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Immunological Agents

Immunological agents are a broad class of drugs that modify the immune system’s activity, either by enhancing or suppressing its function.

They are like tools that help your immune system work better or differently. For example, vaccines help your body fight off specific diseases(enhancing) or autoimmune drugs treat autoimmune diseases, where the immune system attacks the body’s own tissues (suppressing).

Types of Immunological Agents:

Immunostimulants: These are drugs that boost the immune system’s function, often used when the immune system is weakened or underperforming.
Immunosuppressants: These drugs reduce or suppress the immune system’s activity, essential in preventing transplant rejection and treating autoimmune diseases.

Examples include;

IMMUNE STIMULANTS
Interferons
interferon alfa-2b
interferon alfacon-1
interferon alfa-n3
interferon beta-1a
interferon beta-1b
interferon gamma-1b
peginterferon alfa-2a
peginterferon alfa-2b
Interleukins
aldesleukin
oprelvekin

IMMUNE SUPPRESSANTS
T- and B-Cell Suppressors
abatacept
alefacept
azathioprine
Interleukin-Receptor Antagonist
anakinra
Monoclonal Antibodies
adalimumab
alemtuzumab
basiliximab
bevacizumab
certolizumab

Immunostimulants

1. Interferons

Interferons are proteins produced naturally by cells in response to viral infections and other stimuli. They work by interfering with virus replication within host cells, activating immune cells like natural killer cells and macrophages, and increasing the antigen presentation to lymphocytes.

Drug	Indications	Therapeutic Action	Adverse Effects
Interferon alfa-2b	Chronic hepatitis C, Kaposi’s sarcoma, malignant melanoma	Inhibits viral replication, enhances immune response, and increases macrophage activity	Flu-like symptoms, myelosuppression, depression, suicidal ideation
Interferon alfacon-1	Hepatitis C	Inhibits viral replication and boosts immune system	Headache, dizziness, bone marrow suppression, photosensitivity
Interferon alfa-n3	Genital warts, basal cell carcinoma	Inhibits viral replication and tumor growth	Fatigue, anorexia, nausea, vomiting
Interferon beta-1a	Multiple sclerosis	Reduces the frequency of clinical exacerbations and slows the progression of disability in multiple sclerosis	Injection site reactions, flu-like symptoms, liver dysfunction
Interferon beta-1b	Multiple sclerosis	Similar to Interferon beta-1a; modulates the immune system to reduce inflammation	Fatigue, depression, flu-like symptoms, liver impairment
Interferon gamma-1b	Chronic granulomatous disease, severe osteopetrosis	Enhances the respiratory burst of macrophages, stimulating greater antimicrobial activity	Fever, rash, diarrhea, myalgia
Peginterferon alfa-2a	Chronic hepatitis C and B	Increases immune response against hepatitis viruses	Neutropenia, thrombocytopenia, liver enzyme abnormalities, flu-like symptoms
Peginterferon alfa-2b	Chronic hepatitis C	Longer-lasting effects due to its pegylated form, allowing less frequent dosing	Similar to Peginterferon alfa-2a, including hematologic toxicity and depression

Therapeutic Action:

Interferons prevent viral particles from replicating inside host cells.
They stimulate cells to produce antiviral proteins and enhance the cytotoxicity of T-cells and natural killer cells.
They inhibit tumor growth by enhancing the host’s immune response.

Pharmacokinetics:

Interferons are well absorbed via subcutaneous or intramuscular injection, reaching peak plasma levels within 3-8 hours.
They are metabolized in the liver and kidneys and excreted primarily through the kidneys.

Contraindications:

Allergies to interferons or their components.
Pregnancy and lactation (due to teratogenic effects).
Cardiac diseases, particularly arrhythmias and hypertension.
Myelosuppression.

2. Interleukins

Interleukins are cytokines that play an essential role in the immune response by promoting the proliferation of lymphocytes and other immune cells.

Cytokines: The general term for any small protein that helps cells communicate with each other.

Imagine your immune system as a big army. Interleukins are like the signals that tell different parts of the army what to do.

Activate immune cells: Tell certain cells to start fighting off invaders.
Control inflammation: Help regulate how much inflammation happens in response to an infection or injury.
Promote cell growth: Help immune cells multiply and become stronger.

Drug	Indications	Therapeutic Action	Adverse Effects
Aldesleukin	Metastatic renal cell carcinoma, metastatic melanoma	Stimulates the proliferation of T-cells and natural killer cells, enhances the immune response against cancer	Capillary leak syndrome, hypotension, anemia
Oprelvekin	Prevention of severe thrombocytopenia in chemotherapy	Increases platelet production by stimulating megakaryocyte production	Fluid retention, edema, dyspnea, arrhythmias

Therapeutic Action:

Interleukins boost immune cell activity, enhancing the body’s ability to fight tumors and increase platelet production.

Pharmacokinetics:

Interleukins are absorbed via subcutaneous injection, with peak levels occurring within hours.
They are metabolized in the kidneys and excreted in urine.

Contraindications:

Allergies to interleukins or E. coli-produced products.
Pregnancy and lactation due to potential teratogenic effects.
Patients with renal, liver, or cardiovascular impairments.

Immunosuppressants

Immunosuppressants are used primarily to prevent transplant rejection and treat autoimmune diseases by inhibiting the immune system.

These are like the “peacekeepers” of the immune system. They dampen down the immune response, preventing it from overreacting.

Used to treat autoimmune diseases where the immune system attacks the body’s own tissues. Cyclosporine is the most commonly used immunosuppressant.

1. T- and B-Cell Suppressors

T- and B-cell suppressors inhibit the activity of these lymphocytes, reducing the immune system’s ability to mount an attack against transplanted organs or self-tissues in autoimmune diseases.

Drug	Indications	Therapeutic Action	Adverse Effects
Abatacept	Rheumatoid arthritis, juvenile idiopathic arthritis	Inhibits T-cell activation by binding to CD80 and CD86 on antigen-presenting cells	Headache, infections, hypertension, nausea
Alefacept	Plaque psoriasis	Inhibits T-cell activation and reduces T-cell numbers	Lymphopenia, hepatotoxicity, infections
Azathioprine	Prevention of kidney transplant rejection, rheumatoid arthritis	Inhibits purine synthesis, reducing T and B-cell proliferation	Bone marrow suppression, hepatotoxicity, nausea

Therapeutic Action:

These drugs inhibit the proliferation and activity of T-cells and B-cells, essential for preventing transplant rejection and treating autoimmune conditions.

Pharmacokinetics:

T- and B-cell suppressors are generally well absorbed when administered orally or intravenously.
They are metabolized in the liver and excreted primarily via the kidneys.

Contraindications:

Allergies to the drugs or their components.
Pregnancy and lactation (due to potential teratogenic effects).
Renal or hepatic impairment.
Active infections or known neoplasms.

2. Interleukin-Receptor Antagonist

This class of drugs blocks interleukin activity, which is critical in the inflammatory and immune response.

Drug	Indications	Therapeutic Action	Adverse Effects
Anakinra	Rheumatoid arthritis	Blocks the interleukin-1 receptor, reducing inflammation and halting joint damage	Headache, sinusitis, nausea, infections, injection-site reactions

Therapeutic Action:

Interleukin-receptor antagonists prevent the binding of interleukins to their receptors, reducing inflammation and tissue damage.

Pharmacokinetics:

Anakinra is administered subcutaneously and reaches peak plasma levels within hours.
It is metabolized by the liver and excreted primarily in urine.

Contraindications:

Allergies to E. coli–produced products or anakinra itself.
Pregnancy and lactation due to the potential transfer of the drug to the fetus or infant.
Renal impairment, immunosuppression, or active infections.

3. Monoclonal Antibodies

Monoclonal antibodies are laboratory-produced molecules that can mimic the immune system’s ability to fight off harmful pathogens such as viruses.

These are like highly specific “guided missiles” of the immune system.

They’re designed to target and attack specific cells or molecules. They can be used to treat cancer, autoimmune diseases, and even infections. Think of them as a sniper team that only targets the enemy, leaving the rest of the army alone.

Drug	Indications	Therapeutic Action	Adverse Effects
Adalimumab	Rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis	Binds to tumor necrosis factor (TNF) alpha, inhibiting its inflammatory effects	Infections, malignancies, injection site reactions
Alemtuzumab	Chronic lymphocytic leukemia	Targets CD52 on lymphocytes, leading to cell lysis	Infusion reactions, infections, cytopenias
Basiliximab	Prevention of kidney transplant rejection	Blocks interleukin-2 receptor on T-cells, preventing their activation	GI disturbances, infections, hypersensitivity

Monoclonal antibodies include adalimumab (Humira), alemtuzumab (Campath), basiliximab (Simulect), bevacizumab (Avastin), cetuximab (Erbitux), certolizumab (Cimzia), daclizumab (Zenapax)

Indications

Prevention of renal transplant rejection
Treatment of B-cell chronic lymphocytic leukemia
Reduction of the signs and symptoms of Crohn disease
Treatment of paroxysmal nocturnal hemoglobinuria, to reduce haemolysis.
Treatment of B-cell non-Hodgkin lymphoma in conjunction with rituximab.
Treatment of asthma with a very strong allergic component and seasonal allergic rhinitis not occasionally controlled by common medicine.
Prevention of serious RSV(Respiratory syncytial virus) infection in high-risk children.
Treatment of metastatic breast cancer.
Treatment of psoriasis

Therapeutic Action:

Monoclonal antibodies specifically target and neutralize pathogens or inflammatory molecules, providing targeted immune suppression.

Pharmacokinetics:

These drugs are administered via intravenous injection and have variable half-lives depending on the specific antibody.
They are metabolized and excreted through the reticuloendothelial system.

Contraindications

Monoclonal antibodies are contraindicated in the presence of any known allergy to the drug or to murine products and in the presence of fluid overload.
They should be used cautiously with fever (treat the fever before beginning therapy)
They should not be used during pregnancy or lactation unless the benefit clearly outweighs the potential risk to the fetus or neonate.

Adverse Effects

The most serious adverse effects associated with the use of
monoclonal antibodies are acute pulmonary edema (dyspnea, chest pain, wheezing), which is associated with severe fluid retention.
Fever
Chills
Malaise
Myalgia
Nausea
Diarrhea
Vomiting
Increased susceptibility to infection
Intravascular hemolysis with resultant fatigue, pain, dark urine, shortness of breath, and blood clots.

Immunological Agents Read More »

Thyrotoxicosis

THYROTOXICOSIS.

Thyrotoxicosis is the condition that occurs due to excessive thyroid hormone of any cause and therefore includes hyperthyroidism.

Hyperthyroidism is the condition that occurs due to excessive production of thyroid hormone by the thyroid gland. Some, however, use the terms interchangeably

Overactive thyroid, is called hyperthyreosis/Hyperthyroidism

Anatomy of the Thyroid gland.

The thyroid gland is located in the lower portion of the neck in front of the larynx and the trachea at the level of 5th, 6th & 7th cervical and the 1st thoracic vertebrae.

It is a highly vascular gland that weighs about 25 g and resembles a butterfly shape.
It has two lobes, one on either side.
The lobes are joined by isthmus in front of the trachea
Its major function is to produce thyroid hormone (T3 and T4 and calcium).
These hormones are responsible for growth and regulating metabolic rate

Common Terms

a. Hyperthyroidism: Hyperthyroidism is a medical condition characterized by excessive production of thyroid hormones by the thyroid gland. This overactivity of the thyroid gland leads to an increased metabolic rate in the body, resulting in symptoms such as weight loss, rapid heartbeat, irritability, heat intolerance, and tremors.

b. Thyrotoxicosis: Thyrotoxicosis is a condition in which there is an excess of thyroid hormones circulating in the bloodstream. It can be caused by various factors, including hyperthyroidism (excessive thyroid hormone production), inflammation of the thyroid gland, or external sources of thyroid hormone intake. The symptoms of thyrotoxicosis are similar to those of hyperthyroidism.

c. Graves’ disease: Graves’ disease is an autoimmune disorder that is the most common cause of hyperthyroidism. It occurs when the immune system mistakenly attacks the thyroid gland, causing it to produce excessive amounts of thyroid hormones. People with Graves’ disease often experience symptoms such as goiter (enlarged thyroid gland), bulging eyes (exophthalmos), weight loss, tremors, and heat intolerance.

d. Hypothyroidism: Hypothyroidism is a condition characterized by an underactive thyroid gland, leading to insufficient production of thyroid hormones. This deficiency of thyroid hormones slows down the body’s metabolism, resulting in symptoms such as fatigue, weight gain, cold intolerance, constipation, and depression.

e. Cretinism: Cretinism is a condition that occurs when a baby is born with severe hypothyroidism or when the condition is left untreated during early childhood. It leads to stunted growth, intellectual disability, and developmental delays. Cretinism can be caused by iodine deficiency, thyroid gland abnormalities, or genetic factors.

f. Myxedema: Myxedema refers to the severe form of hypothyroidism that develops in adults. It is characterized by the accumulation of mucopolysaccharides (a complex sugar) in the connective tissues, leading to swelling and thickening of the skin. Symptoms of myxedema include extreme fatigue, cold intolerance, weight gain, dry skin, hair loss, and mental sluggishness.

g. Goiter is a medical condition characterized by the enlargement of the thyroid gland, which is located in the front of the neck. It usually appears as a visible swelling or lump in the throat area. Goiter can develop due to various reasons, including iodine deficiency, inflammation of the thyroid gland, or certain thyroid disorders such as Graves’ disease or Hashimoto’s thyroiditis.

h. Hashimoto’s thyroiditis is an autoimmune disorder that affects the thyroid gland which can result in an underactive thyroid or hypothyroidism. In this condition, the immune system mistakenly attacks the thyroid gland, leading to chronic inflammation and damage to the gland.

i. Thyroid storm: Thyroid storm, also known as thyrotoxic crisis, is a life-threatening condition characterized by an extreme and sudden exacerbation of the symptoms of hyperthyroidism. It usually occurs in individuals with untreated or poorly controlled hyperthyroidism, often as a result of Graves’ disease. Symptoms include high fever, severe agitation, delirium, rapid heartbeat, high blood pressure, vomiting, diarrhea, and jaundice. Thyroid storm requires immediate medical attention and hospitalization. Treatment includes medications to block the production and release of thyroid hormones, as well as supportive care to manage symptoms and stabilize vital signs.

Why we need the Thyroid Gland & Hormones

1. Regulation of Metabolism: The thyroid gland plays a central role in regulating metabolism, influencing the rate at which cells convert nutrients into energy. It does so by producing and releasing thyroid hormones (triiodothyronine or T3 and thyroxine or T4), which control the body’s metabolic processes.

2. Body Temperature Control: Thyroid hormones help regulate body temperature by influencing heat production and heat loss mechanisms. They help maintain the body’s core temperature within a normal range.

3. Growth and Development: Thyroid hormones are important for proper growth and development in children. They are essential for the normal development of the skeletal system, brain, and other organs. Insufficient thyroid hormone production can lead to growth and developmental delays.

4. Brain Function: Thyroid hormones are necessary for the normal functioning of the brain. They play a role in cognitive function, mood regulation, memory, and overall mental well-being.

5. Energy Levels: Thyroid hormones contribute to energy production in the body. They help convert food into usable energy, ensuring adequate energy levels for daily activities.

6. Heart Function: Thyroid hormones have an impact on heart rate, heart rhythm, and cardiac output. They help regulate the overall function of the cardiovascular system.

7. Muscle Function: Thyroid hormones are involved in maintaining muscle tone and strength. They contribute to muscle contraction and overall muscle function.

8. Digestion: Proper thyroid function is necessary for healthy digestion. Thyroid hormones influence the movement of food through the digestive tract and the secretion of digestive enzymes.

9. Reproductive Health: Thyroid hormones play a role in reproductive health, including menstrual cycle regulation in women. Thyroid disorders can affect fertility, pregnancy outcomes, and the health of the developing fetus.

10. Maintenance of Healthy Skin, Hair, and Nails: Optimal thyroid function is important for maintaining healthy skin, hair, and nails. Thyroid hormones contribute to the growth, maintenance, and integrity of these structures.

Causes of Hyperthyroidism and/or Thyrotoxicosis

Graves’ Disease: An autoimmune disease, Graves’ disease is the most common etiology worldwide, with a prevalence of 50-80%. It is often linked to varying iodine levels in the diet. Graves’ disease is more prevalent in females, occurring eight times more frequently in women than in men, and is commonly diagnosed in young females aged 20-40 years.
Toxic Thyroid Adenoma: Common in Switzerland (53%), this etiology is believed to be atypical due to a low level of dietary iodine in the country. It involves the development of a toxic adenoma in the thyroid.
Toxic Multinodular Goiter: This condition is characterized by the presence of multiple nodules in the thyroid gland, contributing to excessive thyroid hormone production.
Thyroiditis: Inflammation of the thyroid, such as Hashimoto’s thyroiditis (immune-mediated hypothyroidism) and subacute thyroiditis (de Quervain’s), can initially lead to excess thyroid hormone secretion and progress to gland dysfunction, resulting in hypothyroidism.
Medication and Exogenous Thyroid Hormone: Consumption of excess thyroid hormone tablets or ingestion of ground beef contaminated with thyroid tissue can cause hyperthyroidism. Amiodarone, an antiarrhythmic drug, may lead to under- or overactivity of the thyroid.
Postpartum Thyroiditis (PPT): Affecting about 7% of women after childbirth, PPT undergoes several phases, with the initial phase being hyperthyroidism. This usually corrects itself without treatment.
Struma Ovarii: A rare form of monodermal teratoma containing mostly thyroid tissue, leading to hyperthyroidism.
Excess Iodine Consumption: Particularly from algae like kelp, can contribute to hyperthyroidism.
Excessive Thyroid Hormone Supplements: Taking too much thyroid hormone in the form of supplements, such as levothyroxine, can lead to thyrotoxicosis.
Pituitary Adenoma: Hypersecretion of thyroid-stimulating hormone (TSH) due to a pituitary adenoma accounts for less than 1 percent of hyperthyroidism cases.

General Causes of The above conditions(In Common Terms)

Autoimmune Disorders: Autoimmune disorders, such as Hashimoto’s thyroiditis and Graves’ disease, are among the most common causes of thyroid problems. In Hashimoto’s thyroiditis, the immune system attacks and damages the thyroid gland, leading to hypothyroidism. In Graves’ disease, the immune system stimulates the thyroid gland, causing excessive production of thyroid hormones and resulting in hyperthyroidism.
Iodine Deficiency or Excess: Adequate iodine intake is crucial for proper thyroid function, as iodine is a key component in the synthesis of thyroid hormones. An inadequate intake of iodine can lead to hypothyroidism and goiter. Conversely, excessive iodine intake can disrupt thyroid function and potentially cause hyperthyroidism. Governments provide iodized table salts as a way to avoid less iodine intake.
Thyroid Nodules: Thyroid nodules are abnormal growths or lumps that form within the thyroid gland. They can be benign (noncancerous) or malignant (cancerous). Thyroid nodules may cause problems by affecting hormone production or through physical compression of surrounding structures, leading to symptoms or requiring medical intervention.
Medications and Medical Treatments: Certain medications and medical treatments can interfere with thyroid function. For example, certain drugs, such as lithium, can contribute to hypothyroidism or hyperthyroidism. Radiation therapy to the head and neck region, often used in the treatment of certain cancers, can also affect thyroid function.
Congenital Thyroid Disorders: Some individuals may be born with congenital thyroid disorders, such as congenital hypothyroidism. This condition occurs when the thyroid gland does not develop properly or is absent at birth, resulting in inadequate thyroid hormone production. Early detection and treatment are critical to prevent developmental and growth problems.
Genetic Factors: Genetic factors can contribute to an increased risk of developing thyroid problems. Certain gene mutations or a family history of thyroid disorders may predispose individuals to conditions like thyroid cancer or autoimmune thyroid diseases.
Inflammation and Infection: Inflammation of the thyroid gland, known as thyroiditis, can disrupt thyroid function. Viral or bacterial infections can also affect the thyroid gland and potentially lead to thyroid problems.

Signs and symptoms of Thyrotoxicosis

Thyroid hormone plays a crucial role in normal cellular function. When in excess, it not only over-stimulates metabolism but also increases the effects of the sympathetic nervous system, leading to a “speeding up” of various body systems. This results in symptoms resembling an overdose of epinephrine (adrenaline). Hyperthyroidism may manifest with various symptoms, and while some individuals may be asymptomatic, others may experience significant clinical signs.

Symptoms

Nervousness: Elevated thyroid hormones stimulate the nervous system, leading to increased sensitivity and heightened feelings of nervousness.
Irritability: The overstimulation of the sympathetic nervous system can result in irritability.
Increased perspiration: Hyperactive metabolism causes an increase in sweat production as the body tries to cool down.
Heart racing: Excess thyroid hormones accelerate heart rate and may cause palpitations.
Hand tremors: Stimulated nervous system and increased metabolic activity contribute to hand tremors.
Anxiety: Elevated thyroid hormone levels can induce a constant state of anxiety.
Difficulty sleeping: Hyperthyroidism disrupts normal sleep patterns, leading to insomnia.
Thinning of the skin: Increased metabolism may affect skin thickness and texture.
Fine brittle hair: Changes in hormone levels can impact hair growth and texture.
Muscular weakness: Thyroid hormones influence muscle function, leading to weakness, especially in the upper arms and thighs.
More frequent bowel movements: Accelerated metabolism speeds up digestive processes, causing more frequent bowel movements and diarrhea.
Weight loss: Increased metabolism burns calories rapidly, resulting in weight loss despite a heightened appetite.
Vomiting: Gastrointestinal disturbances, including increased stomach activity, can lead to vomiting.
Changes in menstrual flow: Altered hormone levels affect the menstrual cycle, leading to lighter periods or longer cycles in women.

Major Clinical Signs:

Weight loss: Accelerated metabolism and increased calorie consumption contribute to weight loss.
Anxiety: Overstimulation of the nervous system manifests as heightened anxiety.
Heat intolerance: Elevated metabolism generates more internal heat, causing intolerance to warm environments.
Hair loss: Changes in hormone levels impact hair follicles, resulting in hair loss, particularly in the outer third of the eyebrows.
Muscle aches: Thyroid hormones influence muscle function, leading to aches and weakness.
Weakness: Muscular weakness is a common symptom of hyperthyroidism.
Fatigue: Despite increased activity, individuals may experience fatigue due to the strain on the body.
Hyperactivity: Elevated metabolism and increased energy levels contribute to hyperactivity.
Irritability: Overstimulation of the nervous system can lead to irritability.
High blood sugar: Thyroid hormones can impact glucose metabolism, leading to elevated blood sugar levels.
Excessive urination: Altered kidney function due to hormone imbalances can result in increased urination.
Excessive thirst: Increased fluid loss through urine may lead to excessive thirst.
Delirium: Severe cases of hyperthyroidism can cause mental confusion and delirium.
Tremor: Increased nervous system activity may manifest as tremors in various parts of the body.
Pretibial myxedema: Specific to Graves’ disease, it involves skin changes, swelling, and redness on the shins.
Emotional lability: Mood swings and emotional instability can occur due to hormonal fluctuations.
Sweating: Excessive sweating is a common symptom of hyperthyroidism.
Panic attacks: The combination of heightened nervous system activity and anxiety can lead to panic attacks.
Inability to concentrate and memory problems: Cognitive functions may be affected, leading to difficulties in concentration and memory.

Physical Symptoms:

Palpitations: Increased heart rate and irregular heart rhythms may cause palpitations.
Abnormal heart rhythms: Hyperthyroidism can disrupt normal heart rhythms, notably causing atrial fibrillation.
Shortness of breath: Respiratory and cardiovascular effects may result in shortness of breath (dyspnea).
Loss of libido: Hormonal imbalances can impact sexual desire and lead to a loss of libido.
Gynecomastia and feminization: Altered hormone levels may cause breast enlargement (gynecomastia) and feminine characteristics in males.

Note:

An association between thyroid disease and myasthenia gravis has been recognized, with approximately 5% of patients with myasthenia gravis also having hyperthyroidism.
In Graves’ disease, ophthalmopathy may cause enlarged eyes due to swelling eye muscles pushing the eyes forward, often with one or both eyes bulging.
Swelling of the front of the neck (goiter) may also occur.

Minor Ocular Signs:

Eyelid retraction (“stare”): Overactive thyroid hormones can affect the muscles that control eyelid movement, leading to a wide-eyed or “staring” appearance.
Extraocular muscle weakness: Weakness in the muscles that control eye movement may result in difficulties in moving the eyes.
Lid-lag (von Graefe’s sign): A characteristic eye movement sign where the upper eyelid lags behind the downward movement of the eye.
Double vision: Weakened eye muscles may cause double vision.

Exophthalmos/Proptosis in Graves’ Disease:

Exophthalmos or proptosis, the protrusion of the eyeball, is unique to hyperthyroidism caused by Graves’ disease. It results from immune-mediated inflammation in the retro-orbital fat, leading to forward protrusion of the eyes. Exophthalmos, when present with hyperthyroidism, is diagnostic of Graves’ disease.

Diagnosis and Investigation

Physical examination: enlarged, bumpy or tender gland through the neck, Eyes for swelling, redness or bulging, Heart for for a rapid heartbeat and irregular heartbeats, Hands for tremors, Skin if its moist and warm.

Blood Tests:

The Thyroid Stimulating Hormone (TSH) Test measures TSH levels, a hormone from the pituitary gland that stimulates the thyroid. Abnormal levels may indicate hyperthyroidism or hypothyroidism.
Thyroid Hormone (T3 and T4) Tests evaluate T3 and T4 hormone levels. Elevated levels may suggest hyperthyroidism, while decreased levels may indicate hypothyroidism.
Thyroid Antibody Tests check for antibodies linked to autoimmune thyroid disorders like Hashimoto’s thyroiditis or Graves’ disease.
Thyroid Function Panel combines TSH, T3, and T4 tests for a comprehensive thyroid function assessment.

Imaging Studies:

Ultrasound uses sound waves to create thyroid gland images, aiding in identifying nodules, goiter, or structural abnormalities.
Thyroid Scan utilizes radioactive tracers to assess overall thyroid structure and function.
Radioactive uptake study i.e. For this test, a small, safe dose of radioactive iodine (also called a radiotracer) is taken by mouth to see how much of it your thyroid gland absorbs. After 6 to 24 hours later, the neck is scanned with a device called a gamma probe to see how much of the radioactive iodine your thyroid has absorbed. If your it absorbs a lot, it means that your thyroid gland is producing too much thyroxine (T4)

Fine-Needle Aspiration (FNA) Biopsy:

In cases of suspicious thyroid nodules or potential cancer, FNA Biopsy extracts a sample for laboratory analysis.

Thyroid Imaging:

Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) assess the thyroid and adjacent structures when further evaluation is needed.

ADDITIONAL DIAGNOSTIC MEASURES

TSH Measurement: Initial test for suspected hyperthyroidism, assessing TSH levels produced by the pituitary gland, regulated by the hypothalamus.
Antibody Tests: Checking specific antibodies like anti-TSH-receptor antibodies in Graves’ disease aids in diagnosis, as they indicate autoimmune thyroid disorders.
Confirmation Blood Tests: Confirms hyperthyroidism with blood tests showing low TSH and elevated T4 and T3 levels. Low TSH indicates excess thyroid hormone.
Radioactive Iodine Uptake Test: Measures iodine absorption by the thyroid. Hyperthyroid individuals absorb more iodine, including radioactive iodine used for measurement.
Thyroid Scan: Conducted with the uptake test, it visually examines the over-functioning gland, producing images for characterization.
Thyroid Scintigraphy: Useful in distinguishing causes of hyperthyroidism and thyroiditis. Combines an iodine uptake test and a scan with a gamma camera for comprehensive evaluation.

Medical Management of Hyperthyroidism:

Antithyroid Medications:

– Propylthiouracil (PTU): Adult dose is usually 100-150 mg three times a day. Side effects may include liver toxicity, rash, joint pain, and agranulocytosis (a rare but serious condition characterized by a low white blood cell count).
– Methimazole (Tapazole): Adult dose is 10-30 mg once daily or divided into two doses. Side effects may include rash, itching, nausea, and agranulocytosis.

Beta-Blockers:

– Used to alleviate symptoms associated with hyperthyroidism such as rapid heart rate, tremors, and anxiety. Commonly prescribed beta-blockers include propranolol and atenolol. Adult doses may vary, and side effects can include fatigue, dizziness, and low blood pressure.

Radioactive Iodine (RAI) Therapy:

Administered orally to destroy or reduce the activity of the overactive thyroid gland. Side effects may include temporary worsening of hyperthyroid symptoms, neck tenderness, and radiation sickness.

Management of Thyrotoxicosis

Aims

To reduce the activity of the thyroid gland
To reduce heart rate (hypertension)
To remove part of thyroid gland

Pre-operatively

Admission: The patient is admitted 32 days before surgery in surgical ward.
Position: The patient is made to lie in a comfortable position according to her
choice.
History taking: Patient’s history is taken to details about the patient’s life which includes:
– Demographic data
– Past history
– Medical history for diseases like diabetes, liver cirrhosis e.t.c
– Past family history eg hypertension
– Actual history to rule out the real cause of the disease
Observation
– Vital observation eg TPR/BP to rule out vital abnormalities
– General observation i.e head to toe rule out abnormalities (JACCOLD)
– Specific observations eg palpation of the enlarged gland to any abnormality
Inform the doctor about patient
On waiting for the doctor the following are done: – orientation of the
patient, On arrival of the doctor, he will then order for investigations.
Investigation
– Chest x-ray
– Thyroid function test. (TFT).
– Biopsy of thyroid gland for cytology and histology.
– Indirect laryngoscopy
Medical Management: The doctor will then prescribe preoperative medications depending on the results from lab mainly;
Carbimazole 10-15 mg O.D X 12/52 then reduce to 5 mg 8hrly last
dose given prior to surgery.
Lugols iodine 0.3-0.9ml tds in milk 10 times prior to surgery until
the day of surgery.
Propranolol 40 – 80 mg 12 hourly incase of increased BP.
Diazepam 5mg b.d to seduce the patient
Digoxin 0.25mg o.d if atrial fibrillation is detected
Nursing care
Explain the procedure, the benefits and outcomes of the operation
and consent form obtained.
Re-assurance
Give the informed consent form to be signed
Clean the patient and dress the patient in theater gown
Obtain blood sample for Hb estimations & grouping
Inspect and clean operation site if instructed.
Theater is informed about the patient and the patient is then taken to the theater for operation.
In the theater, partial thyroidectomy is done and the patient transferred to the recovery room.
Ward staff are called to go for their patient.

MANAGEMENT: POST-THYROIDECTOMY (Incase of Surgery)

On receiving information from the theater nurse, two nurses go to receive the patient.
Patients vital observations are taken especially respiratory rate and pulse to confirm whether the patient is alive or dead.
The patient is then transferred back to the ward and laid on a post operative bed after receiving theater instructions about the patient.
Position in recovery position
Observations taken 1/4 hourly, 1/2 hourly, 1 hourly until fully recovered.
Post operative medications. As Doctor will prescribe the following
> Analgesics like – pethidine 50mg-100mg IM in 3 doses, then continues with
– IV tramadol 100mg tds X 1/7
– Sedatives like Diazepam 10-15mg
Specific nursing care: which include the following;
Care of the tube: The drainage tube is removed not later than 48hrs after the operation according to discharges
Care of the wound: Dressing are changed whenever soiled
Stitches removed on the 3rd-4th day, only as instructed by the doctor. Ensuring constant drainage in a drainage bottle or dressing.
Intubation if respiratory edema occurs.
Close observation for hemorrhage.
Creating a calm environment, possibly giving drugs to encourage sleep.
Care of drain and sutures; changing drainage 24 hourly, sutures removed on the third or fourth day.
Minimizing neck movement to reduce pain.
Administering analgesics to reduce pain.
Monitoring vitals every 2 hours to detect complications like thyroid storm or infections.
Giving antibiotics; ceftriaxone 2g 24 hourly.
Diet: High calories diet is ordered to satisfy hunger & to prevent tissue breakdown. Milk is encouraged to be taken then high carbohydrate diet, snacks
high in proteins, minerals and vitamins A, B6, and C are recommended.
Daily Nursing care. Oral care skin care. Bowel & bladder care
Physiotherapy. Patient is encouraged to do some exercise of the throat and then do some deep breathing and coughing exercise.
Psycho therapy
Fluid monitoring. Fluid intake and output is monitored, maintained and recorded on patient fluid balance charts.

NURSING INTERVENTIONS

1. Assess Thyroid Function: Monitor the patient’s thyroid hormone levels and symptoms to evaluate the effectiveness of treatment and detect any changes in thyroid function.

2. Medication Administration: Administer prescribed medications, such as thyroid hormone replacement or antithyroid medications, ensuring accurate dosage, timing, and appropriate route of administration.

3. Educate Patients: Provide comprehensive education to patients and their families about their specific thyroid problem, including the condition, treatment plan, medication regimen, and potential side effects.

4. Monitor Vital Signs: Regularly monitor the patient’s vital signs, including heart rate, blood pressure, and temperature, to assess the impact of thyroid dysfunction and medication therapy.

5. Support Emotional Well-being: Offer emotional support and create a therapeutic environment to help patients cope with the emotional and psychological aspects of living with a thyroid problem.

6. Promote Comfort: Implement comfort measures to alleviate symptoms such as pain, fatigue, and muscle weakness. Encourage rest and provide pain management techniques as appropriate.

7. Nutritional Support: Collaborate with dietitians to develop appropriate dietary plans that support optimal thyroid function and address any specific nutritional needs or restrictions.

8. Monitor Weight and Fluid Balance: Regularly assess and monitor the patient’s weight and fluid balance to identify any changes or imbalances that may indicate thyroid dysfunction.

9. Assist with Thyroid Imaging: Coordinate and assist with thyroid imaging procedures, such as ultrasound or radioactive iodine uptake scans, ensuring patient comfort and safety.

10. Collaborate with Healthcare Team: Work collaboratively with physicians, endocrinologists, and other healthcare professionals to ensure coordinated care and effective communication regarding the patient’s thyroid problem and treatment plan.

11. Monitor for Side Effects: Monitor patients for any potential side effects or adverse reactions to medications, particularly those related to thyroid hormone replacement or antithyroid medications.

12. Educate on Self-Care: Teach patients self-care strategies to manage their condition effectively, including proper medication management, self-monitoring of symptoms, and recognizing signs of worsening thyroid dysfunction.

13. Provide Thyroidectomy Care: If the patient undergoes thyroidectomy (surgical removal of the thyroid gland), provide post-operative care, including wound care, pain management, and monitoring for complications.

14. Manage Thyroid Storm: In cases of thyroid storm (life-threatening condition with severe hyperthyroidism symptoms), closely monitor vital signs, administer medications as ordered (such as antithyroid medications and beta-blockers), and provide supportive care.

16. Advice on Discharge: Collaborate with the healthcare team to plan for the patient’s discharge, ensuring proper medication instructions, follow-up appointments, and education on long-term management and self-care.

Complications of Thyroidectomy:

Hemorrhage due to hyper-vascularization of the thyroid gland.
Thyroid crisis (thyroid storm) characterized by rapid pulse, raised temperature, sweating, and confusion.
Tetany due to removal or trauma to parathyroid glands; characterized by tingling and numbness of the face, lips, and hands.
Sore throat.
Hoarseness due to damage to the recurrent laryngeal nerve.
Hypothyroidism due to thyroid removal.
Recurrent thyrotoxicosis.
Respiratory obstruction due to laryngeal edema.
Wound infection.

Advice on discharge. Advise the patient,

To complete prescribed medications
To do exercise to avoid complication of the neck
On personal hygiene to prevent secondary infections.
To eat a well balanced diet.
To buy a cream like lanolin and rub it on the healed wound.
To not take drugs when not prescribed by the physician
To avoid high temperatures.
To come back for review as indicated.
Follow-up Care: Regular monitoring of thyroid function through blood tests. Adjustments in medication dosage as needed.
Patient Education: Guidance on dietary restrictions and adherence to medication. Awareness of symptoms requiring prompt medical attention.
Long-Term Management: Maintenance therapy based on the chosen treatment modality. Continuous monitoring for potential complications.

Thyroid Storm Management:

Prompt Recognition: Immediate identification of extreme hyperthyroid symptoms.
Resuscitation Measures: Intravenous beta-blockers like propranolol for rapid symptom control. Thioamide, such as methimazole, to inhibit thyroid hormone production.
Additional Interventions: Administration of iodinated radiocontrast agent or iodine solution. Intravenous steroid, hydrocortisone, to address inflammation.
Intensive Monitoring: Continuous assessment of vital signs and thyroid function. Adjustment of treatment based on response.

Complications of Hyperthyroidism/Thyrotoxicosis:

Heart Problems: Elevated thyroid hormones can lead to increased heart rate (tachycardia) and irregular heart rhythms (arrhythmias), such as atrial fibrillation. Chronic strain on the heart may result in heart failure or other cardiovascular complications.
Osteoporosis: Hyperthyroidism can accelerate bone turnover, leading to decreased bone density and an increased risk of osteoporosis. Imbalances in calcium and vitamin D metabolism may further contribute to bone loss.
Thyroid Storm: In rare cases, untreated or severe hyperthyroidism can progress to a life-threatening condition known as thyroid storm. This involves a sudden and severe exacerbation of hyperthyroid symptoms, leading to high fever, extreme tachycardia, and organ failure.
Eye Complications (Graves’ Ophthalmopathy): Graves’ disease, a common cause of hyperthyroidism, is associated with eye complications. Immune-mediated inflammation in the eye tissues can lead to proptosis (bulging eyes), double vision, and in severe cases, vision impairment.
Skin and Hair Issues: Hyperthyroidism may affect skin and hair health. Thinning of the skin and fine, brittle hair are common symptoms. In some cases, individuals may experience skin changes such as redness or swelling.
Psychological Complications: Chronic anxiety, emotional lability, and irritability associated with hyperthyroidism can contribute to psychological complications. Severe cases may lead to mental health issues such as depression or exacerbate pre-existing conditions.
Menstrual Irregularities: Altered levels of thyroid hormones can impact the menstrual cycle in women. Menstrual flow may lighten, and periods may become irregular, with longer cycles than usual.
Muscle Weakness and Wasting: Hyperthyroidism can lead to muscle weakness, especially in the upper arms and thighs. In severe cases, prolonged muscle breakdown may result in muscle wasting.
Gastrointestinal Issues: Increased bowel movements and diarrhea are common symptoms of hyperthyroidism. Chronic gastrointestinal issues may lead to nutritional deficiencies and weight loss.
Impaired Concentration and Memory: Cognitive function may be affected, causing difficulties in concentration and memory. The combination of anxiety and hormonal imbalances can contribute to cognitive impairment.
Thyroid Crisis (Thyroid Storm): In extreme cases, uncontrolled hyperthyroidism can progress to a thyroid crisis or storm. This life-threatening condition involves a sudden surge in symptoms, including hyperthermia, cardiovascular collapse, and neurological dysfunction.
Pregnancy Complications: Hyperthyroidism during pregnancy can pose risks to both the mother and the developing fetus. Complications may include preterm birth, low birth weight, and maternal heart issues.
Liver and Kidney Dysfunction: Prolonged hyperthyroidism may impact liver and kidney function. Elevated thyroid hormones can affect organ metabolism and contribute to dysfunction over time.

Thyrotoxicosis Read More »

Wound Dressing

WOUND DRESSING

Wound dressing is a method of carrying out surgical dressing and operative treatment with an aim to prevent the entry of Microorganisms into the wound.

Indications for wound dressing

To protect the wound from further injury or infection
To absorb exudates such as pus or serum.
To immobilize and support the injured part.
To apply pressure on the wound to control bleeding or approximate the wound
To provide psychological and physical comfort for the patient.

Wound : A cut or break in the normal continuity of the skin or body structure internally or externally.

Classification of Wounds

Wounds can be classified based on manner of production, bacterial content, extent, and time. Below is a detailed breakdown of each classification:

1. Classification by Manner of Production

Abraded Wound (Abrasion)

Caused by friction that removes the superficial layer of the skin.
Commonly occurs due to falls on rough surfaces, such as sand, concrete, or gravel.

Incised Wound

Resulting from a sharp cutting instrument that produces a clean and well-defined separation of tissue.
Example: Surgical incisions or cuts made by a sharp knife.

Contused Wound

Caused by a blunt object, leading to significant injury to the soft tissue.
Characterized by bruising (hemorrhage) and swelling due to damaged blood vessels.
Example: Injuries from a blow, impact from a falling object, or trauma from a blunt force.

Lacerated Wound

Involves tearing of tissue, resulting in irregular and ragged wound edges.
Commonly caused by injuries from glass, metal, machinery accidents, or animal bites.

Penetrating Wound

A wound that pierces through deep tissues and may enter a body cavity or organ.
Example: Stab wounds caused by knives, long nails, or gunshot injuries.

Punctured Wound

Made by a sharp, narrow, and pointed object.
Usually deep with a small entry point, increasing the risk of infection.
Example: Injuries caused by nails, splinters, or glass fragments.

2. Classification by Bacterial Content

Clean Wound

Contains no pathogenic organisms and is made under sterile conditions.
Example: Surgical wounds created with aseptic techniques.
While surgical wounds are clean, the skin cannot be completely sterilized, making some microbial presence inevitable. However, the body’s immune system prevents infection.

Contaminated Wound

A wound that contains a significant number of microorganisms.
All accidental wounds fall into this category since they occur in an uncontrolled environment where aseptic precautions are absent.

Septic (Infected) Wound

A wound infected by pathogenic microorganisms that lead to tissue destruction and pus formation.
Even a previously clean or contaminated wound can become septic if unsterile techniques are used during dressing or if the body’s immune response fails.

3. Classification by Extent

Open Wound

There is a break in the skin or mucous membrane, exposing the underlying tissue to external contaminants.
Open wounds pose a higher risk of infection due to potential entry of microorganisms and foreign objects.
Example: Incisions, abrasions, lacerations, and puncture wounds.

Closed Wound

The skin remains intact, but underlying tissue is damaged.
Internal bleeding, swelling, or bruising (hematoma) may occur.
Example: Contusions (bruises) caused by blunt trauma.

4. Classification by Time

Acute Wound

A wound that heals within four weeks.
Includes surgical wounds, minor cuts, and abrasions that heal without complications.

Chronic Wound

A wound that fails to heal within four weeks and remains in the inflammatory phase of healing.
Chronic wounds may be associated with conditions such as diabetes, poor circulation, or infection.
Example: Pressure ulcers, diabetic foot ulcers, and venous leg ulcers.

WOUND HEALING

Wound healing refers to the body’s natural process of replacing destroyed tissue with new, living tissue.

This complex biological process involves multiple phases and can be influenced by various internal and external factors.

Factors Affecting Wound Healing

Several factors determine the rate and effectiveness of wound healing:

1. Age

Younger individuals tend to heal faster due to higher cellular activity and collagen production.
Elderly individuals may experience delayed healing due to reduced skin elasticity, lower immune response, and slower cell regeneration.

2. Nutritional Status

Proper nutrition is essential for wound healing. Deficiencies in proteins, carbohydrates, lipids, vitamins (especially A, C, and E), and minerals (such as zinc and iron) can delay the process.
Proteins are crucial for cell growth and tissue repair.
Vitamin C is essential for collagen formation, while Vitamin A aids in immune function and epithelial cell formation.

3. Type of Wound

Clean surgical wounds heal faster than contaminated or infected wounds.
Deep wounds with tissue loss take longer to heal than superficial wounds.

4. Blood Supply to the Affected Area

Adequate blood circulation ensures oxygen and nutrient delivery to the wound, promoting faster healing.
Conditions like diabetes, peripheral artery disease, and smoking can impair circulation and slow healing.

5. Presence of Foreign Bodies

Dirt, debris, sutures, or other foreign materials in the wound can delay healing and increase infection risk.

6. Infection and Foreign Bodies in the Wound

Infections introduce bacteria into the wound, causing inflammation, pus formation, and delayed healing.
The presence of bacteria prevents new tissue from forming properly.

7. Lack of Rest of the Affected Part

Continuous movement or strain on a wound can prevent proper tissue formation and delay healing.
Immobilization and rest allow new cells to regenerate effectively.

8. Hemorrhage (Excessive Bleeding)

Uncontrolled bleeding can prevent clot formation, delaying the healing process.
Blood loss reduces oxygen supply to the wound, which is crucial for tissue repair.

9. Presence of Dead Space in the Wound

Dead space refers to empty spaces between tissues where fluid can accumulate, increasing infection risk.
Proper wound closure techniques (suturing or packing) help eliminate dead spaces.

10. Malnutrition

An inadequate supply of proteins, carbohydrates, lipids, vitamins, and trace elements can slow down all phases of wound healing.

11. Medications

Certain medications can impair the healing process, such as:

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): May interfere with inflammation, which is crucial for wound healing.
Chemotherapy and Immunosuppressive Drugs: Reduce cell proliferation, slowing tissue repair.
Corticosteroids: Suppress the immune response and delay new tissue formation.

12. Stress, Anxiety, and Depression

Emotional and psychological stress can negatively affect immune function and hormone balance, leading to slower wound healing.

13. Underlying Diseases

Conditions such as diabetes, autoimmune disorders, anemia, and cancer can impair wound healing by reducing immune function, circulation, and tissue regeneration.

14. Infection

A wound that becomes infected requires additional time to heal due to the presence of bacteria that compete with new tissue growth.
Infections can lead to chronic wounds if left untreated.

Types of Wound Healing (Wound Closure)

1. Healing by Primary Intention (First Intention)

The wound edges are brought together (approximated) using sutures, staples, or adhesive strips.
Occurs in clean, minimal tissue loss wounds such as surgical incisions.
Healing is quick with minimal scarring.

2. Healing by Secondary Intention (Granulation Healing)

Happens when there is significant tissue damage or infection, preventing the wound edges from being approximated.
The wound heals from the bottom up, filling with granulation tissue (new connective tissue and blood vessels).
Requires daily wound dressing as the open wound is at risk of infection.
Healing time is longer, and scarring is more prominent.

Phases of Wound Healing

The wound healing process consists of four overlapping phases, commonly referred to as the “cascade of healing.”

1. Hemostasis Phase (Bleeding Control Phase): The immediate response to physical injury, ensuring that bleeding is controlled.

Includes:

Vasoconstriction (narrowing of blood vessels to reduce bleeding).
Platelet response (platelets form a clot at the injury site).
Biochemical response (release of clotting factors to stabilize the wound).

2. Inflammatory Phase: Damaged cells release cytokines that attract white blood cells to fight infection.

Key events:

Histamine, serotonin, and kinins cause temporary blood vessel constriction, followed by dilation to allow immune cells to reach the wound.
Neutrophils arrive within 24 hours to remove bacteria and dead tissue.

3. Proliferative Phase: Begins once neutrophils have cleared cellular debris.

Key processes:

Fibroblasts migrate to the wound and produce collagen (Type III initially) to provide structural support.
Angiogenesis (formation of new blood vessels) starts within 48 hours.
Wound strength increases significantly during this phase.

This phase lasts up to 3 weeks.

4. Maturation (Remodeling) Phase: Begins around week 3 and continues for 9 to 12 months.

Collagen Type III is replaced with Collagen Type I, increasing tensile strength up to 80% of normal skin.
The wound contracts, and scar tissue forms.

Care of Wounds

Dressing Methods

Dressing Method – Covers the wound to promote healing.
Non-Dressing Method – Leaves the wound open to air for healing.

Advantages of Dressing

Absorbs wound drainage.
Protects from contamination (feces, urine, vomit, etc.).
Provides immobilization and prevents mechanical injuries.
Helps with hemostasis (prevents bleeding).
Provides psychological and physical comfort for the patient.

Advantages of Non-Dressing Method

Prevents bacterial growth by eliminating warmth and moisture.
Allows better observation of the wound.
Facilitates bathing without disrupting healing.
Avoids allergic reactions from adhesive tapes.
More economical and comfortable for the patient.

Disadvantages of Non-Dressing Method

Exposure of large wounds may cause anxiety for some patients.
Increased risk of contamination in an unclean environment.

Qualities of a Good Dressing

Sterile – Free from microorganisms.
Lightweight – Comfortable and non-bulky.
Porous – Allows air circulation to prevent moisture buildup.

Types of Dressings

Dry Dressing

Used for clean wounds.
Typically made of 4 to 8 layers of gauze, applied after antiseptic treatment.

Wet Dressing

Used for infected wounds with pus, softening discharge and promoting drainage.
Made of moistened antiseptic gauze with multiple layers.

Pressure Dressing

Applied with firm bandages to control bleeding and reduce oozing.
Commonly used for trauma or post-surgical wounds.

General Rules for Wound Dressing

Wound infections occur when microorganisms contaminate the wound, often originating from the ward environment. The primary sources of contamination include:

Sources of Wound Infection in the Ward

Airborne Contaminants – Dust particles or infected droplets from the nose and mouth of patients, visitors, and medical staff.
Hands of Healthcare Providers – Bacteria and pathogens from nurses, doctors, and other staff may transfer to wounds if proper hand hygiene is not followed.
Improper Dressing Techniques – Inadequate sterilization and incorrect handling of wounds can introduce infections.
Use of Unsterile Instruments – Dressing materials and instruments that are not properly sterilized can be a source of infection.

To prevent these risks and minimize wound infections, the following essential rules must be followed:

General Rules for Wound Dressing

No.	Rules	Rationale
1.	All bed making, mopping of the floor and dusting must be finished at least one hour before the dressing round is started.	To prevent spread of infections.
2.	Before the dressing round, wash the trolley with soap and water and dry it.
3.	Before each dressing, wipe the trolley shelves with a disinfectant using a mopper.
4.	Sterile articles are placed on the top shelf, un-sterile articles on the bottom shelf.
5.	Clean wounds are always dressed first
6.	Limit movements in the ward and windows near to the patient being dressed must be closed.	To prevent cross infection.
7.	Do not carry out dressing when having a focal wound or droplet infection.
8.	If possible 2 nurses should be available to carry out dressing.	To prevent contamination and save time.
9.	Apply universal infection prevention and control before and after each procedure.	To prevent spread of infections.
10.	Nails must be short, watches and rings should be removed.
11.	Masks are worn if required and once in position they must not be handled. • When removing the mask, handle only the tapes and dispose off immediately. • Never put a used mask in the uniform pocket.	To prevent spread of infections
12.	Lotions: The dressing assistant should pour only enough lotion for one dressing. Unused lotion must be disposed off when clearing the trolley.	To avoid wastage and cross infection.
13.	The trolley is reset for each dressing.
14.	All used equipment must be decontaminated, washed with soap water, brushed, dried and sterilisation.	To be ready for next dressing
15.	The trolley is cleaned with disinfectant.

Wound Dressing Procedures

Dressing a Clean Wound

A clean wound is a superficial wound caused by uncontaminated sharp objects.

It may occur electively (e.g., surgical incision) or accidentally (e.g., cuts from broken glass or sharp metal).

Purpose of Dressing a Clean Wound

To keep the wound clean and free from infection.
To prevent the wound from further injury and contamination.
To hold medications applied locally in place.
To immobilize the wound edges, promoting faster healing.
To apply pressure, minimizing bleeding and swelling.

Requirements for Clean Wounds

Top Shelf	Bottom Shelf	Bed Side
Sterile dressing pack containing: – 2 dressing towels – 2 non-toothed dissecting forceps – 2 dressing forceps – 3 gallipots – 1 for swabs – 1 for the lotion – 1 for gauze dressing – A pair of stitch scissor or a clip remover if required	– A dressing mackintosh and towel – Receiver for soiled dressing – Receiver for used instruments – A bottle of antiseptic lotions – A drum for dressing – A drum for swabs – A tray with bandages, scissors, safety pins, strapping – A container of Cheatle forceps – A pair of gloves and a pair of clean glove – A bowl	– Hand washing equipment
			Extra Requirements For Dirty Wound
– Probe – Sinus forceps	– Hydrogen peroxide – Pus swab – Laboratory form – Hypotonic saline	– Pedal bin

Bed-Side Requirements

Hand washing equipment
Screen for patient privacy
Safety box for disposal of sharps
A good source of ligh

Procedure

Steps	Action	Rationale
1.	Refer to general rules.	–
2.	Dressing assistant positions the patient.	To maintain sterility.
3.	Place a mackintosh and towel under the part to be dressed.	Provides comfort and prevents soiling of bed linen.
4.	Dressing assistant puts on clean gloves, removes the bandage, and loosens the strapping.	For easy removal of the old dressing.
5.	Dressing assistant removes gloves, washes hands, opens the dressing pack, and adds any additional sterile equipment using Cheatle forceps.	To arrange materials for easy use and maintain sterility.
6.	Adds sterile cleaning solution required.	To prevent the spread of infections.
7.	Dressing assistant puts on clean gloves, removes the dressing, and discards it in the receiver.	To prevent the spread of infections.
8.	Dressing nurse washes hands thoroughly with soap and water and dries with a sterile towel.	To reduce the spread of infections.
9.	Puts on sterile gloves.	To maintain surgical asepsis.
10.	Drapes the wound with a dressing towel.	To provide a sterile environment.
11.	Using forceps, swabs the wound, discarding each swab after use (first the center, then each side of the wound, working from the middle outwards).	To minimize the spread of infection.
12.	For a dirty wound, perform necessary toileting as prescribed, which may involve the removal of stitches or clips, probing the wound, or packing the wound.	To promote healing.
13.	Applies dressing to cover the wound and puts additional dressing if oozing or discharge is anticipated.	To protect the wound and prevent soiling of the linen.
14.	Places used instruments in a receiver.	To avoid cross infections.
15.	Removes gloves, applies strapping or a bandage on the wound as required.	–
16.	Washes hands, clears away, and leaves the patient comfortable.	To maintain hygiene and sterility.
17.	Documents the procedure and reports accordingly.	For continuity of care and follow-up.

Dressing of Septic Wound

Septic wound is characterized by the presence of pus, dead skin and offensive odour in the wound.

Purpose of Dressing a Septic Wound

To absorb discharge from the wound.
To apply pressure and prevent excessive fluid buildup.
To apply local medications for infection control.
To reduce pain, swelling, and further tissue injury.

Need irrigation: As for clean wounds and dirty wounds which may not need irrigation, however with addition of the following, on the top shelf.

Additional Items (Top Shelf)

Bowl containing irrigation lotion (e.g., hydrogen peroxide)

Saline 0.9% solution

Receiver containing large syringe and fine catheter

Receiver for used lotion

Procedure

Step	Action	Rationale
1	Explain procedure to the patient	To gain patient cooperation and reduce anxiety.
2	Clean trolley or tray and assemble sterile equipment on one side and surgically clean items on the other side. Make sure the tray or trolley is covered.	To maintain asepsis and prevent contamination of sterile supplies.
3	Drape patient and position comfortably.	To provide privacy and comfort for the patient during the procedure.
4	Place the rubber sheet and its cover under the affected part.	To protect the bed linen from becoming soiled.
5	First remove the outer layer of the dressing.	To expose the inner dressing and wound site.
6	Wear gloves if necessary. Use forceps to remove the inner layer of the dressing smoothly and discard therefore caps.	To prevent contamination of the wound and protect healthcare worker from exposure to infectious materials.
7	Observe the wound and check if there is drainage rubber or tube.	To assess the wound’s condition and identify any complications.
8	Take specimens for culture or slide if ordered (Do not cleanse wounds with antiseptic before you obtain the specimen.)	To accurately identify any infectious organisms present in the wound.
9	Start cleaning the wound from the cleanest part of the wound to the most contaminated part using antiseptic solution. (Hydrogen peroxide 3%) is commonly used for septic wounds). Discard the cotton ball used for cleaning after each stroke over the wound.	To prevent the spread of contamination from the dirtier areas to the cleaner areas.
10	Cleanse the skin around the wound to remove the plaster gum with benzene or ether.	To ensure proper adhesion of the new dressing.
11	Use cotton balls for drying the skin around the wound properly.	To create a clean, dry surface for the new dressing.
12	Dress the wound and make sure that the wound is covered completely.	To protect the wound from infection and promote healing.
13	Fix dressing in place with adhesive tape or bandages.	To secure the dressing and prevent it from dislodging.
14	Leave the patient comfortable and tidy.	To promote patient well-being and satisfaction.
15	Cleanse and return equipment to its proper places.	To maintain a clean and organized work environment.
16	Discard soiled dressings properly to prevent cross infection in the ward.	To prevent the spread of infection to other patients and healthcare workers.
NB: If sterile forceps are not available, use sterile gloves. Immerse used forceps, scissors and other instruments in strong antiseptic solution before cleansing and discard soiled dressing properly. In a big ward it is best to give priorities to clean wounds and then to septic wounds, when changing dressings, as this might lessen the risk of cross infection. Consideration should be given to provide privacy for the patient while dressing the wound. Wounds should not be too tightly packed in effort to absorb discharge as this may delay healing.

Wound Irrigation

Wound irrigation is the process of removing foreign materials, reducing bacterial contamination, and clearing cellular debris or exudate from the wound surface.

It is a critical step in wound management, helping to maintain a clean environment that promotes optimal healing.

The procedure must be vigorous enough to achieve effective cleansing but gentle enough to prevent additional tissue trauma or the unintentional spread of bacteria and foreign particles deeper into the wound.

Since wound irrigation involves bodily fluids, splashing and spraying can occur due to the use of pressure. To ensure the safety of healthcare providers, proper personal protective equipment (PPE) such as gloves, masks, eye protection, and gowns must be worn.

Essential Steps of Wound Irrigation

Assessing the Wound – Evaluate the wound’s size, depth, level of contamination, and presence of infection.
Wound Anesthesia – If necessary, provide local anesthesia to minimize patient discomfort during irrigation.
Wound Periphery Cleansing – Clean the skin around the wound using antiseptic solutions to prevent external contamination.
Irrigation with Solution Under Pressure – Flush the wound using an appropriate solution with controlled pressure to remove debris and bacteria effectively.

Indications for Wound Irrigation

Wound irrigation is recommended for both acute and chronic wounds, especially when:

The wound is contaminated with debris or foreign materials.
The wound will undergo suturing, surgical repair, or debridement.
The wound has exudate buildup, which may delay healing.

Contraindications for Wound Irrigation

Wound irrigation may not be necessary or should be carefully performed in the following situations:

Contraindication	Reason
Highly vascular areas (e.g., scalp wounds)	Excessive irrigation may not be required due to the scalp’s rich blood supply, which naturally aids in cleansing.
Wounds with fistulas or sinuses of unknown depth	Irrigation could push bacteria and debris deeper into the wound or surrounding body spaces, leading to complications.
Extensive tissue damage or fragile wounds	Excessive irrigation pressure can worsen tissue injury.

Wound Cleansing Agents

Various wound cleansing agents are available, each with different bactericidal properties:

Cleansing Agent	Bactericidal Action	Effect on Healthy Tissue
Povidone-Iodine Solution	Strong against both gram-positive and gram-negative bacteria	Mildly toxic to healthy cells and granulation tissues
Chlorhexidine	Strongly bactericidal against gram-positive bacteria, less effective against gram-negative bacteria	Generally safe but may cause irritation
Hydrogen Peroxide	Strong against gram-positive bacteria, less effective against gram-negative bacteria	Can damage healthy tissue and delay healing

Irrigation Solutions for Wound Cleansing

Different irrigation solutions can be used based on wound type and availability:

Irrigation Solution	Properties	Usage Considerations
Normal Saline (0.9%)	Non-toxic, similar in tonicity to body fluids	Most commonly used due to safety and effectiveness
Sterile Water	Non-toxic but hypotonic, may cause cell lysis	Suitable when saline is unavailable but should be used cautiously
Potable Water	Readily available, no significant difference from sterile water in infection rates	Used when sterile water or saline is unavailable

Requirements

2 Receivers
Rubber sheet and its cover
Solutions (Hydrogen Peroxide or Normal Saline)
Adhesive tape or bandage
Bandage scissors
Sterile Syringe (with desired amount of solution) and Catheter
Sterile Forceps (2)

Procedure

Step	Action	Rationale
1	Explain the procedure to the patient and organize the needed items.	To gain patient cooperation and ensure efficiency.
2	Drape and position patient.	To provide privacy and comfort.
3	Put a rubber sheet and its cover under the part to be irrigated.	To protect the bed linen from becoming soiled.
4	Remove the outer layer of the dressing.	To expose the inner dressing.
5	Remove the inner layer of the dressing using the first sterile forceps.	To maintain sterility during dressing removal.
6	Put the receiver under the patient to receive the outflow.	To collect the irrigation fluid and prevent mess.
7	Use a syringe with the desired amount of solution fitted with the catheter.	To deliver a controlled amount of irrigation fluid.
8	Use forceps to direct the catheter into the wound.	To ensure the catheter reaches the desired area of the wound.
9	First inject the solution such as hydrogen peroxide at body temperature gently and wait for the flow. This must be followed by normal saline for rinsing.	Hydrogen peroxide helps to loosen debris, while normal saline rinses away the debris and remaining peroxide.
10	Make sure the wound is cleaned and dried properly.	To prepare the wound for dressing and prevent maceration.
11	Dress the wound and check if it is covered completely.	To protect the wound from infection.
12	Secure dressing in place with adhesive tape or bandage.	To keep the dressing in place.
13	Leave the patient comfortable and tidy.	To promote patient well-being.
14	Record the state of the wound.	To monitor healing progress.
15	Clean and return equipment to its proper place.	To maintain a clean and organized environment.
NB:	Keep patient in a convenient position. According to the need so that solution will flow from wound down to the receiver.

Complications

Wound irrigation should be avoided if the wound is actively bleeding, as it can disrupt clot formation and exacerbate hemorrhage. Incomplete or inadequate wound irrigation can lead to several complications:

Persistent Debris: Failure to thoroughly remove debris, foreign bodies, or necrotic tissue increases the risk of infection and delayed healing.
Sinus Formation: In abscesses, inadequate irrigation can result in the persistence of purulent discharge, potentially leading to chronic sinus tract formation.
Infection: Retained bacteria and contaminants can promote local or systemic infection.
Cytotoxicity: While povidone-iodine is a common antiseptic, excessive use or direct instillation into deep wounds can be cytotoxic, impairing wound healing. It should be used carefully, primarily on wound edges, and avoided in large quantities within the wound.

Wound Assessment

Wound assessment is a critical process in wound management that allows healthcare professionals to determine the appropriate treatment plan and monitor healing progression.

It involves evaluating the type, severity, and condition of the wound, along with assessing for signs of infection, complications, or delayed healing.

Both initial and ongoing wound assessments should be conducted systematically in collaboration with the treating team to ensure optimal patient care.

Key Factors in Wound Assessment

The following considerations are essential for a comprehensive wound assessment:

Type of Wound – Categorized as acute or chronic based on duration and healing progression.
Aetiology (Cause of Wound) – Includes surgical wounds, lacerations, ulcers, burns, abrasions, traumatic injuries, pressure injuries, and neoplastic wounds.
Wound Location & Surrounding Skin – Important for understanding healing potential and the impact on mobility or function.
Tissue Loss – Determines whether the wound is superficial, partial-thickness, or full-thickness.
Clinical Appearance of Wound Bed – Indicates the stage of healing and tissue viability.
Measurement & Dimensions – Includes both two-dimensional and three-dimensional wound assessments.
Wound Edges – Assessed for color, contraction, elevation, and rolling, all of which impact healing.
Exudate (Wound Drainage) – Evaluated for quantity, color, consistency, and odor to detect infection or complications.
Presence of Infection – Identified by local or systemic indicators of bacterial overgrowth.
Pain – Helps assess wound progression and potential underlying complications.
Previous Wound Management – Important for evaluating treatment effectiveness and necessary modifications.

1. Type of Wound

Wounds can be classified based on terminology related to their cause and general healing characteristics.

Wound Type	Description
Surgical Wound	Incision made during a medical procedure under sterile conditions.
Burn	Caused by heat, chemicals, electricity, or radiation.
Laceration	A deep cut or tear in the skin due to trauma.
Ulcer	A wound caused by prolonged pressure, infection, or vascular insufficiency.
Abrasion	Superficial wound caused by friction removing the skin’s surface.
Traumatic Wound	Resulting from external force, such as accidents, falls, or injuries.
Pressure Injury (Bedsore)	Skin and tissue damage due to prolonged pressure, especially in bedridden patients.
Neoplastic Wound	Caused by malignant tumors breaking down skin tissue.

2. Tissue Loss

The depth of a wound determines the level of tissue loss:

Tissue Loss Classification	Description
Superficial Wound	Involves only the epidermis (outer layer of the skin).
Partial-Thickness Wound	Affects both the epidermis and dermis.
Full-Thickness Wound	Extends beyond the dermis into subcutaneous tissue, possibly reaching muscles, bones, or tendons.

3. Clinical Appearance of the Wound Bed

The wound bed provides insight into the healing process. Different tissue types indicate the stage of healing and whether intervention is required.

Wound Bed Appearance	Description
Granulating	Healthy red/pink moist tissue, indicating active healing. Contains newly formed collagen, elastin, and capillary networks. Bleeds easily.
Epithelializing	Thin, pink or whitish layer forming over the wound. Signifies new skin formation over granulation tissue.
Sloughy	Yellow or whitish tissue, made up of dead cells and fibrin. Must not be confused with pus.
Necrotic	Black, dry, or grey dead tissue. Prevents healing and may require debridement.
Hypergranulating	Excess granulation tissue, extending beyond the wound margins. Often caused by infection, irritants, or bacterial imbalance.

4. Wound Measurement

A proper wound assessment requires accurate measurement of its size and depth.

Measurement Method	Description
Two-Dimensional Assessment	Uses a paper tape measure to record the length and width (in mm). Commonly used for chronic wounds.
Three-Dimensional Assessment	Depth is measured using a dampened cotton tip applicator. Helps assess cavity wounds or tracking (tunneling wounds).

5. Wound Edges

The edges of the wound give valuable insight into healing progress.

Wound Edge Feature	Indication
Pink edges	Indicate new tissue growth and healing.
Dusky edges	Suggest hypoxia (lack of oxygen) in the wound.
Erythema (redness)	May indicate inflammation or cellulitis.
Contracting wound edges	Show wound contraction, a normal part of healing.
Raised wound edges	Suggest hypergranulation, which may need intervention.
Rolled edges	Edges rolling inward may delay healing and require corrective action.
Changes in sensation	Increased pain or numbness should be investigated.

6. Exudate (Wound Drainage)

Exudate plays a critical role in healing but requires careful monitoring.

Functions of Exudate in Healing

Provides nutrients and growth factors for cell metabolism.
Contains white blood cells to fight infection.
Cleanses the wound by flushing out bacteria and debris.
Maintains moisture balance, preventing wound desiccation.
Promotes epithelialization, aiding tissue regeneration.

Complications Related to Exudate

Excess exudate → Causes maceration (breakdown of surrounding skin).
Insufficient exudate → Leads to wound dryness, slowing healing.
Odorous, thick exudate → Indicates infection or necrosis.

7. Surrounding Skin Condition

The surrounding skin should be examined for:

Signs of maceration (excess moisture causing soft, broken skin).
Erythema (redness indicating inflammation or infection).
Dryness or cracking, which may slow healing.
Skin integrity changes, requiring protection measures.

8. Presence of Infection

A wound infection occurs when bacteria multiply beyond the body’s ability to control them.

This can lead to delayed healing, tissue destruction, or systemic illness.

Local Signs of Infection

Redness (Erythema or Cellulitis) – Surrounding skin appears inflamed.
Exudate Changes – Purulent (pus-like) or increased drainage.
Foul Odor – A strong smell may indicate bacterial growth.
Localized Pain – Increased pain in or around the wound.
Localized Heat – Warmer than surrounding tissue.
Swelling (Oedema) – Fluid accumulation around the wound.

Systemic Signs of Infection (Indicating worsening condition)

Fever or chills
Increased heart rate
Fatigue or malaise
Spreading redness beyond the wound area

SUTURES and CLIPS

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Self study questions for nurses and midwives

Self Study Question For Nurses and Midwives

PREPARATORY QUESTIONS FOR END OF SEMESTER EXAMINATIONS

SURGERY

1a) define the term epistaxis

b) What are the causes of epistaxis?

c) Write down the management of a patient presenting with epistaxis

2a) define a sty

b) What are the causes of a sty?

c) Outline the signs and symptoms of a sty

3 An adult has been admitted to a surgical ward with difficulty in breathing, he requires urgent tracheostomy.

a) List the indications of tracheostomy

b) Describe the post-operative management of this patient till discharge

c) Outline the complications that are likely to occur

d) Formulate five actual nursing diagnoses and four potential diagnoses from this patient with tracheostomy

4. Mrs Akello 38years old has presented with nasal polyps and she is to undergo polypectomy

a) List the causes of nasal polyps

b) Outline the signs and symptoms of nasal polyps

c) Give the specific pre and post-operative management of this patient

d) List four complications of nasal polyps

5. a) Define tonsillitis

b) List 6 symptoms and signs of a patient with tonsillitis

c) Give the specific post-operative management for a patient who has undergone tonsillectomy

6. Mrs Nabukeera was admitted on a surgical with a diagnosis of adenitis .She is to undergo adenoidectomy

a) Define adenitis

b) List the signs and symptoms of adenitis

c) Describe the specific post-operative management you would give to her till discharge

7. a) Define burns

b) What are the causes of burns?

c) How can burns be classified

d )Mr. KK has sustained burns on the neck and chest

>calculate the percentage of the area burnt

>what specific management do you give to Mr. KK in the first 72hrs of admission

>give five actual nursing diagnoses Mr KK will have due to the burns

8a) Define the term electrolyte imbalance

b) Give the causes of electrolyte imbalance

c) List the signs and symptoms of electrolyte imbalance

d) Mention the types of electrolyte imbalance in the body

e) How can you manage patient with electrolyte imbalance

9a) Define the term gangrene

b) What are the causes of gangrene?

c) Write down the types of gangrene

d) Mention the signs and symptoms of different types of gangrene

e) Describe the specific management which is given to this patient with gas gangrene

10a) Define the term shock

b) Write down the types/classification of shock

c) State the clinical features of shock

d) Write down all possible complications of shock

e) How can a health worker prevent surgical shock?

11a) Outline the classifications of wounds

b) Give the factors that delay wound healing

c) State five complications of wounds

d) What advice do you give to a patient about wound care at home who is due for discharge?

e) Explain the process of wound healing

12a) Define the term a fracture

b) Mention the different types of fracture

c) Describe the management of a closed fracture of a femur

d) List any 6 complications of a fracture

13a) Define the term inflammation

b) List the signs and symptoms of inflammation

c) Describe the process of inflammation

d) Explain the specific management of a 12yr old patient with inflammation on the lower limb

13A 28year old male was admitted on a surgical ward with a diagnosis of tetanus

a) List five cardinal signs and symptoms this patient would present with

b) Explain the specific nursing management you would give to this from admission to discharge

c) Formulate four actual and two potential nursing diagnoses from this patient’s condition

14a) Define the term immunity

b)Classify immunity

c) Explain the factors that affect an individual’s immune system

15a) Define hemorrhage

b) Explain the different types of hemorrhage

c) Explain the mechanism of hemostasis

d) Outline the specific management of a patient with severe bleeding on the left lower leg

16a)What is blood transfusion?

b) Describe five complications that may occur due to blood transfusion

c) What would cause failure of of a blood drip to run during blood transfusion

d) Explain the nurse’s responsibility before , during, and after blood transfusion

17a) Define a cataract

b) outline the cardinal signs of a cataract

c)Describe the management of Mr Moses a 40yr old presented to your OPD department with a cataract using a nursing process

d)list the likely complications of a cataract

MENTAL HEALTH

18. Define the following terms

a)suicide

b) Suicidal ideation

c) Attempted suicide

d) par suicide

e) paradoxical suicide

19a) outline the common psychiatric conditions associated with suicidal ideation

b) Explain the common factors contributing to suicide in the community

c) Mention the impact of suicide to the family and the community

d) Describe the management of a patient who intends to commit suicide

e) Explain the assessment you would carry out on a patient with suicidal ideation

20a) Define PTSD

b) Outline four signs and symptoms of a patient with PTSD

c) Manage an 11yr old girl who presented with PTSD after rape

21a) Define the term delirium tremens

b) Identify the causes of delirium tremens

C) How can you manage the patient with delirium tremens?

d) Formulate 5 potential nursing diagnoses for a patient with delirium tremens

22. Madam EKEB a 26yr old is very aggressive on the ward that she cares away fellow patients

a) Differentiate between aggression and violence

b) What management do you give to madam EKEB who presents with severe aggression on the ward?

23a) what is a psychiatric emergency?

b) List 10 common psychiatric emergencies

c) Which admission procedure would you follow when admitting a patient presenting with any of the psychiatric emergencies

23a) Explain standards of care in psychiatry

b) Who is a class B criminal lunatic?

c) Mention all the orders used to admit mentally ill patient

d) Write down and explain all the sections used in discharging a mentally ill patient

e) Outline the rights of a mentally ill patient

24. A 30yr old patient has presented in a psychiatric ward with status epilepticus

a) Define status epilepticus

b) Manage the patient who presents with status epilepticus on a ward

c) Formulate four potential and 2actual nursing diagnoses for a patient with status epilepticus

25aDefine mental retardation

b) Classify mental retardation

c) Explain 8 causes of mental retardation

d) What advice do you give to a family with a mentally retarded child?

26. ADHD is one of the common psychiatric conditions in children

a) Outline 6 signs and symptoms of ADHD

b) Manage an 11yr old boy with ADHD

c) What specific advice do you give to a family with a child having ADHD?

27a) Define autism

b) Explain the common features of autism

c) Describe the management of the above condition

28. Depression is one of the common psychiatric conditions

a) Define depression

b) Outline the specific management of a patient with severe depression on a psychiatric ward

c) Make 4 priority nursing diagnoses for a patient with severe depression

COMMUNITY HEALTH

29. a) Define PHC

b) Mention the principles of PHC

c) Outline components /elements of PHC

d) What strategies are used to achieve PHC activities in a given community?

30a) What is community assessment?

b) Explain how you would identify any health problems in a given community

c) Outline 9 important information you would find out in a given home during assessment

31a) Define a home visit

b) Explain how you apply a nursing process during a home visit

c) Outline the merits and demerits of a home visit

32a) Define vital statistics in health

b) Explain the importance of vital statistics in health

c) Outline 6 key vital statistics used to determine the health status of a community or country

33a) Explain the relationship between PHC and CBHC

b) Explain the role of a community nurse/midwife in implementation and achievement of any 4 of the PHC principles

c) Outline the advantages of PHC over other specialized medical services

34a) Define community mobilization

b) Describe how you would mobilize a community towards implementation of a health education program

35a) Define school health

b) Explain the importance of a school health program

c) Explain the role of a nurse in the provision of a school health program

d) Outline the components of school health services

36a) Explain the role of a community in PHC services

b) Give 8 advantages of community participation in PHC services

c) Explain the obstacles to effective community participation in PHC programs

37a) Define community diagnosis

b) Discuss why community diagnosis is important

c) Explain the steps in conducting community diagnosis

38Health promotion are actions related to lifestyles and choices that maintain/enhance population health

a) Outline any 5 health promotion interventions you would implement in a given a community

b) Explain 5major steps in community mobilization

39. Describe the different levels of disease prevention

40. Appropriate technology is one of the elements of PHC

a) How is appropriate technology expressed in implementation of PHC services?

b) Explain the advantages and disadvantages of appropriate technology as an element

41. a) Define the term epidemics

b) Explain the factors that contribute to the causes of epidemics

c) What is the role of a nurse in the management of an epidemic in the community?

42a) Define community health and community based health care

b) State the characteristics of CBHC

c) Describe how you would enter a village in Mityana to implement a community health activity

TROPICAL MEDICINE

43a) Define schistomiasis

b) Explain the different types of schistosomiasis

c )Give the clinical manifestations of schistosoma mansoni

d) Describe the lifecycle of schistosomiasis haematobium using a well labelled diagram

e) Outline the preventive measures of all types of schistosomiasis

44The current disease burden in Uganda is attributed to communicable diseases

a) Describe the modes of transmission of communicable diseases in general

b) Describe the methods/approaches used to prevent and control communicable diseases in the community

c) Explain the types of water diseases and their examples

45a) Define diarrhoea

b) Outline the causes of diarrhoea in Uganda

c) Discuss the drugs used in the management of diarrhoea in children

d) Formulate 5 priority nursing diagnoses of this patient

46a) Define measles

b) Outline the signs and symptoms of measles basing on the stages

c) Describe the management of a12yr old child presenting with measles from admission to discharge

d) List the likely complications of measles

47. Malaria is one of the communicable diseases affecting most communities of Uganda

a) Classify malaria

b) Outline the cardinal signs of complicated malaria

c) Describe the lifecycle of malaria in both man and the mosquito with the aid of diagrams

d) How can different communities prevent the spread of malaria?

e) Make 5 actual and 3 potential diagnoses of malaria

48a) Describe the life cycle of ackylostomiasis with the aid of diagrams

b) Explain the preventive measures of hook worm infestation

c) List the likely complications of neglected worms

49a) Ebola is one of the hemorrhagic fevers devastating some communities and countries due to known and unknown reasons

a) Define hemorrhagic fevers

b) List the different hemorrhagic fevers

c) Outline the different causes and predisposing factors to hemorrhagic fevers

d) Describe the management of Mr. X presented to your hospital suspected to be an Ebola patient

50a) Define rabies

b) Describe the management of rabbis both at home and in the hospital

c) Explain the complications of rabies

51a) Define bacilliary dysentery

b) State the differences between bacilliary dysentery and amoebic dysentery

c) Describe the specific management of a 3yr old child with bacilliary dysentery from admission to discharge

52a) Define typhoid fever

b) Explain the cardinal signs and symptoms of typhoid fever

c) Describe the important information you would give to the community concerning prevention of typhoid fever

53a) Define trachoma

b) Outline the signs and symptoms of trachoma

c) Explain the management of 23yr female presenting with trachoma

d) List the complication

54. Samuel a 30yr old peasant has been presented to the OPD with all the features of tetanus

a) Outline the clinical features of tetanus

b) Describe the management from admission to discharge

c) List the complications of tetanus

MIDWIFERY 1 AND 2 AND OBSTETRIC ANATOMY

55. List the 5 medications used in antenatal and discuss them under

a) Dose

b) Indication

c) Side effects

56a) Outline the obstetrical causes of anemia in pregnancy

b) List the five causes of hemolytic anemia

c) Describe the management of Mrs. mucosal who presents at 36weeks with severe anemia

57a) Define a cervix

b) With the aid of a diagram, describe the structure of the cervix

c) Outline the 6 functions of the cervix

58a) Define the term good antenatal care

b) Give the indications of referring a mother to a doctor during this period

c) How would you manage a mother who comes with lower back pain in antenatal at 32weeks?

59a) Define normal puerperium

b) Describe the management of a mother who has had normal delivery up to discharge

c) List the complication that may occur during this period

60a) Outline the symptoms of pregnancy

61a) Explain the characteristics of normal uterine action during first stage of Labour

b) What is the management of a gravid 3 para 2 mother at term who presents to hospital with history of precipitate Labour on the previous pregnancies?

62a) Describe a vagina

b) What information is got on vaginal examination during labor?

c) Mention four contractions of vaginal examination giving reasons for each

d) List the complications of vaginal examination

63a) Define intrauterine fetal death

b) Outline the causes of IUFD

c) How is the diagnosis of IUFD made?

d) What is the management of IUFD in the hospital?

64a) Describe the pelvic floor

b) Outline injuries that can occur to the pelvic floor during Labour

c) Explain how the knowledge of fetal skull can help you as a midwife prevent perineal tears

65a) Describe the fetal skull

b) How is fetal wellbeing monitored during pregnancy?

C) List the indications of ultrasound scan in late pregnancy

66a) Describe a non-pregnant uterus

b) Describe the changes that take place in this organ during pueperium

c) List the likely complication in the first stage of labor

67a) what is the effect of DM on pregnancy?

68a) how does pregnancy affect DM?

b) How would you care for a diabetic mother who has had a caesarean section in the first 48hours of the operation

69a) Describe the umbilical cord

b) Describe the different abnormalities of the cord

70. Malaria is of the conditions contributing affecting pregnancy and contributing factor to increased maternal mortality and morbidity

a) Explain why pregnant women are more susceptible to malaria

b)Describe the a primigravida who presents to your maternity center at 34 weeks with severe malaria

c) Outline the likely complications of malaria on pregnancy

71. Essential hypertension is one of the hypertensive disorders experienced by pregnant women

a) Define essential hypertension

b) Classify hypertensive disorders in pregnancy

c) Describe the management of Mrs Nangobi a G4P2+1 presenting in antenatal clinic at 32weeks with a diagnosis of essential hypertension

d) How does hypertension affect pregnancy?

72a) outline the signs and symptoms of first stage of Labour

b) Describe the management of a young primigravida in first stage of Labour

c) List the complications likely to occur during this stage of Labour

73a) Define hyperemesis gravidarum

b) Outline the causes of hyperemesis gravidarum

c) Describe the management of G2P1+0 presenting to your maternity center with hyperemesis gravidarum at 28 weeks of gestation

d) Explain the likely complications of this condition

74a) what is preeclampsia

b) Outline the signs and symptoms of preeclampsia

c) What are the predisposing factors of this condition?

d) Outline the nursing of a mother with severe preeclampsia

e) List the complication of severe preeclampsia

75a) Describe the placenta at term

b)Explain the functions of the placenta

c) Outline the abnormalities that may be found on the placenta

76a) With the aid of a diagram, describe the structure of the female breast

b) Explain the physiology of lactation

c) Explain the factors that promote successful lactation

77a) Define labor

b) Explain the physiology of the first stage of Labour

c) Describe the management of a mother in the second stage of Labour admitted in the hospital

78a) Outline the changes in the cervix during the first stage of labor

b) What information is found on the partograph?

c) A G2P1+0 mother came to a health center in normal labor , what may make you refer?

79. Most women find it helpful to get further information and support in their own homes.

a) Give 5 advantages of following up post-partum mothers

b) Explain postpartum maternal assessment you would carry out during domiciliary care

c) List the problems that you would identify during domiciliary care

80a) Describe 6 factors that influence the length of second stage of labor

b) Explain 3 phases used in conducting 2^nd stage of labor

c) Give immediate assessment of the baby after 2^nd stage of labor

81a) Mention factors that aid in involution of the uterus

b) Explain how you assess and document uterine involution immediately after delivery to 10days postpartum

c) Give five complications of sub involution of the uterus

82a) Explain the antenatal appointment schedules

b) Give 6 barriers to adherence to goal oriented antenatal visits

c) Identify 5 complications a pregnant woman is likely to get if no antenatal is attended

83a) Describe the structure of the ovary

b) List the functions of the ovary

c) Describe the menstrual cycle

MEDICINE I AND 111

84. Mr. KIBULA known hypertensive has been brought to hospital with suggestive features of hypertensive crisis.

a) Mention 8 clinical features of hypertension

b) List 4 causes of HTN and predisposing factors

c) Explain the specific Nursing Care you will give to Mr. KIBULA from the time of admission to discharge.

85. Write short notes on the following (definition, causes, signs and symptoms and complications).

a) Hydrocele

b) Hodgkin’s disease

c) Ankylosing spondylitis

86 a) Define Paget’s disease/Osteitus, deformans?

b) Explain the pathophysiology and etiology of Paget’s disease

c) Describe the specific nursing care you would give to Mr. Muwonge with Paget’s disease

87. Hepatitis B morbidity and mortality is much higher today than before.

a) What are the factors, contributing to the high prevalence of hepatitis B in the communities

b) How does a patient with hep.B present?

c) Give five priority nursing diagnoses for a patient with Hep B infection.

d) Describe the specific nursing management you would give to a patient with hep B.

e) Mention the complications of hep B.

f) Suggest ways how we can prevent hep B infection in the community

88. Define myocardial infarction. List the clinical features of myocardial infarction.

Explain the specific Nursing care given to a patient with myocardial infarction within the first 24Hrs of admission.

89. An adult male patient has presented to OPD with features of pulmonary tuberculosis

a) Outline five cardinal signs and symptoms of pulmonary tuberculosis.

b) List five specific investigations that can be done to confirm pulmonary tuberculosis.

c) Explain the specific nursing care given to this patient from the time of admission until discharge.

90. Mrs. A, a female patient has been admitted on a medical ward with suspected bronchial pneumonia,

a) Outline the clinical features of bronchial pneumonia

b) Describe the specific nursing management you would give to Mrs. X with in the first 72HRS of admission.

c) Explain five likely complications Mrs. X is likely to get following this condition.

91. Mr. Lusoke, a 62 yrs. old male is presented at the OPD with features of congestive cardiac failure

a) Outline the signs and symptoms of congestive cardiac failure.

b) Mention the causes of congestive cardiac failure.

c) Describe the specific nursing care / management you will give to Mr. Lusoke from time of admission to discharge.

92. Outline the signs and symptoms of Parkinson’s disease.

b) Mention the causes and predisposing factors to Parkinson’s disease.

c) Describe the specific Nursing management given to a patient with Parkinson’s disease.

93. Mr. Okello a 28yrs old male presents at OPD with clinical features of urinary tract infection and was admitted.

a) List 5 causes and 6 signs and symptoms of urinary tract infection.

b) Describe the specific nursing care you would give to Mr.Okello within the first 48 hours of admission.

c) Give the measures that can be taken to prevent urinary tract infections.

94 Define Addison’s disease?

b) Outline the causes and risk factions that leads to Addison’s disease.

c) Using the Nursing process, describe the management of a patient with Addison’s disease.

PEDIATRICS 1 AND 11

95. Define the term Apgar score

a) Outline 10 characteristics of a normal new born baby

b) Describe the care given to the normal new born baby within 72 hours after delivery of the head.

96. Differentiate between SAM and MAM

b) Explain the causes of malnutrition in children under 5 years.

c) Explain the importance of breastfeeding in babies’ up to 2years of age.

97. Define the term congenital abnormalities

a) Classify the congenital abnormalities of the heart

b) Explain ways of preventing congenital abnormalities.

98. Mention the factors that predispose to neonatal infections in new born babies.

b) List 8 clinical features of a child with neonatal tetanus.

c) Describe the specific management of a 3 month old child with tetanus.

99. Outline the factors that predispose to birth injuries

Differentiate between a caput succedaneum and a cephalo hematoma.

c) Describe the specific management you would give to a new born baby who presents with a caput succedaneum.

100. Brandon a five weeks old neonate is admitted on ward with a history of fast breathing, chest in drawing and stridor.

b) Explain the specific nursing care you would offer to Brandon in a hospital within the first eight hours of admission.

101. A five year old child has been bought to OPD in a painful sickle cell crisis.

a) Outline 5 possible causes of sick cell crisis.

b. List 4 diagnostic signs and symptoms of sick cell disease in children.

c) Explain the specific management of this child from admission to discharge.

102. A 4 months old baby has been admitted on a pediatric ward and diagnosed with pneumonia.

a) Outline the clinical presentation of this child.

b) Explain the specific management given to the child with in the first 72 hours.

103. Define the following terms.

1) Fracture

ii)Osteopenia of prematurity

osteogenesis imperfecta

Osteomyelitis

b) Mention 5 signs and symptom of osteomyelitis in children.

c) Describe the nursing management of 3 years old child with osteomyelitis.

104. A 8 month old child has been diagnosed with nephrotic syndrome.

a) List 6 signs and symptoms of nephrotic syndrome in children.

b) Describe the specific nursing management you world give to this child within the first 72 hours of admission on a pediatric ward.

c) Outline five complications of nephrotic syndrome.

105. What are the advantages of breast feeding?

Compare human milk and cow’s milk

Outline problems that are faced by mothers during breastfeeding.

106. List five congenital abnormalities of the G’T and 5 musculoskeletal system

Outline the causes of congenital abnormalities.

How do you cause a mother who has delivered a baby with spinal bifida?

107. List the factors that promote good nutrition in the under-five.

List five pieces of advice you would give to a prime para with a two year old baby suffering from protein calorie malnutrition.

List five problems of birth injuries in Uganda.

Outline the roles of a nurse in prevention of birth injuries in Uganda.

PHARMACOLOGY 1 AND 111

108. Define rational drug use

Outline the medical classification of drugs giving examples of each

Mention the legal classes of drugs with examples of each.

109. Define infertility.

State the common cause of infertility in women

c) State the indications, side effects and contraindications of clomiphene and Bromocriptine.

110. Describe the mechanism of action of non-opioid analgesics.

b) Write briefly about the handling of the class of drugs in a hospital

c) Define the following:-

Chemotherapy

Anti tussive

111. Mention 4 Four sources of drugs

b) Write down all routes which can be used for drug administration giving advantages and disadvantages of each.

c) Write down the factors that affects drugs absorption.

d) What factors affect drug dosage and action?

112. State the clinical uses of oxytocin and mention 6 adverse side effects of the drug.

b) Outline 5(five) contraindications of oxytocin

c) Describe 10 (ten) Nursing considerations while administering oxytocin.

113. Define Narcotic drugs and state the types of narcotics.

b) List down 7 nursing considerations before during and after administrating narcotics on ward.

c) What are the legal implications of Narcotics according to the Uganda narcotic drugs and psychotropic substance control ACT?

114. Define immunity and explain the two major types of immunity.

State the specific side effects, indication and the dosage following drugs:-

Anti D (RHO) Immunoglobulin
B) Rabies vaccine
Pneumococcal Vaccine.

115. Describe the physiology of erection in males

b) State the causes of erectile dysfunction

b) Mention the class, indication, Dosage and side effects of the following drugs.

i) Sildenafil.

ii) Tadalafil

iii) Finesteride.

GYNAECOLOGY

a) Outline signs of breast cancer.

b) Explain post operative care after mastectomy.

c) List possible complications of mastectomy.

. a) Draw a diagram showing possible sites of vaginal fistula.

b) Outline the 5 major causes of vaginal fistula.

c) Explain specific nursing care of a woman after VVF repair.

118. a) Define the different types of Abortion.

b) Outline causes of missed Abortion.

c) Explain different methods used in the management of missed abortion.

d) Outline the 5 elements of PAC.

a) Define ectopic pregnancy.

b) Outline signs and symptoms of tubal pregnancy.

c) A mother presents to the medical facility with a tubal pregnancy, describe her management till discharge.

119. a) List the disorders of menstruation.

b) Explain the advice and treatment given to a 17 year old girl with dysmenorrhea.

120 a) Define Hydatidiform mole.

b) Outline signs and symptoms of hydatidiform mole.

c) Describe the methods of managing the above condition and list complications that may follow.

121. Describe pelvic inflammatory disease.

b) What are the predisposing factors of this condition?

c) Describe management of PID in the hospital.

a) What is infertility?

b) Outline causes of infertility.

c) Explain the different methods that can be used to manage infertility.

a) Draw a diagram of a uterus indicating sites of fibroids.

b) Differentiate between benign and malignant tumor.

c) Give the management of the mother after myomectomy within the first 48 hours.

d) What specific advice would you give this mother on discharge.

REPRODUCTIVE HEALTH

a) Define STDs?

b) Explain ten preventive measures against sexually transmitted infections.

c) Describe the syndromic management of STDs.

a) List 7 components of reproductive health.

b) Outline the advantages and disadvantages of intergrating reproductive health.

c) Outline 10 factors that affect women’s reproductive health.

a) Define sexual abuse?

b) Explain factors that expose adolescent girls to sexual abuse or vulnerability.

c) Outline 5 clinical features of sexual abuse in an adolescent.

a) Define i) Post Abortion Care

ii) Comprehensive abortion care.

b) Explain the Rational for PAC.

a) Who is an adolescent?

b) Describe Tanner’s stage of development in an adolescent.

c) List common health problems faced by adolescents.

a) What is safe motherhood?

b) Outline the 3 delays that can increase maternal mortality.

c) What is your role as a midwife in reduction of maternal mortality in your community?

Describe syndromic approach of managing STIs.
a) Define domestic violence.

b) What are the factors that make you suspect that one is a victim of domestic violence?

c) How would you prevent domestic violence?

Describe manual vacuum aspiration.

FOUNDATIONS OF NURSING.

a) Define wounds.

b) Give 5 types of wounds.

c) Outline the factors that delay wound healing.

d) Give the specific management for a patient with specific wound.

e) What specific advice do you give to a patient with a wound prior to discharge.

f) Describe the process of wound healing.

a) Outline the indications for oxygen administration.

b) Give the rules to follow before, during and after administration of oxygen.

c) Define blood transfusion.

d) Outline the indications of blood transfusion.

e) Outline the appropriate care of the patient before, during and after blood transfusion.

f) Give the complications of blood transfusion.

a) Define drug administration.

b) Outline the different routes of drug administration.

c) Mention the principles of drug administration including the dos and don’ts in drug administration.

a) Define infection prevention and control.

b) Define nosocomial infection.

c) Outline the steps taken to prevent infections of the wound.

d) What are the advantages of oral route drug administration over the parental route.

a) Outline the indications of Tracheostomy.

b) Give the specific pre and post operative nursing care for the patient with tracheostomy.

c) Mention the complications of tracheostomy.

d) Formulate 4 actual nursing diagnoses for a patient with colostomy.

a) Define lumber puncture.

b) Outline the indications of lumber puncture.

c) Explain the specific nursing care given to the patient prior to after the procedure of lumber puncture.

d) List the complications of lumber puncture.

a) Define abdominal paracentesis.

b) Outline the indications of paracentesis.

c) Give the specific care given to the patient before and after abdominal paracentesis.

d) Mention the complications of abdominal paracentesis.

a) Define tractions.

b) Explain the different types of tractions.

c) Outline the specific nursing care given to a patient with tractions.

d) Formulate 5 actual nursing diagnoses for a patient with tractions.

e) Outline the likely complications of the patient on traction.

a) Outline the indications of underwater seal drainage.

b) Give the specific nursing care for a patient on underwater seal drainage.

c) Formulate four nursing diagnoses for a patient on underwater seal drainage.

d) List the complications of underwater seal drainage.

a) Outline 6 indications of gastric lavage.

b) Define colostomy.

c) Formulate 4 actual nursing diagnoses and 4 potential nursing diagnoses for a patient with colostomy.

d) Give the specific nursing care to the patient with colostomy.

a) List the indications of Glasgow coma scale.

b) Describe the Glasgow coma scale.

ANATOMY AND PHYSIOLOGY II

a) With illustration, describe the formation of flow of CSF.

b) List the functions of CSF.

c) Describe the meninges covering the brain and spinal cord.

a) Describe the position and gross structure of the parathyroid glands. Outline the functions of parathyroid hormone and calcitonin.

b) Explain the disorders of the thyroid gland.

a) Describe the structure of a nephron.

b) Explain the processes involved in the formation of urine.

c) Describe how body water and electrolyte balance is maintained.

a) Describe the structure of the ear.

b) Explain the physiology of hearing.

c) Explain the functions of the accessory organs of the eye.

a) Explain the role of lymphatic vessels in the spread of infections and malignant disease.
a) Describe the location of the pharynx and relate it’s structure to it’s function.

b) List the functions of the trachea in respiration.

c) Explain the main mechanisms by which respiration is controlled.

d) Describe the common inflammatory and infectious disorders of the upper respiratory tract.

a) Define a neuron.

b) Outline the 12 cranial nerves of the nervous system.

c) Describe the transmission of an impulse across a synapse.

PALLIATIVE CARE NURSING

150 a) Define palliative care

b) Explain the principles of palliative care

c) Give the challenges faced in implementing in palliative care services in Uganda

151.a) Define pain according to WHO

b) Explain different types of pain in palliative care

c) Describe the principles of pain management in palliative care

d) Describe the steps of breaking bad news

152.a) Explain 6 roles of palliative care in Uganda

b) Outline 6 symptoms commonly experienced by terminary ill patients

153.a) What is grief?

b) Explain 5 stages of grief experienced by palliative care patients

c) Explain the HOPE approach to spiritual pain management

d) Outline the spiritual problems experienced by palliative care patients

Self Study Question For Nurses and Midwives Read More »

Introduction to Community Based Health Care (CBHC)

CBHC is the program on health care in which community members are actively involved in the identification, prioritization of their own health needs and in mobilization of their own resources to meet those needs.

Introduction

Community Based Health Care (CBHC) is part of Primary Health Care (PHC) while more concerned with people.
CBHC is viewed in the context that when giving care to patients, you must put in mind that client needs continuous care even when you have left. It shows that community participation is very important and doesn’t
work in isolation when giving care, involve them in plan so that they take responsibility. Since most of resources come from the community like food and other materials. It will be simple if you can teach them how to make
use of them in the care.

The need for PHC and CBHC arises from the following.

Most illnesses can be prevented: the most common illnesses are preventable or controllable, either by the people themselves or a combined effort between the people and government or other partner
(NGO) services e.g. malaria.
Morbidity and Mortality rates can be reduced: a reduction in this suffering can only happen if there is more “encouragement” and “enablement” of individuals and communities together to have a positive attitude towards preventive habits and to be willing to take part in improving their local amenities, rather than expecting the people to go to the health services and development projects.
The encouraging and enabling cannot go on within the walls of the hospitals and health centers; it must go on in the villages and homes.
Coverage of health services: even if there was full service in the health units, there are still few e.g. dental and mental services and they are mainly located in towns and rural population have little access to essential health care.

Objectives of CBHC

The main objective of CBHC is to encourage and enable the community to take care for its own health and welfare, if the community can,

Identify its own health problems
Find solutions for those problems
Make its own decisions
Find (identify) resources outside the community
Evaluate its actions and replan
Together and individually make healthy behaviors into common practices and habits.

CBHC activities

Provision of information, education and training concerning prevailing health problems in communities and the methods of preventing and controlling them
Promotion of proper nutrition,
Maternal and child care;
Immunization against the major infectious diseases;
Prevention and control of locally endemic diseases such as diarrheal diseases, acute respiratory infection and malaria;
Reproductive health services, including family planning and the prevention and control of sexually transmitted infections with particular emphasis on HIV/AIDS;
Appropriate treatment for common diseases and injuries; ;
Community Mental health;
Rehabilitation for people with disabilities and
School health activities

Advantages of CBHC

Community becomes responsible to care for their own health problems.
Empowers community to take systematic care of their health using available means at affordable costs.
Helps the community members in planning, making decision, implementation and evaluation of health care approach in the community
Gives the communities sense of ownership and belonging in the health care system.
It cuts down costs of health care delivery
It reduces on dependency the government and donors,
Helps health workers to have knowledge base in family theory, principle of communication, group dynamic and cultural diversity in care of the patients at community level.
CBHC forces distance by giving services nearest to the community members, hence become easily accessible.
Creates awareness with – in the community on various health issues.
Individual families and communities are actively involved in health activities
Promotes holistic care that is physical, psychologically, spiritually and culturally.
Bridges the gap between community and extension worker e.g. from other ministries e.g. Agriculture.
It promotes unity
Helps to get appropriate action
Improves the quality of life
Community development
Early identification of the individual
Mutual interaction
Uplifts the standards of living

Disadvantages of CBHC

Diagnosis is made on assumption in most cases no investigations
Increases stigma.

Source of the CBHC services

TASO (The AIDS Support Organization)
UWESO (Uganda Women’s Effort To Save Orphans)
CGC (Concern for the Girl Child)
Hospice that provides palliative care services

Village Health Team (Community Based Workers)

Village Health team / committee; is a non- political health implementing structure responsible for health of the city community members at house hold (HH) level.

The structure is put in place to facilitate the process of community mobilization, empowerment and participation in delivery, management and implementation of health services at house hold level.
The overall goal of the village health team/ committee is to achieve an improved quality of life by strengthening service delivery at house hold level.

Roles or responsibilities of village health team

Facilitate the community to identify an recognize their health problems
Mobilize community for health programs e.g. immunization, malaria control etc
To collect information and maintenance of record book of house hold members and use it for planning and other programs.
Serves as a link between the community and health providers.
Follow up patients or clients
Conduct home visit
Identify individuals who need care at and outside their homes and refer appropriately.
Provide basic health message for behavioral change.
Distribution of drugs, supplies, information , communication, materials , insect treated nets.
Serves as role model in the community, collaborate with other community structures or other ministries.

Basic health services done by the VHT

Advice and information will be given on:
Diseases
> Giving treatment and managing simple illness at home
> Sexually transmitted diseases (HIV/AIDS, )
> Tuberculosis (TB)
Family
> Family Planning (child spacing)
> Pregnancy, delivery and care of new born baby
> Adolescent sexual and reproductive health
> Breast feeding
> Food and nutrition
> Abuse and violence
> Immunization
> Mental health
The home
> Water and sanitation
> Hygiene
> First Aid

How will the basic health services be done?
> Community mapping
> Community registers
> Home visits
> Talking with neighbors about health issues which have been found.

What should community members do?
> Select and support VHT
> Attend village health events
> Use health services

> Improve personal and family health

What should local leaders do?
> Inform communities about VHT
> Advocacy for health at home
> Mobilize communities for health
> Supervision of VHT activities
> Give financial support
> Planning for VHT in district and village health plans
> Attend and support health events

Selecting and training of village health team

Selection of a village Health Team (VHT/C) will be done on popular vote after sensitization and conservation, building of all stake holders.
A = 20 – 30 house holds
The following will be to guide the voting (selecting) process
> Mature 18 years and above
> A resident of the village
> Able to read and write / a least the local language
> A good communication skills).
> A dependable & trust worthy person
> Interested in health and development issues.
> Should be a resource person in the community.

Composition of village health team / committee
> Community own resource persons. (CORPS)
> Local leaders
> Any similar resource persons in the community.

Community own resource person [corps]

A community own resource person (CORP) – is a member of a community residing within the same community selected by the community and trained to help community to improve their own health and facilitate development.

His / her specific tasks are not to be confined to health care delivery alone but also other aspects of development
e.g. food production, and income generating activities.
CORPS includes the following
> Community Health Workers
> Traditional Birth Attendants (TBA).
> Traditional healers
> Community Drug Distributors (CDD).
> Community HIV/AIDS counselor.
> Community reproductive health workers.
> Community DOTS. (DOTS – Directly Observed Therapy Short course.)

> Peer educators, etc.

Responsibilities of A CORP

A CORP has to carry out the following duties/ responsibilities:-
> Home Visiting and advising and personal hygiene and environmental sanitation.
> Advising and educating communities on matters related to:-
– Food production and Nutrition
– Prevention of diseases
– Use of safe water.
– Identify health problems (concerns) and prioritize together with community members.
> Keeping records and using them for organizing, prioritizing, implementing, monitoring, and evaluation of health services.
> Identifying individual and families at risk and refer them for further management.

TECHNIQUES USED TO ESTABLISH COMMUNITY HEALTH ACTIVITIES

Below are the steps taken to establish community health activity.

Community approach
Community entry
Community Assessment
Community situation analysis (Diagnosis)
Community mobilization
Community participation
Community organization
Community empowerment
Community based rehabilitative services for disabled and disadvantaged groups

Introduction to Community Based Health Care (CBHC) Read More »

Medico-Legal Issues

Topic: Medico-legal issues

Learning Outcomes for this Topic/Unit:

By the end of this topic, you should be able to:

Understand the relationship between nursing and the law.
Identify common medico-legal issues in nursing practice.
Understand the different categories of law relevant to nursing.
Explain the importance of the code of conduct and ethics for health workers.
Apply legal and ethical principles in your daily nursing practice.
Understand the rights of patients in healthcare.
Understand some key rights of nurses.

Nursing and the law

The law is a system of rules that society creates and maintains. It helps to protect property and keep people safe from harm. For nurses, understanding the law is very important because it affects how they provide care and their responsibilities.

Importance of Law to Nurses:

Protect the public from persons unqualified to practice nursing. This ensures that only trained and competent individuals provide care.
To define the scope of the nurse’s practice (i.e. what s/he is expected by law to do and not to do). This helps nurses know their boundaries and responsibilities.
To protect patients from legal risks. By following the law, nurses help prevent harm to patients.
To deal with legal threats effectively. Knowing the law helps nurses protect themselves and their practice.
To issue licenses for practice and revoke or suspend a license in case of gross incompetence or negligence. This helps maintain high standards in the nursing profession.

Categories of Law:

Laws that affect nurses fall into different categories:

Criminal law: It encompasses conduct considered offensive to the public or society as a whole. Prosecution is brought by the state against an individual for breaking the law known as a crime. Example; a nurse is arrested for stealing drugs, s/he will be charged and brought before the court to handle the case which is prosecuted by the government of Uganda (Uganda vs. the nurse/criminal).
Civil law: It deals with the rights and responsibilities of private individuals. The civil law is designed to compensate individuals for the harm caused by the health workers. Example; if the nurse negligently administers treatment to a patient which results in to harm, the patient can sue that nurse for his/her negligence and seek compensation for the harm caused. Or the employer of that nurse meets the consequences of the negligence.
Tort Liability/Crimes: These are crimes that are punishable by law. There are two types of tort i.e. intentional and non-intentional. Intentional tort is punishable by law (criminal or civil law.)
- Intentional Torts: These are harmful acts done intentionally.
  - Assault: Threatening or attempting to touch or treat a person with out his/her consent. Example; Administering an injection to a patient who had refused it. Patients have a right to refuse care or withdraw consent at any time.
  - Sexual assault: where find the health worker harasses the patient/client sexually.
  - False detention: restraining another person with out legal justification or his/her consent. An example; Medical asylums or isolation centers for the presumed mentally ill.
  - Fraud: purposeful misrepresentation that causes harm to another person. Example; Misrepresenting qualifications when applying for licensure.
  - Negligence: deviation from standard of care that results in HARM to the patient. Example; Administering treatment negligently and contrary to the professional standards e.g. wrong medication, wrong route of administration, wrong dosage and concentration. Mistaken identity i.e. preparing a wrong patient for an operation, to exchange babies in the labour room/suit, to exchange dead bodies in the mortuary. Failure to communicate verbally or in written concerning the patient’s condition. Poor or no maintenance of patient’ records. Failure to count sponges and instruments during surgery leading to retaining of some in the patient’s body. Loss or damage to patient’s property and fame. Breach of duty (negligent action/omission that violates the standard of care expected.) Physical or psychological damage of the patient. Failure to report and protect victims e.g. child abuse, sexual assault, patients restrained by law, mentally incompetent and infectious disease exposure.
- Abandonment: termination of a patient’s care with out assuring the continuation of care at the same level or higher.
- Euthanasia (mercy killing): taking positive step to kill a person in order to end his/her suffering is murder.
- Breach of scope of practice: failure to follow the range of activities and limitations of a given medical provider as defined by the state legislation, references national curricula or may be enhanced by medical direction, protocols and standing orders.
- Breach of confidentiality: failure to keep privileged information i.e. patient’s history, assessment findings, treatment rendered etc.

Rights of a Patient

Optimal care of a patient requires harmonious collaboration between the patient and the care provider. Understanding patient rights is important.

Purpose of Patient Rights:

Help the patients feel more confident in the health care setting.
To stress the importance of a strong relationship between the patients and their health care givers.
To indicate the key roles patients play in staying healthy.

The following are the rights of a patient:

A patient has a right to accurate and clear information relevant to his/ her health care plan except in emergencies.
The patient has a right to know the identity of medical personnel involved in their care.
Patients have a right to fully participate in decision making related to their health care.
A patient has a right to refuse any recommended treatment or care plan.
They have a right to be informed of the consequences of any action.
Patients who are unable to participate have a right to be represented by parents, guardians or other family members.
Patients have a right to respect and non-discrimination from all members of the health care team at all times and under all circumstances.
The patients have a right to every consideration of privacy concerned with case discussion and consultation. Examination and treatment should be conducted in a manner that protects the patient’s privacy.
All communications and records pertaining the patient’s care must be treated as confidential by the hospital or health care team.
Patients have a right to review the records pertaining to their medical care and to have the information explained or interpreted as necessary except when information is restricted by law.
The patients have a right to choose health care providers who will ensure access to appropriate high quality of care.
The patients have a right to complain about the care or appeal for proper care internally or externally (an independent system).
A patient has a right to know the policies of a hospital regarding their care.

Rights of a Nurse

While the focus is often on patient rights, nurses also have important rights that protect them and enable them to provide good care. Based on the curriculum's content on ethical standards and the Nurses and Midwives Act, some key rights of a nurse include:

The right to a safe working environment: This includes protection from violence, hazards, and infections.
The right to fair treatment and compensation: Nurses are entitled to just payment for their work as agreed in their contract.
The right to refuse to participate in unethical or illegal practices: Nurses are not obligated to carry out orders that are against their professional code or the law (e.g., participating in an illegal abortion).
The right to appropriate resources and support to provide care: This includes having the necessary equipment, supplies, and adequate staffing.
The right to continuing education and professional development: To maintain a high standard of competence, nurses have the right to opportunities for learning and improving their skills.
The right to be treated with respect by patients, colleagues, and superiors.
The right to privacy regarding their personal information.
The right to belong to professional associations (like the Uganda Nurses and Midwives Council).
The right to acknowledge limitations in their knowledge or skills and decline duties they are not competent to perform safely.

Code of conduct and ethics for health workers (from the Nurses and Midwives Act, 1996, Part IV)

This section outlines the expected behavior and responsibilities of health workers in Uganda, as defined by the Nurses and Midwives Act.

Article 29. Code of conduct: This part of the Act contains the specific rules of conduct that all health workers in Uganda must follow in their practice.
Article 30. Responsibility to patients:
- A health worker must put the health, safety and interest of the patient first and always treat each patient with due respect.
- You must ensure that nothing you do or fail to do harms the patient's interest, condition, or safety.
- A nurse must provide the patient with relevant, clear and accurate information about their health and how it will be managed.
- If a patient is able to give consent, medical treatment should only be given with their full, free, and informed consent. In emergencies, when immediate action is needed and getting consent might delay care, intervention may be done. For patients who are minors or not able to give consent (incompetent), consent must be obtained from their parent, relative, guardian, or the head of the hospital.
- Nurses must **respect the confidentiality** of information about the patient and their family. This information should not be shared with anyone without the patient's consent or the consent of an appropriate guardian, unless sharing the information is in the patient's best interest or required by law.
- A health worker taking care of someone who is detained (like in a prison) must do so in the best interest of the detainee and must maintain **strict confidentiality**.
- A health worker shall not take, ask for, or accept any bribe from a patient or their relatives.
- When carrying out an examination or providing a report for an authorized person, maximum care must be taken to protect the **confidentiality and interest** of the patient.
- A health worker shall **no abandon a patient** under their care.
Article 31. Responsibility to the community:
- The nurse must ensure that their actions do not endanger the safety or condition of the public.
- Health workers must promote effective health services and inform the health team and other authorities whenever they become aware of a health **hazard to the community** (e.g., an outbreak of cholera or dysentery).
Article 32. Responsibility to health unit/institution (place of work): Health workers must follow the rules and regulations of their workplace, meet the expectations of the health unit, and work to fulfill the mission of the institution.
Article 33. Responsibility to law, profession and self:
- A health worker must **observe the law** and uphold the **dignity of their profession** and accepted ethical principles.
- Health workers shall not take part in activities that **discredit their profession** or the delivery of health services. They must report anyone who engages in illegal or unethical conduct (like stealing or not following the dressing code) without fear.
- You must **respect the confidentiality** of patient and family information. This information should not be shared with anyone without the patient's written consent or the consent of an appropriate guardian, unless the law requires it.
- A health worker must maintain a **high standard of professional knowledge and skills** by continuing their medical education.
- A health worker shall not advertise their professional skills directly or indirectly, or try to take patients away from colleagues. If they notify the public about available services, they must do so appropriately.
- A health worker shall not perform their duties while under the **influence of alcohol**.
- A health worker shall not engage in **dangerous lifestyles** such as alcoholism or drug addiction, which can damage the reputation of the profession.
- Health workers shall not support or be linked with cults or unscientific practices that claim to contribute to health care.
- A health worker must be **registered** with their relevant professional council and be a member of the national association.
- Nurses must recognize any **limitations in their knowledge and competence** and should refuse a duty or responsibility if they are not able to perform it safely and skillfully.
Article 34. Responsibility to colleagues: A health worker must **co-operate** with their professional colleagues, recognize, and respect each other's expertise to provide the best possible holistic care as a team.

Introduction to the practice room (PEX 1.1.9) & Hospital economy (Sub-topic 1.1.10)

These are practical/observational aspects of this topic.

Introduction to the Practice Room:

This involves getting familiar with the practice room (sometimes called a skills lab). This is where you will practice nursing procedures in a safe environment before working with real patients. You'll learn where equipment is kept and how to use it correctly.

Hospital Economy:

Understanding hospital economy means understanding how resources (like money, supplies, and equipment) are managed efficiently in the hospital. This includes things like managing ward supplies and participating in basic planning related to resources to ensure the hospital runs smoothly.

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

Introduction to Ethical Standards (Sub-topic 1.1.1 to 1.1.8 - includes legal and ethical concepts)
Introduction to the practice room (PEX 1.1.9)
Hospital economy (Sub-topic 1.1.10)

(Note: The curriculum also lists LWAs/PEXs for other topics in CN-1101 like Infection Prevention and Control and General Nursing Care, which we will cover later.)

Underpinning knowledge/ theory for Medico-legal issues:

(This is covered within the sub-topics above.)

Nursing and the law (Categories of Law, Importance of Law to Nurses)
Code of conduct for Nurses
Principles of professional ethics and etiquette
Patient’s rights
Nurses’ rights
Nursing standards and qualities of a nurse
General principles and rules of all nursing procedures
Hospital economy

Revision Questions for Medico-legal issues:

1. Explain why understanding the law is important for nurses.

2. Describe the difference between criminal law and civil law, and provide an example of each related to nursing.

3. What is negligence in nursing? Give three examples.

4. Define 'Assault' and 'False detention' as intentional torts in nursing.

5. According to the Nurses and Midwives Act, what is the primary consideration for a health worker regarding a patient?

6. When can a health worker disclose confidential patient information without the patient's consent?

7. List three responsibilities of a health worker to the community.

8. What does Article 33 of the Nurses and Midwives Act cover regarding the responsibility to law, profession, and self?

9. Explain the importance of acknowledging limitations in knowledge and competence for nurses.

10. What does 'Hospital economy' refer to in the context of nursing training?

11. List at least five rights that a patient has in healthcare.

12. Mention three important rights that nurses have.

References (from Curriculum for CN-1111):

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

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

Medico-Legal Issues Read More »

Ethical Standards in Nursing

Ethical standards or principles are higher than those standards made by law

For-example, to steal is wrong by law and it’s punishable by law. To tell lies is not wrong by law but is wrong by the ethical standards of behavior.

Ethical Standards In Nursing

The following are the ethical standards or principles;

Discipline
Intelligent obedience
Punctuality
Tactiful understanding and patience
Respect for persons
Respect for autonomy-that individuals are able to act for themselves to the level o their capability
Respect for freedom
Respect for beneficience
Respect for non-maleficience
Respect for veracity-truth telling
Respect for justice-fair and equal treatment
Respect for rights
Respect for fidelity-fulfilling promises
Confidentiality-protecting privileged information.
High sense of responsibility.

Ethics of nurses

Nursing as other professions has its standard of right behaviours that all nurses must adhere Some of the nurses’ ethics are as follows;
The fundamental responsibility of a nurse is a three (3) fold:-

> To conserve life
> To alleviate suffering } CAP
> To promote health

The nurse must at all times maintain the highest standard of nursing care and of professional
A nurse must maintain his/her knowledge and skills at constantly high level
Religious beliefs of patient must be respected
Nurses must recognize not only their responsibility but also the limitations of their professional
Nurses must hold confidence in all personal information entrusted to them.
The nurse is under the obligation to carryout physicians’ order intelligently with loyalty and to refuse to participate in unethical procedures g. abortion, mercy killing etc.
A nurse is entitled to just remuneration and accepts only such compensation as the contract, actual or implied
Nurses should no permit their names to be used in connection with advertisement of products or any other form of self advertisement g. going in public with a uniform.
A nurse co-operates with and maintains harmonious relationships with members of other professions and with his/her professional
A nurse should participate and share responsibility(ies) with other citizens and other health professions in promoting efforts to meet the health needs of the public, local, district, national, international component.

ROLES OF A NURSE

Nurses work as a team which comprises of nurses, doctors, occupation therapists, social workers, physiotherapists, nutritionists and many others. The following are some of the roles of a nurse;

Care giver: Care giving encompasses the physical psychological, developmental, cultural and spiritual needs

Patient’s advocate and protector: The nurse must represent the client’s/patient’s needs and wishes to other health professionals e.g. client’s wishes foe information to the physician.

Communicator: A nurse should identify patient’s problems and then communicate these verbally or in writing to other members of the health team.

Teacher: As a teacher, the nurse helps patients/clients, their relatives, colleagues and the community to learn about their health and the health care procedures they need to perform to restore or maintain their health.

Counselor: The nurse counsels health individual with normal adjustments, difficulties and focuses on helping the person to develop new attitudes, feelings and behaviours by encouraging the client to look at alternative behaviours, recognize the choices and developa sense of control.

Nurse educator: Some nurses take up teaching of nursing as their profession for- example as tutors, clinical instructors, lecturers and professors. They maintain their clinical skills and facilitate the development of nursing skills in students.

Manager: Management in nursing is the co-ordination and facilitation of nursing services; nurses are involved in the management of the nursing care by communication i.e.

Directly with hospitalized patients
Within the nursing team
Within the wider health team(including doctors and paramedical staff)

Decision maker: The nurse observes the patient continuously and makes decision regarding nursing diagnosis of the patients and the steps of the nursing process.

Rehabilitator: In the physical medical department, the nurse helps patients in rehabilitation. This is also done in psychiatric department.

CHARACTERISTICS OF A PROFESSIONAL NURSE

Good physical and mental health
Truthful and efficient in technical competence
Cleanliness, tidy, neat and well groomed
Confidence in others and her/himself.
Open minded, co-operative, responsible and able to develop good interpersonal relations
Leadership quality
Positive attitude
Self-belief towards human care and cure.
Conveys co-operative attitude towards co-workers.

ACTIVITIES/FUNCTIONS OF A NURSE

Some of the functions of a nurse include the following;

Receiving of patients in out patient department and giving them guidance.
Admission of patients on wards, ensuring comfort and reassurance to them
Perform duties such as bed making, dump dusting etc.
Administer medications to the patients and monitoring the side effects.
Taking of vital observations i.e. pulse, respirations, blood pressure, oxygen saturation and level of consciousness and record them to the patient’s charts.
Co-ordinates patients with special services such as physiotherapy, radiotherapy psycho-social support etc.
It is also the duty of a nurse to co-ordinate patients to the special clinics like diabetic, cardiac, B, skin, cancer institute etc.
Provides health education, immunization both in the units and out reaches.
Reinforces and repeats doctor’s explanations to the patients in layman’s language (local language or in simple )
Knows the number of the patients at her/his unit and their conditions.
Keeps the ward/unit inventory on daily basis, weekly, monthly and annually
Makes reports about his/her unit per shift.

QUALITIES/STANDARDS OF A GOOD NURSE

Punctuality: This is vital for smooth running of the hospital and speedy recovery of the patients, so a nurse is required to be punctual while performing all duties.

Confidentiality: A nurse is to ensure that the patient’s diagnosis, problems and condition are not discussed with outsiders who are not involved in the patient’s health care. The information should only be released to the relatives and friends with the patients consent.

Fidelity: Obligation to remain faithful to ones commitments

Empathetic: Awareness of and insight into feelings, emotions and behavior of another person and their meaning and significance

Resourcefulness and initiative: The nurse should be able to act immediately during emergency by using her/his common sense, knowledge and with ability to use the available resources or equipment for the benefit of the patients. S/he should execute nursing care with in her/his professional level of responsibility.

Alert and observant: It is the power to see, hear and appreciate what is being done and act accordingly and intelligently.

Tactfulness (creativeness): A nurse must be careful to say and to do the right thing with greatest consideration for the other person’s feelings.

Faithfulness: The nurse should remain true or loyal to the patients always while executing her duty. Also to the colleagues and any other thing entrusted to her.

Loyalty: A nurse must be loyal to her patient colleagues, superiors for the good of the patient.

Truthfulness and genuineness: A nurse must be honest in word and deed to her patients, fellow workers, with self and the entire community. This is the most important, vital virtue and of special value to nursing profession. She should also be able to admit her mistakes whether discovered by herself or by someone else.

Speed and gentility: The nurse should always act fast and in a responsible and polite manner while carrying out her/his procedures especially during the emergencies.

Accuracy (in decision making): The nurse should be correct and precise in whatever she does because the life of the patient is in her hands.

High sense of responsibility; to promote health, restores health and alleviates suffering.

Respectful: The nurse should show respect to self, patient, seniors, juniors and all people in authority.

Courteous: It costs nothing to be polite and considerate to others. S/he should be straight forward in all s/he does.

Integrity: S/he should adhere to moral principles of the profession and be honest to the patients/clients.

Justice: All individuals will have equal and fair access to health care, resources available according to an individual’s need.

Caring: It is the obligation of the nurse to give service of care to the sick person as her calling meeting the patient’s physical, spiritual and psychological needs.

Co-operative: The nurse should have a sense of working with others, so as to be able to give adequate and quality care to the patients and entire community.

Accountable: A nurse must be responsible for any action done either to the patients or for the hospital.

Responsiveness: S/he should be able to react quickly to the situation at hand e.g in emergencies.

Being considerate: A nurse should be thoughtful or kind to the patients when rendering health services to them.

Poise: S/he should be composed or show dignity of manner while carrying out her/his duties.

Intelligent: The nurse should show high sense of knowledge during performance of the procedures to the patients.

Control of emotions: A nurse should be good tempered and able to control or cope with emotions such as anger, irritation, love or hatred. The nurse needs to develop emotional maturity in order to manage the problems and different behaviours of the patients, caretakers and fellow colleagues.

Tolerance and understanding: A nurse must realize that the patients are physically, emotionally, psychologically sick and worried about their health, disease, homes and family. Therefore human understanding, sympathy together with technical knowledge and efficiency are foundation on which a true profession nurse must build her career.

Cleanliness: Personal and environmental cleanliness and tidiness are essential to quick recovery of the patients and the nurse herself. Apart from other infection control methods, orderliness plays a role in the prevention of disease and infections.

N.B Nurses learn about professional values both from formal institutions and from informal observation of practicing nursing staff and gradually incorporates professional values into their personal value system. Some of the values are non-moral and others are moral. Example of non-moral values include the following;

Hairstyle
Uniform
Colours
Fashions of shoes

There are two principles under-minding ethical practices in nursing and health care i.e. beneficience-the obligation to do good, non-maleficience-obligation to do no harm. The two are related but distinct and if the distinction is recognized, it helps to guide moral conduct of a nurse.

AIMS OF A NURSE

To help save life
To help prevent further suffering
To help prevent disease and improve the health of the fellow men.
To assist the individual by performing those activities or duties which he would if able to and knowledgeable by himself.

Liberal Meaning of the word ‘Nurse’

N-Nobility/Knowledgeable

U-Usefulness/Understanding

R-Responsibility

S-Simplicity/Sympathy

E-Efficiency/Equanimity

PROFESSIONAL CODE OF CONDUCT

Is the way how one must behave towards his/her clients/patients, institution and the entire community which is acceptable professionally and publicly. The code of conduct is as follows;

Self:

Report any conduct that endangers client/patients.
Stay informed of current nursing practices, theory and issues and make judgement based on facts

Client/patient:

Provide clients/patients with accurate information about care and conduct nursing in a manner that ensures clients’ safety and well being.

Professional:

Maintain ethical standards in practice. Encourage other professional peers to follow the same ethical standards
Report colleagues with unethical behaviours

Employment institution

Follow practices and procedures defined by the institution.

Community/society:

Maintain ethical conduct in the care of all clients in all settings.
Every health worker must conduct him/her self in a manner that is acceptable professionally and publicly at all times.

Code of conduct and ethics for health workers Part IV.

Article 29. Code of conduct

This part of the act shall constitute a code of conduct and shall be observed by all health workers.

Article 30. Responsibility to patients

A health worker shall hold the health, safety and interest of the patient to be first consideration and shall render due respect to each patient at all times and in all circumstances.
Ensure that no action or omission on your part or sphere of responsibility is detrimental to the interest or condition or safety of the patient.
A nurse shall provide a patient with relevant, clear and accurate information about his/her health and the management for her/his condition.
Treatment and other forms of medical intervention to a patient who has capacity to consent shall not be undertaken without the patient’s full free and informed consent except in emergencies when such intervention may be done in the best of the patient. Incase of minor or other incompetent patients, consent shall be obtained from apparent/relative/guardian or the head of the hospital.
The nurse shall respect the confidentiality information relating to the patient and his family; such information shall not be disclosed to anyone without the patient’s consent or appropriate guardian, except where it is the best interest of the patient
A health worker who attends to a person held in detention shall do so in the interest of the detainee and strict confidentiality must be observed just as with other patients
A health worker shall no take, ask or accept any bribe from the patient or relatives.
Maximum care shall be taken not to compromise the confidentiality and interest of the patient when carrying out an examination or supplying a report at the request of an authorized person.
A health worker shall no abandon a patient under his/her care.

Article 31. Responsibility to the community

The nurse should ensure that no action or omission on her/his part or sphere of responsibility is detrimental (endangers) the interest or condition or safety of the public.
A health worker shall promote the provision of effective health services and shall notify the health team and other authorities whenever he/she becomes aware of the hazard to the community e.g. out break of cholera, dysentery, Ebola etc.

Article 32. Responsibility to health unit/institution (place of work)

The health worker shall abide by the rules and regulations governing the place of work and shall confirm to the expectations of the health unit, and strive to fulfill the mission of the institution.

Article 33. Responsibility to law, profession and self

A health worker shall observe law; uphold the dignity of his/her profession and accepted ethical principles.
A health worker shall not engage in activities that discredit his/her profession or delivery of health services and shall expose without fear or favour all those who engage in illegal or unethical conduct and practice e.g. stealing, poor dressing code etc.
The health worker shall respect the confidentiality of information relating to the patient and his/her family, such information shall not be disclosed to anyone without the patient’s or appropriate guardian’s written consent except where it is required by law.

A health worker shall keep a high standard of professional knowledge and skills in order to maintain a high standard of professional competence through continuing medical education program.
A health worker shall not directly or indirectly advertise his/her professional skills or allow him/her to be advertised directly or indirectly and shall not entice patients from his/her colleagues except h/she shall notify the public of the services available in the health facilities.

A health worker shall not perform his/her duties under the influence of alcohol.
A health worker shall not indulge in dangerous life styles such as alcoholism, drug addiction, that discredit the profession
The health worker shall not support or become associated with cults or unscientific practices professing to contribute to heath care.
A health worker shall be registered with his/ her relevant professional council to be a member of the national association.
Nurses shall acknowledge any limitation in their knowledge and competence and decline any duty or responsibility unless able to perform them in a safe and skilled manner.

Article 34. Responsibility to colleagues:

A health worker shall co-operate with his/her professional colleagues, recognize and respect each others expertise in the interest of providing the best possible holistic care as a health team.

Ethical Standards in Nursing Read More »

History Of Nursing

Module Unit CN-1101: Foundations of Nursing (I)

Contact Hours: 75

Module Unit Description: This unit equips students with knowledge and understanding of ethical standards of nursing, infection prevention and control, and skills in basic nursing care, bed making, vital observations, and patient hygiene.

Learning Outcomes for this Unit:

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

Apply ethical standards in nursing.
Take vital observations from patients.
Carry out basic nursing care, prevent and control infections.
Differentiate normal from abnormal anatomy.
Carry out effective disinfection and sterilisation.

Topic: Introduction to Ethical Standards

Introduction

Nursing has been called the oldest of the arts and the youngest of the professions.

The term ‘nurse’ evolved from the Latin word nutrix which means ‘nourishing’ and the word nursing comes also from the Latin word nutrix meaning to ‘nourish’ or ‘cherish’. Nourish means to ‘supply that which is necessary for life’.

Today nursing emerged as a learned profession that is both a science and art. Science is the observation, identification, description, experimental investigation and theoretical explanation of natural phenomena (it is a body of knowledge). Art is the application of knowledge and skill to individualized action.

History of Nursing

Nursing originated with the desire to nurture, nourish, to provide comfort, care and assurance to the sick children, the ill family and eventually entire tribes. The 1^st known nurse is deaconess Phoebe mentioned in Romans 16:1, who was sent to Rome by St Paul as the visiting nurse to take care of the sick, both women and men during the early years of the Christian church.

Before the foundation of modern nursing, nuns and the military often provided nursing-like services.

The Christian churches have been long term patrons of nursing and influential in the development of the ethics of modern nursing. Elsewhere, other nursing traditions developed such as in Islam.

Early nursing was not recognized and respected but the declaration of Christianity as accepted religion in the Roman Empire drove an expansion of the provision of care which led to its recognition.

History of Nursing in Uganda

In 1852, Florence Nightingale started nursing in hospital setting due to wars and prevailing unemployment for the women in UK.

In 1853, Nightingale, founder of modern nursing, was associated to the beginning of nursing because she was instrumental in establishing sanitary conditions and reducing mortality rates during the Crimean war at the barracks hospital in Turkey from 42.7% to 22% in 6 months.

Florence Nightingale believed that nursing was started in 1810s before that there was poor knowledge of medical and surgical infection and prevention. Surgery was confined to emergency amputation and this had a terrible mortality rate due to poor conditions.

In 1855, she put her theory of nursing and hospital experience into writing so that her system could be continued and therefore Nightingale introduced reforms that changed the care of the sick throughout the world.

In 1860s, she opened the Nightingale training school for nurses in London at St Thomas hospital. She was able to train them with the books and notes she wrote on nursing and hospitals during her experience.

This inspired the opening of the US schools based on her model and all countries adopted the Nightingale format. Helped by missionaries, nursing found its way into Africa and to Uganda by Lady Catherine Cook.

Note: Florence Nightingale felt that she was leading a religious movement therefore a nurse must be dedicated in a religious way as it is a calling.

She inspired such a spirit of devotion up to now in her followers.

The group was entirely female and so the general public has thought of nursing as a woman’s work ever since.

Male nurses were 1^st documented in practicing primitive nursing during the 17^th century. It was during this time in history that men and women provided nursing care while serving punishment.

Mrs. Bedford Fenwick realized that there was a distinct knowledgeable body she believed that she could turn into profession. She also believed that those who trained a qualified standard would allow nursing to evolve as a profession. Thus up to today, worldwide one must undergo prescribed syllabus of theory and practical education to be recognized as a nurse.

NIGHTINGALE’S PLEDGE

''I solemnly pledge myself before God
And in the presence of this assembly
To pass my life in purity
And to practice my profession faithfully
I will abstain from whatever is
Deleterious and mischievous
And will not take or knowingly
Administer any harmful drug.
I will do all in my power to maintain
And elevate the standard of my profession
And will hold in confidence. All personal
Matter committed to my keeping
And all family affairs coming to my
Knowledge in practice of my calling
With loyalty I will endeavour to aid
The physician in his work
And devote myself to the welfare
Of those committed to my care.''

Definition of Some Terms

Here are some key terms you will encounter in nursing:

Nursing: Is defined as the unique function of the nurse to care and nurture the individual, sick or well in the performance of those activities contributing to health or its recovery or peaceful death, that s/he would perform unaided if s/he had the necessary strength, will or knowledge to do so.(international council of nurses, 1973)
Nurse: Is a person who is qualified in the art and science of nursing and meets certain prescribed standards of education and clinical competence.
Or
Is a trained person to look after the sick or well individuals to perform those activities they cannot do on their own.
Health: Is a dynamic state in which an individual adapts to internal and external environment so that there is a state of physical, emotional intellectual, social and spiritual well-being.
Or
Is a state of physical, mental, spiritual, emotional, economical and social well-being and not merely in the absence of disease or other disorders (infirmities.)
Ethics: Is a code of moral principles that govern proper conduct of a profession. The ethics serve to protect the rights of human beings.
Etiquette: These are rules set to govern a specific profession and they vary from one profession to another.
Illness: Is a state in which a person’s physical, emotional, intellectual, social, developmental or spiritual functioning is diminished or impaired compared with that person’s previous experiences.
Disease: Any deviation from or interruption of the normal function or structure of any part, organ or system of the body manifesting with a characteristic set of signs and symptoms.
Profession: Is an occupation with normal principles that are devoted to the human and social welfare. The service is based on specialized knowledge and skills developed in a scientific and learned manner.
Hospital: Is an organized institution which promotes the comfort and the health of the patients.

Ethical Standards & Principles of Professional Ethics and Etiquette

Ethical standards or principles are higher than those standards made by law. For example, to steal is wrong by law and it’s punishable by law. To tell lies is not wrong by law but is wrong by the ethical standards of behavior. The following are the ethical standards of principles;

Discipline
Intelligent obedience
Punctuality
Tactful understanding and patience
Respect for persons
Respect for autonomy-that individuals are able to act for themselves to the level of their capability
Respect for freedom
Respect for beneficence
Respect for non-maleficience
Respect for veracity-truth telling
Respect for justice-fair and equal treatment
Respect for rights
Respect for fidelity-fulfilling promises
Confidentiality-protecting privileged information
High sense of responsibility.

Ethics of Nurses

Nursing as other professions has its standard of right behaviours that all nurses must adhere to. Some of the nurses’ ethics are as follows;

The fundamental responsibility of a nurse is a three (3) fold:

To conserve life
To alleviate suffering
To promote health

The nurse must at all times maintain the highest standard of nursing care and of professional code.

A nurse must maintain his/her knowledge and skills at constantly high level

Religious beliefs of patient must be respected

Nurses must recognize not only their responsibility but also the limitations of their professional functions.

Nurses must hold confidence in all personal information entrusted to them.

The nurse is under the obligation to carry out physicians’ order intelligently with loyalty and to refuse to participate in unethical procedures e.g. abortion, mercy killing etc.

A nurse is entitled to just remuneration and accepts only such compensation as the contract, actual or implied provides.

Nurses should no permit their names to be used in connection with advertisement of products or any other form of self advertisement e.g. going in public with a uniform.

A nurse co-operates with and maintains harmonious relationships with members of other professions and with his/her professional colleagues.

A nurse should participate and share responsibility(ies) with other citizens and other health professions in promoting efforts to meet the health needs of the public, local, district, national, international component.

Roles of a Nurse

Nurses work as a team which comprises of nurses, doctors, occupation therapists, social workers, physiotherapists, nutritionists and many others. The following are some of the roles of a nurse;

Care giver: Care giving encompasses the physical psychological, developmental, cultural and spiritual needs
Patient’s advocate and protector: The nurse must represent the client’s/patient’s needs and wishes to other health professionals e.g. client’s wishes for information to the physician.
Communicator: A nurse should identify patient’s problems and then communicate these verbally or in writing to other members of the health team.
Teacher: As a teacher, the nurse helps patients/clients, their relatives, colleagues and the community to learn about their health and the healthcare procedures they need to perform to restore or maintain their health.
Counselor: The nurse counsels health individual with normal adjustments, difficulties and focuses on helping the person to develop new attitudes, feelings and behaviours by encouraging the client to look at alternative behaviours, recognize the choices and develop a sense of control.
Nurse educator: Some nurses take up teaching of nursing as their profession for example as tutors, clinical instructors, lecturers and professors. They maintain their clinical skills and facilitate the development of nursing skills in students.
Manager: Management in nursing is the co-ordination and facilitation of nursing services; nurses are involved in the management of the nursing care by communication i.e.
- Directly with hospitalized patients
- Within the nursing team
- Within the wider health team (including doctors and paramedical staff)
Decision maker: The nurse observes the patient continuously and makes decision regarding nursing diagnosis of the patients and the steps of the nursing process.
Rehabilitator: In the physical medical department, the nurse helps patients in rehabilitation. This is also done in psychiatric department.

Characteristics of a Professional Nurse

Good physical and mental health.
Truthful and efficient in technical competence.
Cleanliness, tidy, neat and well groomed.
Confidence in others and her/himself.
Intelligence.
Open minded, co-operative, responsible and able to develop good interpersonal relations.
Leadership quality.
Positive attitude.
Self-belief towards human care and cure.
Conveys co-operative attitude towards co-workers.

Activities/Functions of a Nurse

Some of the functions of a nurse include the following;

Receiving of patients in out patient department and giving them guidance.
Admission of patients on wards, ensuring comfort and reassurance to them.
Perform duties such as bed making, dump dusting etc.
Administer medications to the patients and monitoring the side effects.
Taking of vital observations i.e. pulse, respirations, blood pressure, oxygen saturation and level of consciousness and record them to the patient’s charts.
Co-ordinates patients with special services such as physiotherapy, radiotherapy psycho-social support etc.
It is also the duty of a nurse to co-ordinate patients to the special clinics like diabetic, cardiac, T.B, skin, cancer institute etc.
Provides health education, immunization both in the units and out reaches.
Reinforces and repeats doctor’s explanations to the patients in layman’s language (local language or in simple terms.)
Knows the number of the patients at her/his unit and their conditions.
Keeps the ward/unit inventory on daily basis, weekly, monthly and annually.
Makes reports about his/her unit per shift.

Qualities/Standards of a Good Nurse

Punctuality: This is vital for smooth running of the hospital and speedy recovery of the patients, so a nurse is required to be punctual while performing all duties.
Confidentiality: A nurse is to ensure that the patient’s diagnosis, problems and condition are not discussed with outsiders who are not involved in the patient’s health care. The information should only be released to the relatives and friends with the patients consent.
Fidelity: Obligation to remain faithful to ones commitments
Empathetic: Awareness of and insight into feelings, emotions and behavior of another person and their meaning and significance
Resourcefulness and initiative: The nurse should be able to act immediately during emergency by using her/his common sense, knowledge and with ability to use the available resources or equipment for the benefit of the patients. S/he should execute nursing care with in her/his professional level of responsibility.
Alert and observant: It is the power to see, hear and appreciate what is being done and act accordingly and intelligently.
Tactifulness (creativeness): A nurse must be careful to say and to do the right thing with greatest consideration for the other person’s feelings.
Faithfulness: The nurse should remain true or loyal to the patients always while executing her duty. Also to the colleagues and any other thing entrusted to her.
Loyalty: A nurse must be loyal to her patient colleagues, superiors for the good of the patient.
Truthfulness and genuineness: A nurse must be honest in word and deed to her patients, fellow workers, with self and the entire community. This is the most important, vital virtue and of special value to nursing profession. She should also be able to admit her mistakes whether discovered by herself or by someone else.
Speed and gentility: The nurse should always act fast and in a responsible and polite manner while carrying out her/his procedures especially during the emergencies.
Accuracy (in decision making): The nurse should be correct and precise in whatever she does because the life of the patient is in her hands.
High sense of responsibility; to promote health, restores health and alleviates suffering.
Respectful: The nurse should show respect to self, patient, seniors, juniors and all people in authority.
Courteous: It costs nothing to be polite and considerate to others. S/he should be straight forward in all s/he does.
Integrity: S/he should adhere to moral principles of the profession and be honest to the patients/clients.
Justice: All individuals will have equal and fair access to health care, resources available according to an individual’s need.
Caring: It is the obligation of the nurse to give service of care to the sick person as her calling meeting the patient’s physical, spiritual and psychological needs.
Co-operative: The nurse should have a sense of working with others, so as to be able to give adequate and quality care to the patients and entire community.
Accountable: A nurse must be responsible for any action done either to the patients or for the hospital.
Responsiveness: S/he should be able to react quickly to the situation at hand e.g in emergencies.
Being considerate: A nurse should be thoughtful or kind to the patients when rendering health services to them.
Poise: S/he should be composed or show dignity of manner while carrying out her/his duties.
Intelligent: The nurse should show high sense of knowledge during performance of the procedures to the patients.
Control of emotions: A nurse should be good tempered and able to control or cope with emotions such as anger, irritation, love or hatred. The nurse needs to develop emotional maturity in order to manage the problems and different behaviours of the patients, caretakers and fellow colleagues.
Tolerance and understanding: A nurse must realize that the patients are physically, emotionally, psychologically sick and worried about their health, disease, homes and family. Therefore human understanding, sympathy together with technical knowledge and efficiency are foundation on which a true profession nurse must build her career.
Cleanliness: Personal and environmental cleanliness and tidiness are essential to quick recovery of the patients and the nurse herself. Apart from other infection control methods, orderliness plays a role in the prevention of disease and infections.

N.B: Nurses learn about professional values both from formal institutions and from informal observation of practicing nursing staff and gradually incorporates professional values into their personal value system. Some of the values are non-moral and others are moral. Example of non-moral values include the following;

Hairstyle
Uniform
Colours
Fashions of shoes etc.

There are two principles under-minding ethical practices in nursing and health care i.e. beneficence-the obligation to do good, non-maleficience-obligation to do no harm. The two are related but distinct and if the distinction is recognized, it helps to guide moral conduct of a nurse.

AIMS OF A NURSE

To help save life.
To help prevent further suffering.
To help prevent disease and improve the health of the fellow men.
To assist the individual by performing those activities or duties which he would if able to and knowledgeable by himself.

Liberal Meaning of the word ‘Nurse’ (Acronym)

N-Nobility/Knowledgeable
U-Usefulness/Understanding
R-Responsibility
S-Simplicity/Sympathy
E-Efficiency/Equanimity

REQUIREMENTS OF NURSING

Interest-As a nurse/health worker to be, one should show interest in people and the profession.
Instinct of parental love and care-Since the nurse is the care giver to the patient, s/he must show love and care for the sick individuals during their stay in the hospital.
Liking of people- so that service is not offered coldly but with warmth and tolerance that makes it easy for social interaction.
Empathy-is called for rather than sympathy.
Physical fitness- nursing involves physical work that is quite heavy and in an environment of many infections.
Trustworthy-a nurse should be truthful and dedicated to her/his work at all times.
Intelligence and adequate education- so as to cope with the scientific terms used in the medical profession (knowledge in technique, drugs skills etc.)
Integrity and self respect- must be maintained in all circumstances with faithful assurance.

PROFESSIONAL CODE OF CONDUCT

Is the way how one must behave towards his/her clients/patients, institution and the entire community which is acceptable professionally and publically. The code of conduct is as follows;

Self: Report any conduct that endangers client/patients. Stay informed of current nursing practices, theory and issues and make judgement based on facts.
Client/patient: Provide clients/patients with accurate information about care and conduct nursing in a manner that ensures clients’ safety and well being.
Professional: Maintain ethical standards in practice. Encourage other professional peers to follow the same ethical standards. Report colleagues with unethical behaviours
Employment institution: Follow practices and procedures defined by the institution.
Community/society: Maintain ethical conduct in the care of all clients in all settings. Every health worker must conduct him/herself in a manner that is acceptable professionally and publically at all times.

Code of conduct and ethics for health workers (Extracted from relevant Act)

Part IV.

Article 29. Code of conduct: This part of the act shall constitute a code of conduct and shall be observed by all health workers.

Article 30. Responsibility to patients:

A health worker shall hold the health, safety and interest of the patient to be first consideration and shall render due respect to each patient at all times and in all circumstances.
Ensure that no action or omission on your part or sphere of responsibility is detrimental (endangers) the interest or condition or safety of the patient
A nurse shall provide a patient with relevant, clear and accurate information about his/her health and the management for her/his condition.
Treatment and other forms of medical intervention to a patient who has capacity to consent shall not be undertaken without the patient’s full free and informed consent except in emergencies when such intervention may be done in the best of the patient. Incase of minor or other incompetent patients, consent shall be obtained from apparent/relative/guardian or the head of the hospital.
The nurse shall respect the confidentiality information relating to the patient and his family; such information shall not be disclosed to anyone without the patient’s consent or appropriate guardian, except where it is the best interest of the patient.
A health worker who attends to a person held in detention shall do so in the interest of the detainee and strict confidentiality must be observed just as with other patients.
A health worker shall not take, ask or accept any bribe from the patient or relatives.
Maximum care shall be taken not to compromise the confidentiality and interest of the patient when carrying out an examination or supplying a report at the request of an authorized person.
A health worker shall no abandon a patient under his/her care.

Article 31. Responsibility to the community:

The nurse should ensure that no action or omission on her/his part or sphere of responsibility is detrimental (endangers) the interest or condition or safety of the public.
A health shall promote the provision of effective health services and shall notify the health team and other authorities whenever he/she becomes aware of the hazard to the community e.g. outbreak of cholera, dysentery, bola etc.

Article 32. Responsibility to health unit/institution (place of work):

The health worker shall abide by the rules and regulations governing the place of work and shall confirm to the expectations of the health unit, and strive to fulfill the mission of the institution.

Article 33. Responsibility to law, profession and self:

A health worker shall observe law; uphold the dignity of his/her profession and accepted ethical principles.
A health worker shall not engage in activities that discredit his/her profession or delivery of health services and shall expose without fear or favour all those who engage in illegal or unethical conduct and practice e.g. stealing, poor dressing code etc.
The health worker shall respect the confidentiality of information relating to the patient and his/her family, such information shall not be disclosed to anyone without the patient’s or appropriate guardian’s written consent except where it is required by law.
A health worker shall keep a high standard of professional knowledge and skills in order to maintain a high standard of professional competence through continuing medical education program.
A health worker shall not directly or indirectly advertise his/her professional skills or allow him/her to be advertised directly or indirectly and shall not entice patients from his /her colleagues except h/she shall notify the public of the services available in the health facilities.
A health worker shall not indulge in dangerous life styles such as alcoholism, drug addiction, that discredit the profession.
The health worker shall no support or become associated with cults or unscientific practices professing to contribute to heath care.
A health worker shall be registered with his/her relevant professional council to be a member of the national association.
Nurses shall acknowledge any limitation in their knowledge and competence and decline any duty or responsibility unless able to perform them in a safe and skilled manner.

Article 34. Responsibility to colleagues:

A health worker shall co-operate with his/her professional colleagues, recognize and respect each others expertise in the interest of providing the best possible holistic care as a health team.

AIMS OF COMPREHENSIVE NURSING

The overall objective is to train a multi-skilled cadre of nurses who will provide promotive, preventive, curative and rehabilitative services in the minimum health care package.

Rationale for Comprehensive Nursing

It helps to take health care services to the rural communities in order to reduce mortality and mortality as stipulated by national health policy (1999).
It is cost effective because a multiple skilled professional is capable of delivering the minimum health care package unlike the single enrolled nurse, midwife or psychiatric nurse.
The teachers and tutors for this course and the students are available.
Because of this multipurpose nature it attracts development partners who can support the program.
Comprehensive nursing limits duplication of course, which wastes the learners’ precious time.

Patient's rights (Covered in Medical Legal Issues)

(Click Here)

Healthcare Team and Their Roles & Responsibilities

(This section in the provided notes goes beyond the explicit subtopics of "Introduction to Ethical Standards" in the curriculum outline, but is included here as it follows the ethical/legal content in your notes. It relates to the underpinning knowledge on general principles in patient care.)

Medical staff

Physician:

Assessment:

Performing complete health assessments including: Taking a full medical history including presenting complaint, past illnesses, social history, family history, and performing a complete physical examination.
Screening patients at risk for hereditary conditions and potentially preventable disorders.
Assessment, diagnosis, primary medical treatment and advice for management of acute medical conditions and injuries.
Assessment of the exacerbations and complications of chronic medical problems.

Treatment/Management:

Provision of continuous care to patients over their lifetime based on the delivery of the following services:
- Acute medical treatment for a range of medical problems from minor ambulatory care visits to severe life threatening illness presenting to emergency rooms, in hospitals, in the home and in long term care facilities.
- Provide primary reproductive care including maternal and newborn care.
- Provide screening for and treatment of sexually transmitted diseases (STDs.)
- Provide primary mental health care.
- Provide palliative care.
- Provide hospital care where required.
- Provide early intervention and counseling to reduce risk or development of harm from disease.
- Provide appropriate immunizations.
- Provide care and monitoring of chronic illnesses, including patients with complex co-morbidities.
- Provide early access for assessment of episodic illness or injury with provision of diagnosis, primary medical treatment and advice on self-care and prevention.
- Maintain and keep safe the medical record of each patient.
- Perform surgeries where required.

Education/Advocacy:

Provide counseling on many health and health care issues including but not limited to birth control, prevention of STDs, prevention of disease and issues related to the effects of disease on family members.
Perform the role of advocate to assist patients to navigate through a complex health care system in order to obtain the best care in the most expeditious way in a cost effective manner.
Identify and meet the needs of the individual patients, the practice population and the community in general by working with a variety of partners throughout the public health, community, and hospital sectors.

Referrals/Collaboration:

Assist with discharge planning, rehabilitation services, out patient follow-up and home care services.
Coordinate referrals to other health care providers and agencies, including specialists, rehabilitation and physiotherapy services, home care and palliative care services, and diagnostic services, as required.
Collaborate with other mental health care providers when required.
Coordinate referrals to secondary and tertiary facilities based on patients’ needs.
Report births, deaths, and contagious and other diseases to governmental authorities.
Collaborate with necessary public health initiatives.

Registered Nurses (PNO, SPNO) & Other Nursing Staff

(Note: The provided notes list "Registered Nurses" and "other nursing staff" together, and also list "Midwives" separately. The curriculum lists "Nursing procedures and applications" and "Standard nursing process" as underpinning knowledge for CN-1101, and "Apply nursing process" as a learning outcome for CN-1201. The roles described here encompass various aspects of nursing practice.)

Depending on the population health needs and the mix of other providers, the Family Health Team may choose to integrate an RN, RPN, or both into the interdisciplinary team.

Assessment:

Assess holistically and provide services to patients in all developmental stages, and to families and communities.
Complete health assessments, including a health history and physical examination.
Formulate and communicate medical diagnoses.
Synthesize information from patients to identify broader implications for health within the family.
Use family assessment tools to evaluate family strengths and needs.
Determine the need for, and order from, an approved list of screening and diagnostic laboratory tests and interpret the results.
Determine the need for, and order and interpret reports of X-rays, ECGs and diagnostic ultrasounds for diagnosis.
Assess patient preferences.
Assessment of patient health care needs (physical, emotional, psychological, and spiritual.)
Analysis of the findings of a health assessment.
Interpret patient health records.
Observe and record outcomes.
Collect data through a therapeutic relationship with a patient.

Treatment/Management:

Initiate and manage care of patients with diseases or disorders.
Monitor the ongoing therapy of patients with chronic stable illness by providing effective pharmacological, complementary or counseling interventions.
Prescribe drugs from an approved list.
Use nursing strategies arising from the best available evidence and consistently incorporate patient’s perspectives in care.
Determine the appropriate service or treatment, the appropriate care provider or the appropriate equipment.
Provide nursing care and treatment (including complementary therapies and/or counseling) for health problems.

Education/Advocacy:

Determine the need for, and implementation of, health promotion, and primary and secondary prevention strategies for individuals, families, and communities, or for specific age and cultural groups.
Provide health education to individuals and groups.
Identify community needs and resources and develop age and culturally sensitive community programs.
Help patients to identify and use health resources.
Involve patients in decisions about their own health.
Encourage patients to take action for their own health.
Initiate health education and other activities that assist, promote and support patients as they strive to achieve the highest possible level of health.
Develop learning resources for nurses and other health care providers.
Develop and deliver health education programs for patients, or communities.

Referrals/Collaboration:

Consult with a physician in accordance with the standards for consultation with physicians, and/or refer the patient to another healthcare professional.
Collaborate with other healthcare providers.
Coordinate patient care.
Refer to community programs and mental health services.

Midwives

(Note: Midwifery is often a separate specialization, but foundational nursing includes aspects of maternal and child health.)

Assessment:

Assess and monitor women during pregnancy.
Provide pre-natal education.
Order tests if necessary.

Treatment/Management:

Deliver babies.
Administer some medications during delivery if necessary.
Manage labour and conduct spontaneous normal vaginal deliveries.
Perform episiotomies and amniotomies and repairing episiotomies and lacerations, not involving the anus, anal sphincter, rectum, urethra and periurethral area.
Administer, by injection or inhalation, a substance designated in the regulations (Midwifery Act, 1991, c. 31, s. 4.)
Take blood samples from newborns by skin pricking or from women from veins or by skin pricking.
Insert urinary catheters into women.
Prescribe drugs designated in the regulations (Midwifery Act, 1991, c. 31, s. 4)
Monitor women in post partum period.
Assess/monitor new babies.

Education/Advocacy:

Assist women in making informed decisions about their care and choice of birthplace.

Referrals/Collaboration:

Arrange consultation or transfer to physician if necessary.
Assist in complicated deliveries.
Report births to governmental authorities.

Dietitian

The Registered Dietitian (R.D.) is a healthcare professional trained in the single specialty of nutrition science. Their goal is to promote health and fight illness by fostering the practice of proper nutrition to individuals and groups.

Assessment:

Work with individual patients to determine nutritional needs.
Conduct nutritional and weight assessments.

Treatment/Management:

Develop nutritional plans based on comprehensive needs assessments.
Provide nutritional counseling.
Provide weight management counseling.

Education/Advocacy:

Promote behaviour change related to food choices, eating behaviour and preparation methods to optimize health.
Promote patient independence and autonomy in decision making for patient to achieve health.
Conduct patient workshops and seminars.
Identify community capacities and facilitate community skill building, health advocacy, and social action.

Referrals/Collaboration:

Work with physicians on medication monitoring plans as they relate to nutrition.
Communicate relevant nutritional information to other health care providers.

Pharmacists

Pharmacists dispense drugs and medications prescribed by physicians, physician assistants, nurse practitioners, and dentists. They also advise healthcare professionals and patients on the use and proper dosage of medications, as well as expected side effects and interactions with other prescription and nonprescription medicines. These professionals also order and maintain supplies of medications and various medical supplies required for use in the clinical setting.

Assessment:

Ensure appropriate patient information is gathered and recorded.
Review patient profile including known patient risk factors for adverse drug reactions, drug allergies, known contraindications to prescription drugs, nonprescription drugs, natural health products, and complementary or alternative medicines.
Evaluate patient drug therapy and identify potential and actual drug-related problems and determine appropriate therapeutic options to resolve or prevent them.
Conduct patient assessments for medication problems.

Treatment/Management:

Manage medication.
Monitor patient compliance.
Home follow-up.

Education/Advocacy:

Patient education to facilitate patient’s understanding of her/his drug therapy and ability to comply with the therapy regimen.

Referrals/Collaboration:

Refer the patient to appropriate health care providers within the Family Health Team if necessary.
Communicate with physicians to help the patient achieve maximum benefit from drug therapy and to prevent medication errors or potential significant adverse reactions.

Orthopedists

Assessment:

Complete health assessment through information gathering, lower extremity physical examination, patient health history and relevant clinical findings.
Evaluation of overall lower extremity foot and ankle function relating to activities of daily living.
Examination and review of lab tests, diagnostic tests and consulting medical and surgical notes.
Assessment of the impact of an injury, disability or disease (rheumatoid arthritis/diabetes/sprains/strains) on foot function.

Treatment/Management:

Perform surgery by cutting into subcutaneous tissues of the foot.
Administer, by injection into feet, a substance designated in the regulations.
Prescribe drugs designated in the regulations.
Perform surgery by cutting into bony tissues of the forefoot if the required training has been completed.
Communicate a diagnosis identifying a disease or disorder of the foot as the cause of a person’s symptoms.
Take x-rays under the Healing Arts Radiation Protection Act.

Education/Advocacy:

Educate and advise patients about the prevention and care of morbid conditions relating to chronic diseases (e.g., diabetes and peripheral vascular disease.)

Referrals/Collaboration:

Chiropodists and podiatrists work as key interdisciplinary practitioners in hospitals, community health care centres, and nursing and retirement homes. In private practice, they receive referrals from medical and other health care practitioners and consult with these referring practitioners to provide timely and optimal care for their patients.

Social worker

The role of social workers in an interdisciplinary team is to provide the psychosocial perspective to complement the biomedical perspective.

Assessment:

Assessment and social work diagnosis of psychosocial problems.

Treatment/Management:

They provide counseling, and enable individuals, families, and communities to obtain social services. They work with clients on issues of unemployment, illness, disability, housing, abuse, and financial problems. Social workers specializing in providing mental health services and counseling are called Clinical Social Workers. In the community, they may be active in organizing communities to improve health and social services. Social workers often assist families in crisis situations and during periods of transitions.

Individual, couple, family and group counseling and psychotherapy.
Case Management, including linkages to community resources.

Education/Advocacy:

Health Promotion.
Psycho-education related to the prevention of mental health problems.
Assistance in navigating service delivery networks to find required resources.
Advocacy to establish and access needed resources.

Referrals/Collaboration:

Development, management and delivery of programs alone or in collaboration with other professionals.
Consultation with other professionals related to patient needs.

Psychologists

Assessment:

Evaluation, diagnosis, and assessment of the functioning of individuals and groups related to mental disorders as well as wellness and mental health.

Treatment/Management:

Interventions with individuals and groups and organizations.
Treatment of serious mental health disorders.
Treatment of individual, marital and family relationships problems.
Maintenance of wellness and disease prevention.
Management of psychological factors and problems associated with physical conditions and disease (e.g., diabetes, heart disease, stroke.)
Management of psychological factors in terminal and chronic illnesses such as cancer, brain injury, and degenerative brain diseases.
Treatment of addictions and substance use and abuse.
Pain management.
Assist with stress, anger and other aspects of lifestyle management.
Management of the impact and role of psychological and cognitive factors in accidents and injury, capacity, and competence one’s to manage personal affairs.
Treatment of problems associated with cognitive functioning such as learning, memory, problem solving, intellectual ability and performance.
Management of psychological factors related to work such as motivation, leadership, productivity, and healthy workplaces.
Administration of psychological services.

Education/Advocacy:

Public education regarding wellness and the promotion of mental health.
Implementation of primary and secondary prevention strategies.
Program development and evaluation.

Referrals/Collaboration:

Consultation relating to the assessment of or interventions with individuals and groups to facilitate the prevention or treatment of difficulties.
Referral to community agencies/services.

Counselors

Assessment:

Intake and assessment.
Develop treatment plan.

Treatment/Management:

Counsel individuals, couples and families.
Facilitate/run counseling groups (e.g., relapse prevention, guided self-change, anger management, stress management.)
Assess and adjust and adjust of treatment plans on an ongoing basis.
Develop discharge plan.

Education/Advocacy:

Provide information about community resources.
Assist patients accessing other services.

Referrals/Collaboration:

Advise physicians and other health care workers regarding indicators of substance abuse, relapse prevention and appropriate referral techniques.
Collaborate with physicians, psychologists, and other professionals regarding after care plan and follow-up activities.
Refer to community programs and mental health services.
Refer to psychologists, psychiatrists, and other professionals as appropriate.

Health Educators

Health educators teach clients, both individually and in groups, about various health topics. Although all members of the healthcare team are charged with client education, health educators are focused on providing adequate information to the client to assure understanding of the medical problem and treatment plan. These individuals may focus their educational efforts in health promotion and disease prevention activities that reduce the burden of disease in the community. Some health educators are utilized to provide in-depth instruction to clients about specific illnesses after being diagnosed.

Community health worker

Community Health Workers (CHW) can be broadly defined as individuals who connect healthcare consumers and providers, promoting health particularly among groups who have traditionally lacked access to care. The CHW is a member of the community and play an important role in identifying a community’s problems and in developing solutions. Examples of successful uses of the CHW include: using ex-addicts to educate intravenous drug users about AIDS risks and increasing breast, cervical, and colon cancer screening in minority communities. CHWs may play critical roles in improving community health status by providing cultural and technical linkages between community members, primary care providers, and the health care delivery system.

Assessment:

Intake Assessment.

Treatment/Management:

Facilitate coordinated access to services in areas such as assistance with daily living, housing, crisis intervention, treatment, health promotion and prevention.
Facilitate linkages with appropriate services, supports, and resources.
Provide crisis intervention and intensive/short-term support.
Evaluate achievement of patient goals.
Financial management: budgeting, banking.
Nutrition: menu planning, grocery shopping, food preparation.
Personal effectiveness: problem-solving, decision making, communication and interpersonal skills, goal- setting, time structuring and management.
Community integration: use of transit, social/recreational, peer support and other services.
Health and wellness: support clinical plan including medication, appointments, healthy choices and lifestyle.
Employment/service: support maximum involvement in volunteer, community service or paid employment.
Personal care: hygiene grooming, self-care skills, clothing maintenance.
Household management: such as laundry and house cleaning.
Housing support: finding and maintaining adequate housing, liaison/support to landlord, utilities.

Education/Advocacy:

Advocacy: support appropriate use of available community public services and programs.
Advocate for patient’s civil and legal rights.

Referrals/Collaboration:

Collaborate with other professionals regarding after care plan and follow-up activities.
Refer to community programs and mental health services.

Physiotherapists

Assessment:

Assess movement, strength, endurance and other physical abilities.
Assess the impact of an injury or disability on physical functioning.
Assess physical preparation for work and sports.
Evaluate pain and movement patterns, muscle balance, joint function, cardio-respiratory status, reflexes and sensation.
Examine relevant x-rays, lab tests, medical records and surgical notes.
Evaluate overall functional ability both in the workplace and in other activities of daily living.

Treatment/Management:

Plan treatment programs, which include education, to restore movement and reduce pain.
Provide individualized treatment of an injury or disability based on scientific knowledge, a thorough assessment of the condition, environmental factors and lifestyle.
Provide treatment which can include an individualized exercise program, manual therapy, modalities, as well as patient and family education and home exercise prescription.

Education/Advocacy:

Educate to restore movement and reduce pain.
Encourage patients/patient to take charge of their health by teaching techniques for recovery, pain relief, injury prevention and improved physical movement, with emphasis on what the patient can do for her/himself.
Promote independence and facilitate patients assuming responsibility for their rehabilitation and self-care.

Referrals/Collaboration:

Based on assessment the physiotherapist either plans an appropriate treatment program and carries it out or refers the patient to another professional.
Coordinates treatment with other providers.

Occupational therapists

Assessment:

Assessment of physical, emotional, and cognitive functioning with environmental considerations.
Evaluation of the home, work or school environment to assess the need for specialized equipment modifications and/or supports.

Treatment/Management:

Individualized treatment plans to develop, maintain, or augment function using evidence based treatment modalities.
Teaching daily living and community life skills.
Prescribing specialized adaptive equipment and teaching proper usage.
Modification of the physical and social home, work or school environments.

Education/Advocacy:

Educating and counseling family members and caregivers regarding the impact of disability, injury or disease on the individual and their potential role within the recovery process.
Educating and counseling to promote function and independence including health promotion and injury prevention.

Referrals/Collaboration:

Based on assessment the occupational therapist refers the individual to additional health care and community services as needed.
Collaborates with other health care professionals and community service providers to promote comprehensive and coordinated care.

Neurologists

Assessment:

Diagnosis, including differential diagnosis, of musculoskeletal disorders or referral for non-musculoskeletal complaints.
Ongoing evaluation of treatment/management outcomes using standard measurement tools.
Request/utilize X-Rays as authorized by the Healing Arts Radiation Protection Act.
Assessment or evaluation of workplace or home environments to inform treatment decisions and to provide ergonomic, activity, or other advice.

Treatment/Management:

Treatment of acute conditions and management of chronic or recurrent complaints with a focus on self-care.
Manual care including joint manipulation and mobilization and a wide variety of soft tissue techniques.
Electrotherapies such as ultrasound, electrical stimulation, laser, etc.
Planning, instruction, and supervision of therapeutic exercise programs.

Education/Advocacy:

Education for self-management of musculoskeletal conditions, including injury prevention, lifestyle and ergonomic advice.
Encouraging fundamental health promotion activities are integral to chiropractic practice.

Referrals/Collaboration:

Refer to physicians, physiotherapists, occupational therapists, psychologists, and others where appropriate.
Share care where the expertise of others is appropriate.
Communicate with other health professionals to facilitate patient care.

Volunteers

Volunteers are individuals that that provide services in the clinical setting with no monetary payment. They may be retired healthcare practitioners or citizens with a strong desire to provide public service to the community. Many clinics utilize these volunteers to perform a variety of jobs, such as interpreters, filing, answering telephones, or more patient oriented services, such as taking vital signs, assisting patients in completing forms, and assisting other health care team members.

Other Team Members

Other members of the interdisciplinary health care team may include: surgeons, ophthalmologists, ENT specialists, radiotherapists, laboratory technicians, speech and language therapists, and art or music therapists. The availability of these additional members of the health care team depends on the community served and the health care services offered.

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

Topic: Introduction to Ethical Standards (Sub-topic 1.1.1 to 1.1.8)
PEX 1.1.9: Introduction to the practice room
Sub-topic 1.1.10: Hospital economy

Revision Questions for Introduction to Ethical Standards:

1. In your own words, explain the meaning of the word 'nurse'.

2. Describe the key differences between nursing as a science and nursing as an art.

3. Who is considered the first known nurse mentioned in historical texts, and what was her role?

4. Briefly explain how nursing training started in Uganda.

5. What are the three main responsibilities of a nurse according to the ethical principles?

6. List at least five ethical standards or principles that guide a nurse's behavior.

7. Why is confidentiality important in nursing, and when can patient information be shared?

8. Give two examples of negligent actions that can result in harm to a patient.

9. What is the purpose of patient rights?

10. Explain the difference between criminal law and civil law in the context of nursing practice.

Nurses Revision

References (from Curriculum for CN-1111):

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

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

History Of Nursing Read More »

Introduction to Surgical Nursing

Nursing Notes - Surgical Nursing Introduction

Module Unit: CN-2103 - Surgical Nursing (I)

Contact Hours: 75

Credit Units: 5

Module Unit Description:

This module unit is intended to provide students with the opportunity to learn techniques and approaches of providing nursing care for conditions related to surgical attention. The content in this unit includes, introduction to surgical nursing, common surgical conditions, pre- and post-operative management, natural body defense mechanisms and specific surgical conditions.

Learning Outcomes:

Identify the common surgical conditions
Manage common surgical infections among pre-and post-operative patients
Identify surgical cases for referral
Apply infection prevention and control measures in the management of surgical conditions

INTRODUCTION TO SURGICAL NURSING

Definition of Surgery:

Surgery is a specialized branch of medicine that involves the diagnosis, treatment, and management of diseases, injuries, or deformities through physical intervention, typically by cutting, manipulating, or repairing tissues and organs. It is performed using a combination of manual and instrumental techniques.

HISTORICAL BACKGROUND OF SURGERY:

The history of surgery is a testament to humanity's continuous efforts to heal and improve health, evolving from rudimentary practices to highly sophisticated procedures.

Ancient Surgery: Early surgical practices were often rudimentary, driven by necessity, and based on empirical observations. Operations, though often crude, included trepanation (drilling holes in the skull), setting fractures, and wound care. Without understanding anatomy, physiology, or microbiology, these procedures were associated with immense pain and high mortality rates. Anesthesia was non-existent or relied on natural sedatives like opium or alcohol. Aseptic techniques were unknown, leading to rampant infections and septicemia. Practitioners were often individuals with practical skills, rather than formally trained medical professionals.

Transition and Early Modern Surgery: Significant advancements began in the 19th century with the revolutionary discoveries of anesthesia and antiseptic/aseptic techniques.

Anesthesia: The introduction of ether (by William Morton in 1846) and chloroform dramatically changed surgery by allowing patients to undergo painful procedures without consciousness or pain. This extended the duration and complexity of operations possible.
Antiseptic and Aseptic Techniques: Joseph Lister's work in the mid-19th century, applying Louis Pasteur's germ theory, led to the use of carbolic acid as an antiseptic. This drastically reduced post-operative infections and mortality. Aseptic techniques, emphasizing sterile environments, instruments, and surgical attire, further minimized contamination.

Modern Surgery: The 20th and 21st centuries have witnessed exponential growth in surgical capabilities, driven by:

Specialization: Emergence of distinct surgical specialties (e.g., cardiothoracic, neurosurgery, orthopedics).
Technological Advancements: Development of advanced imaging (X-rays, CT, MRI), minimally invasive techniques (laparoscopy, endoscopy), robotics, laser surgery, and microsurgery.
Improved Diagnostics and Pre-operative Care: Better understanding of patient physiology, improved diagnostic tools, and meticulous pre-operative preparation have significantly enhanced patient outcomes.
Post-operative Care: Advances in critical care, pain management, infection control, and rehabilitation have revolutionized recovery.
Formal Training and Research: Establishment of rigorous surgical training programs and continuous research contribute to evidence-based practices and innovation.

Implication of Surgery to Patients: From the patient's perspective, surgery has evolved from a terrifying last resort to a precise and often life-saving or quality-of-life-improving intervention. However, it still carries significant physical and psychological implications:

Physical Implications: Pain, risk of infection, bleeding, scarring, potential for complications related to anesthesia, and recovery time.
Psychological Implications: Anxiety, fear (of the unknown, pain, death, disfigurement), body image changes, loss of independence, and emotional distress.

Healthcare providers, especially nurses, must demonstrate empathy, provide comprehensive information, manage expectations, and offer psychological support to help patients navigate these implications.

TERMS USED IN SURGERY

Abscess: A localized collection of pus.
Adenoma: A benign epithelial tumour of glandular origin.
Aneurysm: Dilation of an artery/vein.
Colitis: Inflammation of the colon.
Dysplasia: Abnormal development or growth of tissue organs or cells.
Empyema: A collection of pus in a body cavity.
Cutaneous: Relating to or existing on or affecting the skin.
Gangrenous: Localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection.
Haematoma: A solid swelling of clotted blood within the tissues.
Haemorrhage: A heavy bleeding from a ruptured blood vessel.
Necrosis: Death of most or all of the cells in an organ or tissue due to disease, injury or failure of the blood supply and hence tissue death (ischemia).
Sepsis: The presence of pus-forming bacteria or their toxins in the blood or tissues.
Slough: A piece of dead soft tissue. Or a necrotic tissue separated from the living structure.
Stoma: Surgical opening/artificial opening made in an organ, especially an opening in the colon (colostomy) or ileum (ileostomy) made via the abdomen.
Suture: The fine thread or other material used surgically to close a wound or join tissues, an immovable joint (especially between the bones of the skull).
Thrombus: A blood clot that forms in a blood vessel and remains at the site of formation.
Infection: Is the invasion of the body tissue by pathogenic microorganisms.
Disinfectant: Is a chemical substance that is used for rendering only inanimate objects free from disease causing microorganisms with the exception of their spores. They include, phenol, chlorine.
Anti-septic solution: Is a substance that is used on a person’s skin to inhibit the growth and activity of micro-organisms, but not necessarily destroying them.
Contamination: Is the process by which something is rendered unclear or unsterile.
Carriers: Are people or animals that show no symptoms of illness but have pathogens on or in their bodies that can be transferred to others.
Disinfection: Is the elimination of virtually all pathogenic microorganism on inanimate objects with the exception of their spores, i.e., reducing the level of microbial contamination to an acceptably safe level.

COMMON SUFFIXES USED IN SURGERY

Angio: relating to blood vessels e.g. angiograms, contrast imaging of an artery
Antegrade: going in the direction of flow e.g. antegrade pyelogram; injection of contrast medium under imaging control into the renal pelvis percutaneously
Chole: related to the ability tree or bill e.g. cholelithiasis; gall stones
Cele: a cavity containing gas or fluid e.g. hydrocele, lymphocele, galactocele
Ectasia: related to dilation of the ducts e.g. sialectasia; dilation of salivary gland ducts
Ectomy: cutting something out e.g. gastrectomy
Gram: an imaging technique using radio-opaque contrast medium e.g. cholangiogram; to visualize the bile ducts
Lith: stone e.g. pyelolithotomy; removal of a stone from the renal pelvis by opening the renal pelvis
Oscopy: the inspection of a cavity, tube or organ with an instrument e.g. cystoscopy inspection of the bladder
Ostomy: opening something into another cavity or to the outside e.g colostomy; an opening of the colon on to the skin
Oma: denotes tumour/ neoplasm
Pyelo: relating to the pelvis of the kidney e.g. pyelogram; contrast imaging showing the renal pelvis
Otomy: making an opening in something e.g. laparotomy; exploring the abdomen
Per: going through a structure e.g. percutaneous; going through the skin
Plasty: refashioning something to alter functioning e.g. angio-plasty; to widen an obstruction in an artery
Retrograde: going in a reverse direction against the flow e.g. endoscopic retrograde, cholangiopancreatogram (ERC)
itis: denotes inflammation
rrhage: excessive flow
pnea: relates to breathing
rrhoea: means discharge
plegia: means paralysis
scopy: means examining
galy: relates to enlargement of an organ/structure
logy: study of
ase: related to enzyme
trans: going across a structure e.g percutaneous transluminal angioplasty

GENERAL CAUSES OF DISEASES

The study of causes of diseases is referred to as etiology.

THE GENERAL CAUSES INCLUDE:

Congenital: It’s when an individual is born with a disease in any of the organs due to damage in early weeks of development while in the uterus.
Hereditary: This is whereby an individual inherits (is passed on) the disease from the ancestors via genes e.g. sickle cell disease.
Traumatic: These include gunshots, surgical operations, excessive heat, or cold, corrosive chemicals, poisonous gases and electricity.
Mechanical: Those are any agencies that cause obstruction to the normal passages e.g. GIT, RT and blood vessels.
Deficiency: These are due to the absence of diet substances necessary for normal health, growth and replacement e.g. Kwashiorkor, Marasmus, Rickets, etc.
Metabolic disorders: Is the inability to deal with certain results of food. It may result in accumulation of unwanted chemical in the blood which may lead to trouble e.g. excess sugar in the blood which leads to diabetes mellitus.
Tumours: These are over growth of cells which have undergone changes that makes them multiply themselves. This can be benign or malignant.
Hypersensitivity: Some people are hypersensitive to small amounts of certain proteins and if exposed to them, they react. Hypersensitivity can be;
1. An allergy
2. Anaphylaxis.
Degenerative diseases: The ageing process usually results in various conditions e.g. osteo-arthritis, stroke etc.
Psychological factors: This can be an important cause of disease e.g. stress, anxiety, disappointments etc.

Aims of Surgery:

Surgery is performed with various objectives, often categorized by the primary goal of the intervention:

Diagnostic Purpose: To obtain tissue samples (e.g., biopsy) or to explore the body to confirm or determine the cause of a disease or condition.
Curative Purpose: To remove diseased tissue or an organ, repair damaged structures, or correct a deformity to cure a disease (e.g., appendectomy for appendicitis, tumor excision).
Palliative Purpose: To relieve symptoms or improve quality of life when a cure is not possible (e.g., tumor debulking to reduce pressure, colostomy for bowel obstruction).
Preventive Purpose (Prophylactic): To prevent the occurrence of a disease or complication in an at-risk individual (e.g., prophylactic mastectomy for high-risk breast cancer, removal of a precancerous polyp).
Reconstructive/Restorative Purpose: To repair or restore damaged tissue or organs, often after injury or disease (e.g., skin graft for burns, joint replacement).
Cosmetic Purpose: To improve physical appearance (e.g., rhinoplasty, facelift), though this often overlaps with reconstructive surgery.

Types and Classification of Surgery:

Surgery can be classified based on urgency, invasiveness, and purpose.

Classification by Urgency:

Emergency Surgery: Performed immediately to save a life, preserve function, or restore a vital body part (e.g., severe bleeding, ruptured appendix).
Urgent Surgery: Performed within 24-48 hours to address a condition that requires prompt intervention but is not immediately life-threatening (e.g., acute cholecystitis, kidney stones with obstruction).
Planned or Elective Surgery: Scheduled in advance, often to correct a non-life-threatening condition, improve quality of life, or for cosmetic reasons (e.g., cataract removal, hernia repair). This allows for thorough pre-operative assessment and patient preparation.

Classification by Extent/Magnitude:

Major Surgery: Involves significant risk, often requires general anesthesia, extensive tissue manipulation, and typically involves a longer hospital stay (e.g., open-heart surgery, organ transplantation).
Minor Surgery: Involves minimal risk, often performed under local or regional anesthesia, limited tissue manipulation, and may be done in an outpatient setting (e.g., removal of a skin lesion, carpal tunnel release).

Other Classifications:

Multistage Surgery: Procedures performed in several separate operations to achieve a complete outcome, often due to the complexity of the condition or the patient's recovery needs (e.g., reconstructive surgery after severe trauma).
Invasiveness:
- Open Surgery: Involves a large incision to access the surgical site.
- Minimally Invasive Surgery: Performed through small incisions using specialized instruments and cameras (e.g., laparoscopic surgery, robotic surgery, endoscopic surgery).

Principles of Surgery:

Fundamental principles guide surgical practice to ensure patient safety and optimal outcomes.

Safe Administration of Anesthesia: Ensuring the patient's physiological stability and comfort throughout the procedure, minimizing risks associated with anesthetic agents.
Asepsis and Infection Control: Strict adherence to sterile techniques to prevent surgical site infections, including meticulous hand hygiene, sterile draping, and instrument sterilization.
Hemostasis (Control of Bleeding): Meticulous control of bleeding to maintain patient's circulatory volume and provide a clear surgical field.
Gentle Tissue Handling: Minimizing trauma to tissues to promote healing and reduce post-operative pain and complications.
Accurate Anatomical Dissection: Precise identification and manipulation of anatomical structures to avoid damage to vital organs and achieve the surgical objective.
Prevention/Treatment of Circulatory Failure: Maintaining adequate fluid balance, blood pressure, and tissue perfusion throughout the perioperative period.
Quick and Effective Wound Healing: Employing proper surgical closure techniques, providing optimal wound care, and managing factors that can impair healing.
Prevention/Treatment of Complications: Proactive identification and management of potential complications such as DVT, pulmonary embolism, respiratory compromise, and organ dysfunction.
Restoration of Function: The ultimate goal of many surgeries, aiming to return the affected body part or system to its normal or near-normal function.
Patient Safety and Advocacy: Prioritizing patient well-being, verifying correct patient and site, and advocating for the patient throughout the surgical journey.

Patient's Concept of Disease:

A patient's concept of their disease significantly influences their acceptance of surgical intervention, adherence to pre- and post-operative instructions, and overall recovery. This concept is shaped by a multitude of factors, including:

Personal Beliefs and Experiences: Prior experiences with illness, surgery, or healthcare, as well as personal beliefs about health and illness, can heavily influence a patient's understanding and emotional response to a new diagnosis.
Cultural Background: Cultural beliefs about the causation of disease (e.g., spiritual, supernatural, environmental), traditional healing practices, and societal roles can affect how a patient perceives their illness and the proposed surgical treatment.
Socioeconomic Status: Access to information, educational background, and financial stability can impact a patient's ability to understand complex medical information and comply with treatment plans.
Emotional State: Feelings of fear, anxiety, depression, or denial can distort a patient's perception of their illness and their capacity to process information about their condition.
Information Received: The clarity, completeness, and manner in which information about the disease and surgery is conveyed by healthcare professionals plays a crucial role. Misinformation or lack of understanding can lead to mistrust or non-adherence.
Support Systems: The presence or absence of family and social support can influence a patient's emotional well-being and ability to cope with their illness and recovery.
Perceived Severity and Impact: How serious the patient perceives their condition to be, and its anticipated impact on their life, livelihood, and family, will shape their perspective.

Nurses play a critical role in assessing and understanding the patient's concept of disease, clarifying misconceptions, providing culturally sensitive care, and offering appropriate emotional and educational support.

Factors Affecting the Success of Surgical Care:

The success of surgical care is multifaceted, extending beyond the technical proficiency of the surgeon. It encompasses a complex interplay of patient-related, disease-related, surgical team-related, and systemic factors.

Patient-Related Factors:

Overall Health Status and Comorbidities: Pre-existing conditions (e.g., cardiovascular disease, diabetes, renal impairment, malnutrition, obesity) can significantly impact surgical risk, recovery, and susceptibility to complications.
Age: Extremes of age (very young or very old) often present unique physiological challenges and increased risks.
Nutritional Status: Poor nutrition can impair wound healing, immune function, and overall recovery.
Psychological State: High levels of anxiety, stress, or depression can negatively affect pain perception, immune response, and patient cooperation.
Compliance with Pre/Post-operative Instructions: Adherence to dietary restrictions, medication regimens, and post-operative rehabilitation is crucial for optimal outcomes.
Lifestyle Factors: Smoking, alcohol consumption, and substance abuse can increase surgical risks and hinder recovery.

Disease-Related Factors:

Severity and Stage of Disease: Advanced disease or critical conditions generally carry higher surgical risks and potentially less favorable outcomes.
Type and Location of Pathology: The nature of the condition and its anatomical location can influence surgical complexity and potential for complications.
Presence of Infection: Active infection at the surgical site or systemically can increase the risk of complications and delay healing.

Surgical Team and Process Factors:

Surgeon's Expertise and Experience: The skill, experience, and specialization of the surgical team directly influence the technical success of the procedure.
Anesthesia Management: Safe and effective administration of anesthesia, tailored to the patient's needs and the procedure, is vital.
Aseptic Technique and Infection Control: Strict adherence to sterilization and aseptic practices minimizes the risk of surgical site infections.
Pre-operative Assessment and Optimization: Thorough evaluation of the patient before surgery to identify and mitigate risks.
Intra-operative Management: Meticulous surgical technique, proper hemostasis, and efficient management of the surgical environment.
Post-operative Care: Comprehensive nursing care, pain management, early mobilization, and monitoring for complications.
Team Communication and Coordination: Effective communication among all members of the multidisciplinary surgical team (surgeon, anesthesiologist, nurses, technicians) is paramount for seamless and safe care.

Systemic and Environmental Factors:

Availability of Resources: Access to appropriate equipment, technology, blood products, and medical supplies.
Hospital Infrastructure and Policies: Quality of facilities, staffing levels, and adherence to evidence-based protocols.
Access to Follow-up Care: Availability of timely and appropriate post-discharge care, including rehabilitation and specialist consultations.
Socioeconomic Support Systems: Patient's access to social support, transportation, and home care resources after discharge.

ANESTHESIA

Introduction

Anesthesia is a critical component of modern surgical practice, derived from the Greek word "anaisthesia," meaning "without sensation." It is a pharmacologically induced and reversible state characterized by controlled and temporary loss of sensation, consciousness, or both, enabling painful medical procedures or surgical operations to be performed without the patient experiencing pain, touch, pressure, or temperature. The primary aim is to ensure patient comfort, safety, and cooperation during invasive procedures.

Medications that cause anesthesia are called anesthetics. These agents work by interfering with the transmission of nerve signals to the brain, thereby preventing the processing of painful stimuli. When the anesthetic effect wears off, nerve signals resume normal function, and sensation returns.

How Anesthetics Work

Anesthetics exert their effects by interacting with various components of the nervous system, primarily by altering the flow of ions across nerve cell membranes, which in turn inhibits the generation and propagation of electrical signals (nerve impulses). Specifically:

They can block voltage-gated sodium channels in nerve axons, preventing the initiation and conduction of action potentials (nerve signals).
They can enhance the activity of inhibitory neurotransmitters (like GABA) or suppress excitatory neurotransmitters, leading to a general depression of central nervous system activity.
The precise mechanisms vary depending on the class of anesthetic (e.g., local anesthetics directly block nerve conduction, while general anesthetics primarily affect the brain and spinal cord).

By stopping these nerve signals from reaching the brain, anesthetics allow medical procedures to be carried out without the patient experiencing pain or awareness. As the anesthetic is metabolized and eliminated from the body, its effects dissipate, allowing nerve signals to function normally and sensation to return.

Types of Anesthesia

Anesthesia is categorized based on the extent of the body affected and the level of consciousness maintained:

Local Anesthesia: This involves numbing a small, specific area of the body by injecting an anesthetic agent directly into the tissues around the nerves supplying that area. The patient remains fully conscious but does not feel pain in the numbed region. It is typically used for minor procedures (e.g., dental procedures, suturing a small cut, skin biopsies).
Regional Anesthesia: This type of anesthesia blocks sensation in a larger region of the body, such as an entire limb or the lower half of the body, by injecting anesthetic near a cluster of nerves (nerve block) or into the spinal canal. The patient typically remains conscious but may be sedated.
- Spinal Anesthesia: Anesthetic is injected into the cerebrospinal fluid (CSF) in the subarachnoid space surrounding the spinal cord. This rapidly produces profound numbness and muscle relaxation in the lower body, used for lower abdominal, pelvic, or lower limb surgeries.
- Epidural Anesthesia: Anesthetic is injected into the epidural space (outside the dura mater, the outermost membrane covering the spinal cord). A catheter can be left in place to allow for continuous or repeated administration of medication, providing prolonged pain relief. Commonly used for childbirth (labor analgesia) and surgeries of the lower body.
- Peripheral Nerve Blocks: Anesthetic is injected near specific nerves or nerve plexuses (networks of nerves) to numb a particular limb or area (e.g., brachial plexus block for arm surgery, femoral nerve block for leg surgery).
General Anesthesia: This induces a state of controlled, reversible unconsciousness, where the patient is completely unaware and experiences no pain or memory of the procedure. It involves a combination of medications administered intravenously and/or by inhalation. The patient's vital functions (breathing, heart rate) are carefully monitored and supported, often requiring mechanical ventilation. It is used for major surgeries or procedures that require the patient to be completely still and unaware.
Sedation: This involves administering medications to depress the central nervous system, producing a state of reduced awareness, relaxation, and sometimes amnesia, but the patient remains able to respond to verbal commands or light tactile stimulation. It is used for uncomfortable or anxiety-provoking procedures that do not require full general anesthesia (e.g., colonoscopy, some dental procedures, minor orthopaedic reductions). Levels can range from minimal (anxiolysis) to deep sedation.

Route of Administration of Anesthetics

The method of delivery depends on the type of anesthesia and the specific agent used:

Inhalation: Volatile liquid anesthetics (e.g., Sevoflurane, Isoflurane) are vaporized and delivered as gases through a mask or endotracheal tube into the patient's respiratory system for general anesthesia. Nitrous oxide is also given via inhalation.
Intravenous (IV): Many anesthetic agents (e.g., Propofol, Ketamine, Midazolam, Fentanyl) are administered directly into the bloodstream through a vein, used for induction of general anesthesia, maintenance of anesthesia, or for sedation.
Local Infiltration: Anesthetic is injected directly into the tissue surrounding the surgical site (e.g., Lidocaine for suturing a wound).
Regional Injection: Anesthetic is injected near specific nerves or into the epidural or subarachnoid space (e.g., Bupivacaine for spinal or epidural blocks).
Topical/Transdermal: Applied to the skin or mucous membranes (e.g., lidocaine cream for numbing skin before an injection, sprays for throat numbing).

Side Effects of Anesthetics

While generally safe, anesthetics can cause various side effects, most of which are temporary and manageable:

Gastrointestinal: Feeling sick (nausea) or vomiting, which can be managed with antiemetics.
Neurological: Dizziness and feeling faint, headache (especially after spinal or epidural anesthesia), confusion or disorientation (particularly in older adults).
Temperature Regulation: Feeling cold and shivering (post-anesthesia shivering is common).
Local Reactions: Bruising and soreness at the injection site (for local or regional blocks).
Skin Reactions: Itchiness (especially with opioid use).
Throat Irritation: Sore throat or hoarseness (after endotracheal intubation for general anesthesia).
Muscle Aches: Generalized muscle pain from muscle relaxants used during general anesthesia.

Complications and Risks of Anesthesia

Serious complications are rare but can occur and are usually discussed during the pre-operative consent process:

Allergic Reactions: Severe allergic reactions (anaphylaxis) to anesthetic agents, though rare, can be life-threatening.
Cardiovascular Complications: Hypotension (low blood pressure), arrhythmias (irregular heartbeats), myocardial infarction (heart attack), or stroke, particularly in patients with pre-existing cardiac conditions.
Respiratory Complications: Respiratory depression, aspiration of gastric contents into the lungs (pneumonitis), bronchospasm, or laryngospasm.
Nerve Damage: Temporary or, rarely, permanent nerve damage (causing prolonged numbness, weakness, or paralysis) due to direct trauma from injection or compression.
Malignant Hyperthermia: A rare, life-threatening genetic condition triggered by certain general anesthetics, leading to a rapid rise in body temperature and muscle rigidity.
Awareness During Anesthesia: A rare occurrence where a patient gains some level of consciousness during general anesthesia.
Death: Extremely rare, but possible, particularly in patients with severe underlying health conditions.

Nurse’s Role in Surgical Diagnosis

The nurse plays a pivotal and continuous role in the diagnostic phase of surgical care. While the surgeon makes the definitive diagnosis, the nurse's observations, assessments, and data collection are crucial for accurate, timely, and holistic diagnosis, contributing significantly to the patient's care plan.

Taking a Comprehensive Patient History: The nurse often conducts the initial and ongoing patient assessments, collecting subjective data through detailed history taking. This includes the chief complaint, history of present illness, past medical and surgical history, family history, social history (e.g., smoking, alcohol, substance use), medication history, allergies, and review of systems. Proper documentation of this history is essential for the medical team.
Performing Physical Assessments and Documenting Observations: The nurse regularly performs physical assessments (e.g., vital signs, head-to-toe assessment, focused assessment on the affected area). Accurately recording and monitoring these objective observations (e.g., temperature, pulse, respiration, blood pressure, pain level, wound characteristics, changes in patient condition) provides critical data points for diagnostic reasoning.
Assisting with Diagnostic Procedures and Examinations: The nurse prepares the patient and the environment for physical examinations and various diagnostic tests. This includes setting up equipment (e.g., for physical exam, wound assessment), ensuring patient comfort and privacy, providing explanations of procedures, and assisting the physician as needed during examinations or specimen collection.
Carrying Out Ordered Investigations and Other Orders: The nurse is responsible for ensuring that prescribed diagnostic tests (e.g., blood tests, imaging studies like X-rays, CT scans, MRI, ECG) are performed correctly and that specimens are collected and transported appropriately. This includes preparing the patient for the test (e.g., NPO status, contrast dye administration), verifying orders, and ensuring patient safety during the process.
Patient Education and Preparation: Explaining the purpose of diagnostic tests and procedures to the patient, ensuring understanding and compliance.
Recognizing and Reporting Changes: Constantly observing the patient for changes in symptoms, physical signs, or responses to interventions, and promptly reporting significant findings to the medical team.
Advocacy: Advocating for the patient's needs and ensuring that all necessary diagnostic steps are taken to arrive at an accurate diagnosis.

Identification of a Patient (Patient Safety and Verification)

Correct patient identification is a fundamental and non-negotiable principle in healthcare, especially in the surgical setting, to prevent errors and ensure patient safety. Errors in patient identification can lead to wrong-patient, wrong-site, or wrong-procedure surgeries, medication errors, and incorrect test results.

Using Multiple Identifiers: Patients should be identified by at least two unique identifiers, never by room or bed number alone. Acceptable identifiers include:
- Patient's full name (first and last).
- Date of birth.
- Medical record number.
Active Patient Participation: Whenever possible, the patient should be actively involved in the identification process by stating their name and date of birth. Nurses should be aware that some patients may respond "yes" when another patient's name is called due to confusion, hearing impairment, or a desire to be cooperative; therefore, asking open-ended questions like "Can you please state your full name and date of birth?" is crucial.
Addressing Bed Swaps: Nurses must be vigilant about potential bed or room changes without their knowledge. Re-identification of the patient should occur at every significant interaction, including medication administration, before procedures, and before transport.
Site Marking for Surgical Procedures: For procedures involving laterality (e.g., right vs. left limb), multiple structures (e.g., specific finger), or levels (e.g., spinal surgery), the surgical site should be clearly and unambiguously marked by the surgeon with indelible ink while the patient is awake and involved in the process. This is a critical component of the "Universal Protocol" for preventing wrong-site, wrong-procedure, wrong-person surgery.
"Time Out" Procedure: Immediately before the start of any invasive procedure, a "time out" (or pause for cause) is performed by the entire surgical team. During this time-out, the team collectively confirms:
- The correct patient.
- The correct site.
- The correct procedure.
- Availability of correct implants/equipment.
This final verification step is a crucial safety barrier.
Wristbands/Identification Bands: Patients should wear identification wristbands with their unique identifiers throughout their hospital stay. These should be checked against medical records before any intervention.

DECONTAMINATION

Decontamination is a crucial initial step in the reprocessing of reusable medical instruments and equipment. It refers to the process of physically or chemically removing or neutralizing harmful substances, particularly pathogenic microorganisms, from objects or surfaces to render them safe for subsequent handling, cleaning, and sterilization. The goal of decontamination is to protect healthcare workers from exposure to potentially infectious materials and to prevent cross-contamination.

Principles of Decontamination:

Risk Reduction: Reduces the bioburden (number of microorganisms) on instruments, making them safer to handle for staff involved in cleaning and sterilization.
Immediate Action: Should occur as soon as possible after use to prevent drying of organic matter (blood, tissue), which makes cleaning more difficult.
Personal Protective Equipment (PPE): Healthcare workers involved in decontamination must wear appropriate PPE, including gloves, gowns, masks, and eye protection, to prevent exposure to contaminants.

Methods of Decontamination:

Manual Cleaning (Pre-cleaning):
- Initial step often done at the point of use or in a designated decontamination area.
- Involves rinsing instruments with cool water to remove gross contamination, followed by scrubbing with brushes using enzymatic detergents or neutral pH detergents.
- This step is critical as sterilization cannot compensate for inadequate cleaning.
Automated Cleaning:
- Ultrasonic Cleaners: Use high-frequency sound waves to create cavitation bubbles that dislodge debris from instruments, especially in hard-to-reach areas.
- Washer-Disinfectors: Automated machines that clean and thermally disinfect instruments, rendering them safe for handling before sterilization. They often include pre-rinse, wash, rinse, and thermal disinfection cycles.
Chemical Decontamination:
- Use of chemical solutions to kill or inactivate microorganisms. Often used for heat-sensitive instruments or for surface disinfection.
- Examples include glutaraldehyde or hydrogen peroxide solutions, but these are typically for high-level disinfection rather than full sterilization.

Importance in Surgical Nursing:

Nurses are often responsible for the initial decontamination at the point of use (e.g., wiping instruments during surgery) and ensuring proper transport of soiled instruments to the central sterile supply department.
Understanding decontamination processes is vital for preventing surgical site infections and maintaining a safe environment for both patients and staff.

STERILIZATION

Sterilization is the process by which all forms of microbial life, including bacteria, viruses, fungi, and highly resistant bacterial spores, are completely destroyed or removed from an object or surface. It represents the highest level of microbial killing and is essential for any medical device or instrument that will come into contact with sterile body tissues or the bloodstream during surgical procedures. The aim is to prevent healthcare-associated infections (HAIs).

Key Principles of Sterilization:

"All or Nothing": An item is either sterile or not sterile; there are no degrees of sterility.
Packaging Integrity: Sterile items must remain in intact, undamaged packaging until the point of use to maintain sterility.
Time-Related or Event-Related Sterility: Sterility is maintained until the package is opened, damaged, or expires, depending on the storage conditions and packaging.
Cleaning First: Sterilization cannot effectively occur if instruments are not thoroughly cleaned and decontaminated beforehand.

Common Methods of Sterilization:

Steam Sterilization (Autoclaving):
- The most common, reliable, and cost-effective method for heat- and moisture-stable items.
- Uses saturated steam under pressure at high temperatures (e.g., 121°C or 132°C) for a specific duration.
- Works by denaturing and coagulating proteins within microorganisms.
Dry Heat Sterilization:
- Used for materials that can be damaged by moisture (e.g., powders, oils, heat-stable glassware).
- Involves exposure to high temperatures (e.g., 160°C to 170°C) for longer periods than steam sterilization.
- Works by oxidation of cell components.
Ethylene Oxide (EtO) Sterilization:
- Used for heat- and moisture-sensitive medical devices.
- A colorless, flammable gas that kills microorganisms by alkylation of proteins and nucleic acids.
- Requires a lengthy aeration time to dissipate residual EtO, which is toxic and carcinogenic.
Hydrogen Peroxide Gas Plasma Sterilization (e.g., Sterrad):
- A low-temperature sterilization method suitable for heat- and moisture-sensitive instruments.
- Uses hydrogen peroxide vapor in a plasma state, which generates reactive free radicals that destroy microorganisms.
- Faster cycle times and safer than EtO as it produces non-toxic byproducts (water and oxygen).
Peracetic Acid Sterilization (e.g., Steris System):
- A liquid chemical sterilant used for immersible, heat-sensitive instruments, often used for flexible endoscopes.
- Rapidly destroys microorganisms by oxidation.

Monitoring Sterilization:

Sterilization processes are monitored using various indicators to ensure effectiveness:

Mechanical Indicators: Gauges and displays on the sterilizer that show temperature, pressure, and exposure time.
Chemical Indicators: Tapes, strips, or packages that change color when exposed to specific sterilization conditions (e.g., heat, steam, EtO). They indicate that the item has been processed, but not necessarily that it is sterile.
Biological Indicators: Vials containing highly resistant bacterial spores (e.g., Geobacillus stearothermophilus for steam, Bacillus atrophaeus for EtO/dry heat). These are the only indicators that directly monitor the lethality of the sterilization process by demonstrating whether the most resistant organisms have been killed.

Role of the Nurse in Sterilization:

Understanding the principles of sterility and aseptic technique.
Checking the integrity of sterile packaging before opening.
Maintaining a sterile field during surgical procedures.
Properly handling and storing sterile supplies.
Advocating for correct sterilization practices within the healthcare setting.

CONSENT IN SURGICAL NURSING (INFORMED CONSENT)

Informed consent is a cornerstone of ethical and legal medical practice, particularly in surgical nursing. It is a process by which a patient, or their legally authorized representative, grants voluntary permission for a medical procedure or treatment only after receiving and comprehending all relevant information about it. This ensures patient autonomy and protects their right to self-determination regarding their healthcare decisions.

Key Elements of Valid Informed Consent:

Disclosure of Information: The healthcare provider (typically the physician or surgeon performing the procedure) must provide the patient with comprehensive information, including:
- The nature of the proposed procedure or treatment.
- The purpose of the procedure (what it aims to achieve).
- The expected benefits of the procedure.
- The potential risks, common side effects, and serious complications associated with the procedure (including those related to anesthesia).
- Available alternative treatments, including their risks and benefits.
- The consequences of not undergoing the proposed procedure.
Patient Understanding: The patient must be able to comprehend the information provided. The information should be presented in a language and manner understandable to the patient, avoiding medical jargon. The provider should assess the patient's understanding by asking open-ended questions.
Voluntariness: The patient's decision to consent or refuse treatment must be made freely, without any form of coercion, manipulation, or undue pressure from healthcare providers, family, or others.
Competence/Capacity: The patient must have the mental capacity to make healthcare decisions. This means they must be able to understand the information, appreciate the consequences of their decision, and communicate their choice. If a patient is deemed incompetent (e.g., due to severe cognitive impairment, unconsciousness), a legally appointed surrogate decision-maker (e.g., power of attorney for healthcare, legal guardian, next of kin in a hierarchical order defined by law) will provide consent on their behalf.

Role of the Nurse in Informed Consent:

While the responsibility for obtaining informed consent rests with the physician performing the procedure, nurses play a crucial and multifaceted role in the informed consent process:

Reinforcing Information and Clarifying: Nurses often reinforce the information provided by the physician, clarify any misunderstandings the patient may have, and answer questions within their scope of practice. They should not provide new information that changes the scope of the consent.
Assessing Patient Understanding: Nurses are frequently present during the consent discussion or review the consent form with the patient. They can assess the patient's comprehension and identify if the patient has further questions or appears to be unduly influenced.
Witnessing the Signature: Nurses often witness the patient's signature on the consent form. By witnessing, the nurse is verifying that the patient signed the form and that, to their knowledge, the patient appeared to be competent and voluntarily signed. It does not imply that the nurse provided all the information or explained the procedure.
Advocating for the Patient: If a nurse believes the patient does not understand the information, is being coerced, or is not competent, they have an ethical responsibility to advocate for the patient. This may involve notifying the physician, nursing supervisor, or ethics committee.
Documentation: Accurately documenting the informed consent process, including who provided information, when it was discussed, and any patient questions or concerns, is essential.
Ensuring Valid Consent Before Procedures: Before any surgical procedure, the nurse is responsible for verifying that a valid informed consent form is present in the patient's chart and that it is complete and signed.

Informed consent is an ongoing process, not a one-time event, and applies to changes in treatment plans or additional procedures that may arise during the course of care.

Introduction to Surgical Nursing Read More »

Apnea

APNEA

Apnea is defined as sudden cessation of breathing for more than 20 seconds in full term babies.

It is often associated with Bradycardia and cyanosis. Bradycardia (below 80-100 beats /minute) appears 30 seconds after cessation of respiration.

Apnea is more common in preterm infants, and in this case, it is referred to as Apnea of prematurity and requires a specific assessment and treatment. It is rare among full-term healthy infants and if present, usually indicates an underlying pathology.

Apnea is a disorder of respiratory control and may be: obstructive, central, or mixed.

Types of Apnea

Central Apnea: This occurs due to a depressed respiratory center. This means it is caused by a failure of the brain to send the necessary signals to the muscles involved in breathing.
Obstructive Apnea: Occurs due to obstruction of the airway. This type is caused by a blockage of the airway, often due to the soft tissues of the throat collapsing during sleep.
Mixed Apnea: This type is a combination of both central and obstructive apnea.

NB: Short episodes of apnea are usually central whereas prolonged ones are often mixed.

Causes of Apnea

Immature Respiratory System: Premature babies have underdeveloped respiratory systems, making them more susceptible to apnea.
Brain Immaturity: The brains of premature babies are still developing, and they may not be able to regulate breathing as effectively as full-term babies.
Neurological Problems: Some premature babies may have neurological problems that affect their breathing.
Systemic disorders: e.g
Cardiovascular: Anemia, hypo / hypertension, patent ductus arteriosus,coarctation of the aorta (conditions that impair oxygenation)
Central nervous system: Intraventricular haemorrhage, intracranial haemorrhage, brainstem infarction or anomalies, birth trauma, congenital malformations (conditions that will increase intracranial pressure)
Respiratory: Pneumonia, intrinsic / extrinsic mass or lesions causing airway obstruction, upper airway collapse, atelectasis, respiratory distress syndrome, meconium aspiration, pulmonary haemorrhage (conditions that cause impairment of ventilation and oxygenation)
Gastrointestinal: Oral feeding, bowel movement, gastro esophageal reflux, necrotizing enterocolitis
Metabolic: Hypoglycemia, hypocalcaemia, hypo / hypernatraemia, hyperammonemia, low organic acids, hypo / hyperthermia
Infection: Respiratory infections can worsen apnea in premature babies e.g meningitis or encephalitis.
Medications: Certain medications used in premature babies can also cause apnea. Maternal prenatal exposure drugs through transplacental transfer and postnatal exposure e.g. opiates, high levels of phenobarbitone, or other sedatives, general anesthetic.
Pain: Acute and chronic.
Head and neck poorly positioned
Toxin exposure

Clinical features of apnea

Episodes of no breathing: This is the most obvious sign of apnea.
Decreased heart rate(Bradycardia): Apnea can also cause a decrease in heart rate.
Change in skin color(Cyanosis): The baby’s skin may turn blue or pale during an episode of apnea.
Irritability: Some babies with AOP may be irritable or fussy.
Poor feeding: Apnea can make it difficult for babies to feed.

Management of Apnea

Aims of Management

Maintain Adequate Oxygenation: Ensure the infant receives enough oxygen to prevent hypoxemia (low blood oxygen levels) and its associated complications.
Support Respiratory Function: Provide assistance to the infant’s respiratory system to maintain adequate breathing and prevent episodes of apnea.
Prevent Complications: Minimize the risk of potential complications associated with AOP, such as brain damage, developmental delays, and long-term respiratory issues.

Assessment

Check the infant for signs of breathing and skin colour, if apnoeic, pale, and cyanotic or has Bradycardia give tactile stimulation
Find out about the frequency and duration of episodes, level of hypoxia and degree of stimulation needed.

Note: If the infant doesn’t respond, use bag and mask ventilation along with suctioning and airway positioning

All babies born before 34 weeks of pregnancy (premature babies) should have their heart rate, breathing, and oxygen levels closely watched for at least the first week of their life. This monitoring continues until they have gone a full week without any pauses in breathing (apnea).
Above 34 weeks gestation neonates only need to be monitored if they are unstable.

Acute management

Positioning: Ensure the neonate’s head and neck are positioned correctly (head and neck in neutral position) to maintain a patent airway.
Tactile stimulation: Gentle rubbing of soles of feet or chest wall is usually all that is required for episodes that are mild and intermittent.
Clear airway: Suction mouth and nostrils.
Provision of positive pressure ventilation: May be required until spontaneous respirations resume. If positive pressure ventilation is required to treat apneic episodes mechanical ventilation should be considered.
Continuous Positive Airway Pressure (CPAP); is effective in treating both mixed and obstructive apnea but not central. It’s most commonly delivered by nasal prongs or endotracheal tube. It works by improving lung volume and reduces inspiratory duration hence preventing airway collapse. It also increases stabilization of the chest wall musculature

Ongoing management

Pulse oximeter. Detects changes in the heart rate, respiratory rate and oxygen saturation due to apnoeic episodes.
Identify cause: If apnea is not physiologic, investigate to identify underlying cause and treat appropriately.
Apnea monitor: This detects abdominal wall movement and may alarm falsely with normal periodic breathing.
Caffeine citrate: it can be given orally or intravenously and is usually routinely given to neonates <34 weeks gestation. It acts as a smooth muscle relaxant and a cardiac muscle and central nervous system stimulant.
High flow nasal Cannula (HFNC): This is especially effective with mixed and obstructive apneas. Often used when treatment with caffeine has failed.
Mechanical ventilation: This is used when caffeine and HFNC and CPAP have been tried and there are still significant apneas. It is effective in all types of apnea.

Medical Management

Methylxanthines are a class of medications commonly used to manage apnea. These include caffeine, theophylline, and theobromine. They work by blocking adenosine receptors. Adenosine naturally inhibits respiratory drive, but methylxanthines counteract this effect, stimulating respiratory neurons and enhancing ventilation.

Two commonly used methylxanthines are:

Caffeine Citrate: Due to its longer half-life and lower toxicity, caffeine citrate is often preferred for routine management of AOP, especially in premature infants.
- Loading Dose: 20 mg/kg, administered either intravenously (IV) or orally (P.O.).
- Maintenance Dose: 5 mg/kg/day.
Theophylline: Theophylline acts as a bronchodilator, making it particularly beneficial for neonates with bronchopulmonary dysplasia (BPD) as it addresses both apnea and bronchospasm.
- Loading Dose: 6 mg/kg/dose, administered IV or P.O.
- Maintenance Dose: 6 mg/kg/day, divided into six hourly doses.

Documentation and Family-Centered Care

Documentation: Ensure all apnea episodes are well documented, including the interventions required to correct them, the frequency of episodes, and their duration.
Parental Education:
- Explain the cause of apnea and the rationale behind treatment approaches (e.g., antibiotics for infection).
- Reassure parents that AOP is a common occurrence in premature infants and will typically resolve by 34 weeks gestation.
- Clearly explain all interventions, such as caffeine administration, continuous positive airway pressure (CPAP), or mechanical ventilation, and emphasize their importance in managing the condition.

Nursing care plan for a pediatric patient with Apnea

Assessment	Nursing Diagnosis	Goals/Expected Outcomes	Interventions	Rationale	Evaluation
1. Child presents with episodes of apnea lasting more than 20 seconds, cyanosis, and bradycardia (heart rate < 100 bpm).	Ineffective Breathing Pattern related to immature respiratory control as evidenced by episodes of apnea, cyanosis, and bradycardia.	The child will maintain effective breathing patterns with no episodes of apnea, and oxygen saturation will remain above 95%.	– Continuously monitor the child’s respiratory rate, effort, and oxygen saturation using a cardiorespiratory monitor. – Position the child in a supine or side-lying position with the head slightly elevated to facilitate airway patency. – Administer oxygen as prescribed to maintain adequate oxygenation during and after apneic episodes. – Stimulate the child gently (e.g., rub the back or flick the soles) during apneic episodes to prompt breathing. – Prepare for possible resuscitation if apnea persists despite stimulation.	Continuous monitoring helps detect apneic episodes and guide interventions. Proper positioning promotes airway patency and reduces the risk of obstructive apnea. Administering oxygen improves oxygenation during apneic episodes. Gentle stimulation often restarts breathing in infants with apnea. Resuscitation may be necessary in severe cases to restore breathing.	The child maintains a normal breathing pattern, with no further episodes of apnea, and oxygen saturation remains within the target range.
2. Child exhibits signs of fatigue and decreased responsiveness between apneic episodes.	Activity Intolerance related to recurrent apneic episodes as evidenced by fatigue and decreased responsiveness.	The child will exhibit improved activity tolerance with increased periods of alertness and responsiveness.	– Allow for rest periods between feedings and activities to reduce fatigue. – Monitor the child’s energy levels and responsiveness closely, adjusting activity levels as needed. – Educate parents on the importance of providing a calm, low-stimulation environment to promote rest. – Provide small, frequent feedings to minimize energy expenditure during feeding.	Rest periods help conserve the child’s energy and prevent excessive fatigue. Close monitoring allows for timely adjustments to activity levels based on the child’s energy reserves. A calm environment reduces stress and supports the child’s recovery. Small, frequent feedings reduce the effort required during feeding, conserving energy.	The child demonstrates improved activity tolerance, with increased alertness and responsiveness between rest periods.
3. Parents express anxiety about the child’s condition and fear of apneic episodes occurring at home.	Anxiety related to fear of apneic episodes and uncertainty about the child’s condition as evidenced by parental verbalization of concern.	The parents will verbalize understanding of the child’s condition and demonstrate confidence in managing apneic episodes at home.	– Provide clear, concise information to the parents about apnea, including causes, signs, and interventions. – Teach parents how to monitor the child’s breathing and how to respond to apneic episodes at home, including the use of home monitoring equipment if prescribed. – Offer emotional support and reassurance, acknowledging the parents’ feelings and concerns. – Encourage parents to ask questions and participate in the child’s care to increase their confidence.	Educating parents helps reduce anxiety by providing them with the knowledge and skills needed to manage the child’s condition. Hands-on teaching and use of monitoring equipment empower parents to respond effectively to apneic episodes. Emotional support reassures parents and validates their concerns. Involving parents in care increases their confidence and sense of control.	The parents verbalize understanding of the child’s condition, demonstrate correct management of apneic episodes, and express increased confidence in caring for their child at home.
4. Child is at risk for impaired gas exchange due to recurrent apneic episodes.	Risk for Impaired Gas Exchange related to apneic episodes and immature respiratory control.	The child will maintain adequate gas exchange as evidenced by normal oxygen saturation levels and absence of cyanosis.	– Monitor oxygen saturation and signs of respiratory distress continuously, intervening promptly during apneic episodes. – Administer supplemental oxygen as needed to maintain target oxygen saturation levels. – Provide continuous positive airway pressure (CPAP) or mechanical ventilation if prescribed to support the child’s respiratory efforts. – Monitor arterial blood gases (ABGs) or transcutaneous CO2 levels if indicated to assess gas exchange.	Continuous monitoring allows for prompt intervention during episodes of impaired gas exchange. Supplemental oxygen supports adequate oxygenation during apneic episodes. CPAP or mechanical ventilation provides respiratory support in cases of severe or persistent apnea. Monitoring ABGs or CO2 levels provides information on the child’s gas exchange status, guiding treatment.
5. Child is at risk for infection due to immature immune system and potential for aspiration during apneic episodes.	Risk for Infection related to immature immune system and potential aspiration.	The child will remain free from infection as evidenced by normal temperature, white blood cell count, and absence of signs of infection.	– Practice strict hand hygiene and aseptic technique during all care and procedures. – Monitor for signs of infection, including fever, increased WBC count, and changes in respiratory status. – Provide prophylactic antibiotics if prescribed, especially in cases of suspected aspiration. – Educate parents on infection prevention measures, including proper feeding techniques to minimize the risk of aspiration.	Strict hand hygiene and aseptic technique reduce the risk of introducing pathogens. Early detection and treatment of infection are crucial to prevent complications. Prophylactic antibiotics may reduce the risk of infection following aspiration events. Parental education ensures adherence to infection prevention practices at home.

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