative communication methods effectively.

Patient reports difficulty sleeping, frequent awakenings due to pain

Altered Sleep Pattern related to trigeminal neuralgia pain disrupting normal sleep cycles as evidenced by patient verbalizing difficulty getting sleep.

– Improve sleep quality within 1 week.

– Patient reports sleeping for at least 6 hours uninterrupted.

– Assess the impact of pain on sleep patterns.

– Encourage a bedtime routine with relaxation techniques (e.g., warm bath, deep breathing).

– Administer prescribed pain medication 30 minutes before bedtime.

– Chronic pain may interfere with the patient’s ability to achieve restful sleep, potentially leading to altered sleep patterns.

– Relaxation techniques can promote sleep.

– Pain medication can reduce pain levels and improve sleep quality.

– Patient reports improved sleep quality.

– Sleeps for at least 6 hours without interruption.

Patient appears self-conscious, wears concealing clothes

Disturbed Body Image related to altered facial expressions and communication difficulties as evidenced by patient putting on concealing clothes.

– Improve body image within 2 weeks.

– Patient expresses acceptance of appearance and interacts more confidently.

– Encourage the patient to express feelings about body image.

– Provide positive reinforcement and support during social interactions.

– Refer to a counselor if needed to address self-esteem issues.

– Changes in facial appearance and communication challenges may contribute to feelings of decreased self-esteem.

– Expressing feelings can help process negative emotions.

– Counseling can provide strategies to improve self-esteem.

– Patient expresses acceptance of appearance.

– Interacts more confidently in social settings.

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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’s organized into the central nervous system (CNS) and the peripheral nervous system (PNS).

The CNS consists of the brain and spinal cord, both of which originate in the embryo. The PNS comprises all neural structures outside the CNS, connecting it to the rest of the body. These structures develop from neural crest cells and as extensions of the CNS itself. The PNS includes spinal and cranial nerves, visceral nerves and plexuses, and the enteric nervous system.

Functionally, the nervous system is divided into somatic and visceral components. The somatic nervous system (from the Greek ‘soma,’ meaning body) innervates structures derived from somites, such as skin and most skeletal muscle.

It’s primarily responsible for receiving and responding to external environmental information. The visceral nervous system (from the Greek ‘viscera,’ meaning guts) innervates organ systems and other visceral elements like smooth muscle and glands throughout the body. It mainly detects and responds to information about the body’s internal environment. The neuron, with its cell body, axon, and synapse, is the functional unit of the entire nervous system.

Structural Division:

Central Nervous System (CNS): Composing the brain and spinal cord.
Peripheral Nervous System (PNS): Includes structures outside the CNS connecting it to the body.

Functional Division:

Somatic Part: Innervates structures from somites (skin, skeletal muscles). Responds to external environmental stimuli.
Visceral Part: Innervates organ systems, smooth muscles, and glands. Detects and responds to internal environmental stimuli.

Structure of a neuron

FUNCTIONS OF NEURON STRUCTURES

Nucleus – controls the entire neuron.
Dendrite – receives 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 neurotransmitters.
Axon – fiber which carries impulses away from the cell body i.e it forms a 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 wraps 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.

Neuron – Functional Unit:

Composed of nucleus, dendrites, cell body (soma), axon, Schwann cells, myelin sheath, Node of Ranvier, and axon terminals.
Three types: sensory neurons (to CNS), motor neurons (from CNS), and interneurons (between sensory and motor neurons in CNS).

Other Nervous System Cells:

Satellite Cells: Surround neuron cell bodies in ganglia. Maintain a micro-environment and provide insulation.
Ependymal Cells: Line CNS cavities, secrete cerebrospinal fluid, and form choroid plexuses.
Oligodendrocytes: Wrap around CNS neurons to produce myelin sheath.
Astrocytes: Glial cells in the CNS. Anchor neurons to blood vessels and form the blood-brain barrier.
Microglia: Monocytes in the nervous system. Move to damaged tissue for phagocytosis.

CENTRAL NERVOUS SYSTEM

Brain Anatomy & Physiology.

Cerebrum:

Largest brain structure with frontal, temporal, parietal, and occipital lobes.
Divided into hemispheres by the longitudinal cerebral fissure.
Cerebral cortex (gray matter) and subcortical white matter.
Responsible for memory, sensory perception (pain, temperature, touch, sight, hearing, taste, smell), and control of skeletal muscle contractions.

Cerebellum:

Located behind the pons, below the occipital lobe.
Oval-shaped with hemispheres separated by vermis.
Contains gray and white matter.
Coordinates voluntary muscle movement, maintains posture and balance, and contributes to learning and language processing.

Brain Stem (Midbrain and Hindbrain – Pons & Medulla Oblongata):

Midbrain surrounds the cerebral aqueduct, connecting cerebrum and pons.
Pons, in front of the cerebellum, have nuclei and nerve fibers.
Medulla oblongata extends from the pons, continuous with the spinal cord, containing gray and white matter.
Midbrain acts as a relay station for ascending and descending nerve fibers, connecting cerebrum with lower brain fibers and spinal cord.
Pons collaborates with the medulla to control respiration.
Medulla oblongata controls respiration, cardiovascular function, and reflexes (vomiting, coughing, sneezing, swallowing).

Diencephalon (Thalamus, Hypothalamus):

Connects cerebrum and midbrain.
Houses thalamus (gray and white matter masses) and hypothalamus (below thalamus, connected to pituitary gland).

Thalamus

Relays and distributes impulses from various brain parts to the cerebral cortex.
Plays a role in memory processing.

Hypothalamus

Controls the autonomic nervous system.
Regulates appetite, thirst, body temperature, water balance, emotional reactions, and sexual behavior.
Influences sleeping and waking cycles through melatonin from the pineal gland.
Secretes ADH (antidiuretic hormone) and oxytocin.

Anatomy of the Spinal Cord

Cylindrical shape with circular to oval cross-section and a central canal.
Comprises 31 pairs of spinal nerves, each with sensory (dorsal root) and motor (ventral root) fibers.

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.

Facilitates communication between the brain and peripheral nerves.
White matter tracts carry sensory impulses to the brain and motor impulses from the brain to skeletal muscles.
Grey matter serves as the site for reflex integration, rapid involuntary actions in response to stimuli.

Meninges:

Three connective tissue coverings surrounding and protecting the brain and spinal cord.

Dura Mater: Thickest and outermost layer, continuous with cranial dura mater. 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.
Arachnoid Mater: Thin, delicate membrane 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.
Pia Mater: Adherent to the brain and spinal cord, extends into the anterior median fissure, and forms the denticulate ligament. 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 and ASSESSMENT

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 (I):

Function: Smell.
Assessment: Identify different smells with eyes closed.

Optic Nerve (II):

Function: Vision.
Assessment: Visual test and examination with a special light.

Oculomotor Nerve (III):

Function: Pupil size and certain eye movements.
Assessment: Pupil examination with light, eye movement in various directions.

Trochlear Nerve (IV):

Function: Eye movement.
Assessment: Eye movement evaluation.

Trigeminal Nerve (V):

Function: Face sensation, inside mouth sensation, and chewing.
Assessment: Touch face, observe biting down.

Abducens Nerve (VI):

Function: Eye movement.
Assessment: Follow light or finger for eye movement.

Facial Nerve (VII):

Function: Face muscle movement and taste.
Assessment: Identify tastes, smile, move cheeks, show teeth.

Acoustic Nerve (VIII):

Function: Hearing.
Assessment: Hearing test.

Glossopharyngeal Nerve (IX):

Function: Taste and swallowing.
Assessment: Identify tastes on the back of the tongue, test gag reflex.

Vagus Nerve (X):

Function: Swallowing, gag reflex, taste, and part of speech.
Assessment: Swallowing, elicit gag response with a tongue blade.

Accessory Nerve (XI):

Function: Shoulder and neck movement.
Assessment: Turn head side to side against resistance, shrug shoulders.

Hypoglossal Nerve (XII):

Function: Tongue movement.
Assessment: Stick out tongue, speak.

FIND THE REST OF THE ASSESSMENT BY CLICKING HERE

Spinal Nerves

Spinal nerves, like most nerves, contain both sensory and motor fibers. They are named and numbered according to the region of the vertebral column from which they originate:

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 emerges between the cranium and the atlas (first cervical vertebra). All other spinal nerves emerge below the vertebra (or former vertebra, in the case of the sacrum) corresponding to their number.

A plexus is a network of interconnected nerve fibers that recombine to form new, named peripheral nerves.

Dermatomes are areas of skin and muscle innervated by specific spinal nerves. A dermatome map (as shown in the figure) is a valuable diagnostic tool. It helps determine the origin of somatic pain, numbness, or tingling, especially when these symptoms result from pressure or inflammation of the spinal cord or nerve roots.

Dermatomes are somatic or musculocutaneous areas served by fibers from specific spinal nerves.
Dermatome map aids in diagnosing somatic pain, numbness, tingling caused by spinal cord or nerve root pressure or inflammation.

Myotome:

Region of skeletal muscle innervated by a single nerve or spinal cord level.
Most muscles receive input from multiple spinal cord levels.

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Orthopedic Nursing Care

Orthopedic Care

Orthopedic care is concerned with preventing, recognizing, and treating injuries, diseases, and ailments that affect 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;

1. Musculoskeletal Trauma:

Fractures: Broken bones ranging from simple hairline fractures to complex compound fractures.
Dislocations: Displacement of bones from their normal joint positions.
Sprains and Strains: Injuries involving ligaments (sprains) and muscles/tendons (strains).
Soft Tissue Injuries: Bruises, contusions, lacerations, and other damage to muscles, ligaments, and tendons.

2. Sports Injuries:

ACL Tears: Tears in the anterior cruciate ligament, often occurring during pivoting or sudden stops.
Rotator Cuff Tears: Tears in the muscles and tendons surrounding the shoulder joint.
Hamstring Injuries: Muscle strains or tears in the hamstring muscles at the back of the thigh.
Achilles Tendinitis: Inflammation of the Achilles tendon, commonly seen in athletes.

3. Degenerative Diseases:

Osteoarthritis: A common condition characterized by wear and tear on joint cartilage.
Rheumatoid Arthritis: An autoimmune disease causing inflammation in the joints.
Spinal Stenosis: Narrowing of the spinal canal, often causing pain, numbness, and weakness.
Osteoporosis: Weakening of the bones, making them more prone to fractures.

4. Infections:

Osteomyelitis: An infection of the bone, often requiring antibiotics or surgery.
Septic Arthritis: An infection within a joint, causing pain, swelling, and redness.
Tendonitis: Inflammation of a tendon, which can be caused by infection or overuse.

5. Tumors:

Bone Cancer: Malignant tumors that develop in the bones, requiring treatment with surgery, chemotherapy, or radiation.
Benign Bone Tumors: Non-cancerous growths that can cause pain or pressure.

6. Congenital Disorders:

Scoliosis: A sideways curvature of the spine.
Clubfoot: A condition where the foot is turned inward at birth.
Hip Dysplasia: A condition where the hip joint doesn’t develop properly.

7. Other Common Orthopedic Issues:

Back Pain: A widespread issue that can be caused by a variety of factors, including muscle strain, spinal problems, and disc herniation.
Carpal Tunnel Syndrome: A condition affecting the median nerve in the wrist, causing numbness and tingling in the hand.
Knee Pain: Can be caused by osteoarthritis, injuries, or overuse.
Shoulder Pain: Can be caused by rotator cuff tears, arthritis, or nerve compression.

Orthopedic Techniques

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

DRESSINGS & BANDAGING

A dressing is a sterile material applied to a wound or surgical site to promote healing and protect it from infection or further injury.

A dressing is any protective cover for the wound. It is usually a cotton material.

Uses of Dressings

Protection from Infection: Dressings act as a barrier to prevent microbial contamination.
Control Bleeding: Dressings can help apply pressure to a wound, assisting in controlling bleeding.
Absorption of Discharge: They are designed to absorb any fluid or discharge from the wound, reducing the risk of infection and promoting a healthy healing environment.
Prevent Further Injury: Dressings help protect the wound from external impacts and irritants, preventing further injury to the area.
Moisture Management: Dressings help maintain a moist wound environment, which can enhance healing.
Pain Reduction: Certain dressings can provide cushioning and support around a wound, reducing discomfort.
Promotion of Healing: Some dressings contain agents that promote healing, such as growth factors or antimicrobial treatments.

General Rules for Applying Dressings

Wash your hands thoroughly before and after applying the dressing, whenever possible.
If the wound is not too large and bleeding is under control, clean it and the surrounding skin before applying the dressing.
Avoid touching the wound or any part of the dressing that will be in contact with the wound.
Never talk or cough over a wound or the dressings.
If necessary, cover non-adhesive dressings with cotton wool pads and a bandage to control bleeding and absorb discharge.
Use a swab soaked in antiseptic or disinfectant to clean the wound only once.
If the dressing slips over a wound before it is fixed in place, discard it and use a fresh one, as the first may have picked up germs from the surrounding skin.
Always place dressings directly onto the wound. Never slide it in from the side.

BANDANGING

A bandage is a piece of gauze or cloth material used for any of the purposes to support, hold or to immobilize any part of the body.

A bandage is a strip of material (such as cloth or elastic) used to secure, support, or protect a dressing or injured area.

Bandaging is a technique of application of specific roller bandages to different parts of the body.

Bandaging refers to the process of applying a bandage to a wound or injured body part.

Purposes of Bandaging

To Cover and Retain Dressings: Bandages help keep dressings securely in place, ensuring proper protection for the wound.
To Protect a Wound: They offer a barrier against dirt, bacteria, and other contaminants that can lead to infection.
To Support Injuries: Bandages provide support for injured areas, such as sprains, aiding in immobilization and stability.
To Compress: They apply pressure to control bleeding or reduce swelling by compressing the affected area.
To Secure Dressings: Bandages keep dressings in place, ensuring that the wound is adequately protected and that the dressing functions effectively.
To Immobilize Fractures: Certain bandages, such as plaster of Paris casts, immobilize fractures, allowing them to heal properly.
To Control Bleeding: Bandages help apply pressure to a wound, assisting in controlling bleeding.
To Restrict Movement: Bandages can limit movement in injured areas, promoting healing and reducing pain.

Types of Bandages

1. Triangular Bandages: This type of bandage is used in emergency treatment and first aid. It can be utilized for:

- Head Bandage: Used to cover and protect head injuries.
- Sling: Provides support for an injured arm.

2. Roller Bandages: Long strips of cloth or elastic material rolled up for easy application. They can be used to apply compression and secure dressings in various ways:

- Circular: Applied in circles around the wound.
- Spiral: Wrapped in a spiral manner to cover the area.
- Recurrent: Used to cover areas like the stump of an amputated limb.

3. Plaster Bandages: Made from plaster of Paris, these bandages immobilize fractures of bones, providing necessary support during healing.

4. Adhesive Bandages: These are used for fractures at the clavicle bone, providing support and securing the area.

5. Gauze Bandages: Made of woven or non-woven fabric, these bandages are used to cover wounds and absorb exudate.

6. Crepe Bandages: These elastic bandages allow for a degree of stretch when applied, determining the amount of pressure they exert. They are widely used for sprains and strains.

General rules of bandaging

	Rule/Step	Rationale
1	Use a tightly rolled bandage of suitable width and material.	To promote neatness and efficiency.
2	Face the patient when bandaging limbs.	To observe the patient’s facial expression.
3	Hold the head of the bandage uppermost.	To apply even pressure and tension.
4	Bandage the limb well aligned in an anatomical position.	To prevent deformity and discomfort.
5	Hold the bandage in the right hand when bandaging a left limb and vice versa.	To promote correct bandaging.
6	Bandage the limb from inside outwards and from below upwards, keeping the bandage even throughout.	To ensure proper coverage and support.
7	Ensure that the bandage is neither too tight nor too loose.	To prevent interference with circulation and avoid slippage if loose.
8	Finish off the bandage with a straight turn, fold in the end and secure avoiding joints and the site of injury.	To prevent localized pressure, irritation, and discomfort.
9	Fasten with safety pins or with the provided fastener.	To prevent loosening of the bandage.
10	Apply tape in psychiatric, mentally handicapped, or pediatric patients instead of pins or other sharp appliances.	To prevent injury.

Materials Used to Make Various Bandages

Material	Description
Cotton	Heavy weaves are used for slings, thin porous ones from open weave bandages which are cheap, light, and disposable. Firmer ones with a fast edge can be washed repeatedly.
Domette	This woven material with a slightly fluffed surface makes a firm supporting bandage, which has some resilience but can be used to give firm support.
Crepe	These bandages are elastic, and the degree to which they are stretched when applied determines the amount of pressure they exert. They are widely used.
Plaster	Plaster muslin is the basis for making plaster of Paris bandages.
Stockinet	Used beneath plaster.
Proprietary Tubular Material	Such as tube gauze or Hetelast.

Bandaging patterns

Bandaging patterns refer to the specific techniques used to apply bandages effectively to secure dressings, support injured areas, and control bleeding. The choice of pattern depends on the location and type of injury, as well as the desired outcome (e.g., compression, immobilization).

Figure of eight: This pattern wraps the bandage in a figure-eight shape around the joint, creating a shape that stabilizes while still allowing for mobility.

Use: Mainly used for bandaging joints such as the knee, ankle, or elbow to provide support while allowing limited movement.

Steps	Action	Rationale
A. Figure of Eight
1	Observe general rules of all nursing procedures.	To maintain standards.
2	Put the patient in a comfortable position exposing the affected part.	To promote comfort, circulation, and prevent deformity.
3	Hold bandage with the drum facing upwards.	Allows application of even tension and pressure.
4	Wrap bandage around the limb twice below the joint.	To stabilize the bandage and provide firmness.
5	Use alternating ascending and descending turns to form a figure of eight; overlap each turn by one half to two-thirds the width of the strip.	To promote venous return and reduce edema.
6	Wrap bandage around the limb twice, above the joint to anchor it and secure it with a clip or safety pin.	To prevent venous complications early.
7	Elevate the bandaged extremity for 15 to 30 minutes after application of bandage.	To promote venous return and reduce edema.
8	Assess the skin for color, integrity, pain, and temperature.	To detect complications early.
9	Leave the patient comfortable and clear away.	Maintain standards.
B. Spiral Bandaging (e.g., bandaging the ear)
1	Make a fixing turn around the head.	As above.
2	Bring the bandage under the ear and straight over the head and down the back, leaving the other ear unbandaged.	To provide comfort.
3	Repeat these turns three or four times until the affected ear is gradually covered.	As above.
4	Finish with a fixing turn and secure the bandage at the center of the forehead using a safety pin or tape.	To stabilize the bandage.
C. Divergent Spica (pattern used to cover a dressing wound at a fixed joint e.g., knee, heel, or elbow)
1	Make two turns over the center of the joint.	To stabilize the joint.
2	Now make alternate turns above and below these turns forming a pattern at each side of the joint.	To provide support and stability.
D. Triangular Bandaging (Arm sling)
1	Place the injured arm across the patient’s chest so that the fingers almost touch the opposite shoulder.	To mobilize and relieve pain.
2	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.	Proper alignment of the arm.
3	Tuck the other end of the bandage well beneath the forearm and elbow.
4	Carry the remaining ends around the neck and tie the ends with a reef knot, which lies in the hollow above the clavicle on the injured side.
5	The right angle is folded and pinned to enclose the elbow.
6	Place a pad under the knot if it seems likely to cause pressure.	To prevent skin irritation.
E. Bandaging the Eye
1	Facing the patient, hold the eye pad in position until the bandage covers it.	To secure the bandage.
2	Begin from the affected side to the normal side across the forehead and round the head in a fixing turn, then from the back of the head the bandage comes under the eye, covering the nasal side of the pad and straight over the head and down the back.
3	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.
4	Fix a pin should be in the center of the forehead.
F. Capeline Bandage (Use a double-headed roller bandage)
1	Position patient in sitting up position and stand behind the patient.	To promote convenience to apply the head bandage.
2	Place the center of the outer surface of the bandage in the center of the forehead.
3	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.	Ensure that the ear is not covered.
4	Bring the upper bandage around the head and the other head of the bandage over the center of the top of the scalp and then to the root and nose.	To ensure firmness and neatness.
5	Bring the bandage which circles the victim’s head over the fore head covering and fixing the bandage which crosses the scalp. The bandage is then brought back over the scalp.
6	Ensure that each turn of the bandage covers 2/3 of the previous turn.	Adheres snugly to the body part.
7	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 covering the other margin of its original turn.
8	Repeat the back and forward turns to alternate side of the center, each one begin in front by the encircling bandage until the whole scalp is covered.
G. Recurrent Bandaging
1	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.	To provide firmness.
2	Stand facing the patient and take a fixing turn.	To observe the facial expression.
3	Carry the bandage upward across the front of the limb at 45° rounds behind it at the same level and downwards over the front to cross the first turn at a right angle.	To provide firmness and neatness.
4	Repeat these turns until the limb has been sufficiently covered.

ORTHOPAEDIC SPLINTS

Orthopaedic splints are medical devices used to immobilize, support, or protect a broken, fractured, or injured limb or joint.

They are made from materials such as plaster, fiberglass, or various synthetic materials, and can be either rigid or flexible. Splints are designed to prevent movement in the injured area, thereby facilitating healing and preventing further injury.

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 for Orthopaedic Splints

Splints are placed to immobilize musculoskeletal injuries, support healing, and 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.
Fractures to stabilize broken bones, ensuring proper alignment during healing.
Post-surgical immobilization following orthopedic procedures to maintain healing and alignment.
Dislocations to stabilize a joint until it can be properly repositioned and treated.
Tendon injuries to immobilize the area for healing.
Chronic pain conditions, such as carpal tunnel syndrome, where splints alleviate pain by providing support.
Bone stabilization in pediatric patients for fractures where traditional casting may be impractical.
Temporary stabilization before surgery to prepare the area for intervention.

Indications for Splinting

Splints are used in various musculoskeletal conditions to immobilize injuries, support healing, and prevent further trauma. The most common indications include:

Condition	Purpose of Splinting
Acute fractures, sprains, or strains	Provides temporary stabilization before further evaluation or surgery.
Occult fractures (e.g., scaphoid fracture)	Immobilization of suspected fractures that may not appear on initial imaging.
Severe soft tissue injuries	Prevents further injury and allows proper healing.
Stable fractures	Can serve as definitive treatment in specific fracture patterns.
Peripheral neuropathy	Protects affected extremities from accidental trauma.
Minor soft tissue injuries	Partial immobilization to reduce pain and movement.
Joint instability (e.g., dislocations)	Prevents excessive motion and supports joint recovery.

Equipment Required for Splint Application

Before applying a splint, it is essential to gather and organize all necessary materials:

Equipment	Purpose
Sheet or towel	Protects patient’s clothing.
Stockinette	Soft stretchable fabric placed under the splint for skin protection.
Under-cast padding (cotton padding)	Provides cushioning and prevents skin irritation.
Plaster or padded fiberglass	Forms the rigid supportive structure of the splint.
Water bucket (cool water)	Activates plaster or fiberglass materials.
Elastic bandage	Secures the splint in place while allowing for swelling.
Sling (for upper extremity injuries)	Supports the injured limb.
C-arm X-ray (if fracture reduction is attempted)	Confirms proper alignment of fractured bones before splint application.

General Steps for Splint Application

Pre-Splinting Preparation

Ensure adequate pain management – Provide analgesia or sedation as necessary to promote muscle relaxation and facilitate fracture reduction.
Address soft tissue injuries – Clean and dress any open wounds before applying the splint.
Prepare the affected area – Apply a stockinette circumferentially around the injury, ensuring it extends beyond the splinting area to protect the skin.

Splint Application Process

Pad bony prominences (e.g., elbow, knee, calcaneus) with 1–2 cm of soft padding to prevent pressure sores or necrosis.
Apply 2–3 layers of cast padding (0.25 cm to 0.5 cm) to provide additional cushioning.
Reduce any fracture by restoring bone length, alignment, and rotation (radiographic confirmation may be required).
Activate plaster or fiberglass sheets by saturating them in cool water.
Layer and laminate the splinting material, pressing the sheets together to increase strength.
Mold the splint around the injured area, ensuring proper support and resistance to deforming forces.
Do not completely encircle the limb – Splints must accommodate for swelling. If circumferential overlap occurs, the splint should be cut open after setting.
Fold the stockinette edges over the splint to protect the skin from sharp plaster or fiberglass edges.
Secure the splint with an elastic bandage – Apply it loosely to hold the splint in place while allowing for soft tissue expansion. Avoid direct contact with the skin.
Reassess the patient’s neurovascular status – Check for pulses, capillary refill, sensation, and motor function. Any compromise requires immediate splint removal and reassessment.
11. Educate the patient about splint care, warning signs (e.g., numbness, swelling, pain), and follow-up instructions.

Types of Splints

Splints are categorized based on their location and function.

Common Upper Extremity Splints

Splint Type	Indication
Coaptation Splint	Used for humeral fractures, preventing excessive movement.
Sugar Tong Splint	Immobilizes the forearm and prevents wrist/elbow rotation.
Posterior Long Arm Elbow Splint	Used for elbow dislocations and fractures.
Ulnar Gutter Splint	Supports 4th and 5th metacarpal fractures (boxer’s fracture).
Radial Gutter Splint	Immobilizes fractures of the 2nd and 3rd metacarpals.
Volar/Dorsal Short Arm Splint	Used for wrist sprains and carpal bone fractures.
Thumb Spica Splint	Commonly used for scaphoid fractures and thumb injuries.

Common Lower Extremity Splints

Splint Type	Indication
Posterior Long Leg Splint	Used for tibial fractures, knee ligament injuries.
Posterior Short Leg Splint	Immobilizes ankle fractures and foot injuries.
Posterior Short Leg Splint with Stirrups	Provides added stability for ankle fractures and severe sprains.

Complications of Splinting

Although splints are effective in immobilizing injuries, they can lead to complications if not applied correctly.

Complication	Cause & Risk Factors
Loss of fracture reduction	Movement or improper molding of the splint may cause the fracture to shift out of alignment.
Skin irritation or breakdown	Inadequate padding or excessive pressure may result in skin ulcers or irritation.
Joint stiffness	Prolonged immobilization can lead to decreased range of motion.
Thermal injury	Plaster generates heat when setting, and excessive layers may cause burns.
Neurovascular compromise	Tight splints may cause acute carpal tunnel syndrome or nerve compression.
Compartment syndrome	If a splint becomes circumferential (like a cast), it may increase pressure, leading to vascular compromise and tissue ischemia.

Traction

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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 »

Care of The Patients ears

EAR IRRIGATION

Ear irrigation is the process of flushing the external ear canal with sterile water or sterile saline.

Ear irrigation is a procedure where a warm, gentle stream of water is used to flush out debris, wax, or other foreign objects from the ear canal. It is the washing of the external auditory canal with a stream of fluid.

Ear syringing, also known as ear lavage, is a similar procedure but uses a larger volume of water and a more forceful stream, delivered through a syringe.

Aims /Purposes of Ear Irrigation

Remove earwax: This is the most common reason for ear irrigation. Accumulated earwax can block the ear canal, leading to hearing loss, discomfort, or even infection.
Remove foreign objects: Small objects, such as insects or seeds, can become lodged in the ear canal and need to be removed.
Cleanse the ear canal: Irrigation can help to remove dirt, debris, or other substances that may be present in the ear canal.

Indications for Ear Irrigation:

Earwax impaction: To soften and remove impacted cerumen.
Foreign body in the ear: Dislodge a foreign body (except hygroscopic substances like ethanol, sodium chloride).
Otitis externa (swimmer’s ear): To cleanse the ear canal and remove debris that may be contributing to this infection.
Chronic otitis media with effusion (glue ear): To cleanse the ear in case of purulent discharge caused by middle ear infection.
Preparation for ear surgery: To cleanse the ear canal before certain ear surgeries.
Prior to hearing tests: To improve the accuracy of hearing tests by removing debris that may interfere with sound transmission.
Removal of ear mold impressions: To remove a mold impression from the ear canal after an ear impression is taken for hearing aids or other devices.
Relief of ear pressure: To relieve ear pressure caused by changes in altitude or air pressure.
To relieve localized inflammation and discomfort: Can be used to reduce inflammation and discomfort in the ear canal.
For antiseptic effect: Can be used to deliver antiseptic solutions to the ear canal.
To apply heat or cold: Can be used to apply warm or cold water to the ear canal for therapeutic purposes.
To evaluate vestibular functions (e.g. bi-thermal caloric test): Used to assess the function of the balance system in the inner ear.

Contraindications of Ear Irrigation

Perforated Eardrum: A perforated eardrum (a hole in the eardrum) allows water to enter the middle ear, which can lead to infection. Irrigation could further damage the eardrum and worsen the situation.
Active Ear Infection: An ear infection, especially if it’s acute or severe, can make the ear canal more sensitive and prone to irritation. Irrigation could worsen pain, inflammation, and potentially spread the infection.
Recent Ear Surgery: The ear canal needs time to heal after surgery. Irrigation could disturb the healing process and potentially lead to complications.
History of Ear Surgery: Depending on the type of surgery, irrigation may not be safe. For example, if a ventilation tube has been inserted, irrigation could push the tube out of place.
Excessive Pain or Discomfort: If ear irrigation causes significant pain or discomfort, it should be stopped immediately. This could indicate a problem with the ear canal or a more serious condition.
Certain Medical Conditions: Conditions like diabetes, immune system disorders, or certain skin conditions could make the ear canal more susceptible to infection after irrigation.

Prescribed Solution/Solution that can be used:

Boric acid 2-4% solution
Sodium bicarbonate solution 1%
Normal saline
Hydrogen peroxide 2%
Sterile water

Equipment:

Tray:

Ear Syringe in a Receiver
Auroscope
Basin and Vomitus Bowl
Receiver

Clean Gloves
Mackintosh Cape
Patient’s Towel
Cotton Swabs
Prescribed Solution:

Boric acid 2-4% solution
Sodium bicarbonate solution 1%
Normal saline
Hydrogen peroxide 2%
Sterile water
Bowl of warm water for solution temperature regulation

Bedside:

Adjustable Light and Screen
Plastic Apron
Handwashing Equipment

Procedure for ear irrigation

Explain the procedure to the patient to obtain consent and cooperation
Provide privacy by screening or closing nearby windows.
Wash hands,
Prepare the equipment and bring at bedside.
Position the patient in sitting up.

Steps	Action	Rationale
1.	Follow general rules of nursing procedures.
2.	Inspect the auditory canal using the otoscope under good light.
3.	Ask the patient to sit and tilt the head slightly toward the affected ear. Place the mackintosh and towel over the shoulder and upper arm, under the affected ear. Place the curved part of the receiver below the tilted ear.
4.	Request the patient to support the receiver under the ear.
5.	Clean the auricle and meatus of the auditory canal with cotton wool swabs moistened with the solution.
6.	Fill the bulb syringe with irrigating solution. If an irrigating container is used, allow air to escape from tubing.	Air forced into the ear canal is noisy and therefore unpleasant for the patient.
7.	Straighten the auditory canal by pulling the auricle down and back for the child and up and back for an adult.	To straighten the auditory canal so that the solution can flow the entire length of the canal.
8.	Insert the tip of the syringe gently; direct a steady slow stream of solution against the roof of the auditory canal, using sufficient force to remove the secretions.	Gentleness aids in preventing injury to the tympanic membrane. Continuous in and out flow of the irrigating solution prevents pressure in the canal.
9.	Observe the patient throughout syringing.	To detect complications and be ready to act.
10.	When the irrigation is completed, place a cotton ball loosely in the auditory meatus and request the patient to lie on the affected ear on a towel or absorbent pad.	Cotton ball absorbs fluid while gravity allows remaining fluid in the canal to escape from the ear.
11.	Dry the patient’s auricle and remove the patient’s towel and mackintosh cape.
12.	Wash hands.
13.	Document the procedure, appearance of discharge and patient’s response.
14.	Clear away.
15.	Decontaminate items used in the procedure.
16.	Return in 10 to 15 minutes and remove the cotton ball and review the patient.	To detect pain that may indicate injury to the tympanic.

Care of The Patients ears Read More »