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Vulva Toilet / Swabbing

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

Objectives:

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

Indications:

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

Requirements:

A Trolley (Top Shelf):

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

Bedside:

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

Procedure:

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

Points to Remember:

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

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Carryout admission transfer and discharge of patients

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

Admission (PEX 2.5.1: Admit patients)

ADMISSION, OBSERVATION AND DISCHARGE OF PATIENTS

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

Purpose (of Admission):

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

Types of admission:

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

General Rules on Admission:

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

Equipment needed for admission:

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

Procedure (Admitting a Patient):

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

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

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

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

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

Methods of Examination:

Inspection: Visual examination of the body is called inspection. It is the observation with the naked eyes to determine the structure and functions of the body.
Palpation: It is the feeling of the body or parts with the hands to note the size and positions of the organs. In palpation the finger pads are used to feel, not the finger tips.

Percussion: Is the examination by tapping with the fingers on the body to determine the condition of the internal organs by the sound that’s produced. It is done by placing a finger of the left hand firmly against the part to be examined and tapping with the finger tips of the right hand.

Auscultation: It is the listening to sounds within the body with the aid of a stethoscope, fetoscope or directly with the ear placed on the body.

Others:
- Manipulations: It is moving of the part of the body to note the flexibility. A limitation of movements is discovered by this method.
- Testing reflexes: The response of the tissues to external stimuli is tested by the means of percussion patellar hammer, safety pins, wisp of cotton, hot and cold water etc.

ROLES OF NURSE BEFORE, DURING AND AFTER THE DIAGNOSTIC EXAMINATION

Before (Diagnostic Examination):

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

During (Diagnostic Examination):

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

After (Diagnostic Examination):

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

Transfer (PEX 2.5.2: Transfer patients) & Referral

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

Purpose (of Transfer/Referral):

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

Types of transfer of the patient:

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

Equipment needed (for Transfer):

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

Procedure (Transferring a Patient):

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

Discharge (PEX 2.5.3: Discharge of patients)

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

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

Key aspects of the discharge process generally include:

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

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

Decontamination (PEX 2.6.1: Carry out decontamination)

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

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

This PEX focuses on demonstrating:

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

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

Sterilization (PEX 2.6.2: Carry out sterilization) & Disinfection

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

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

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

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

This PEX focuses on demonstrating:

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

Principles related to Sterilization and Disinfection from the notes:

Proper sterilization policy is a code of practice, which if correctly followed will ensure a clean and safe health unit, where multiplication and spread of harmful microbes is kept under control.
Disinfect, clean and sterilize items like **Drainage under water seal gadgets**.
Wash the flatus tube with soap and water, autoclave or sterilize the tube for 5 minutes.

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

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

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

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Carry out adequate feeding of patients

Adquate Feeding and Ward Reports

Carry out adequate feeding of patients (PEX 1.3.1)

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

Purpose of Assisting with Feeding:

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

Patients Requiring Assistance with Feeding:

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

Requirements:

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

Procedure for Assisting with Feeding:

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

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

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

Purpose of Ward Reports:

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

Key Information to Include in a Ward Report:

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

Methods of Giving/Receiving Ward Reports:

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

General Guidelines for Giving a Ward Report:

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

General Guidelines for Receiving a Ward Report:

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

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Perform bladder and bowel care

Perform bladder and bowel care (PEX 1.3.3)

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

This PEX focuses on demonstrating the skills required to:

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

Giving a Urinal

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

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

Purpose:

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

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

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

Requirements (for giving a urinal/bedpan):

Trolley:

Top shelf:

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

Bottom shelf:

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

At the bedside:

Screens

Procedure:

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

Giving a Bed Pan

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

Purpose:

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

Indications (for giving a bedpan):

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

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

Procedure:

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

Passing a flatus tube (PEX 1.3.4)

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

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

Requirement: Tray

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

Procedure:

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

Administration of enemata (PEX 1.3.5)

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

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

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

Purpose:

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

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

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

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

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

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

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

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

Contraindications (Enemas):

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

Methods of giving enema:

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

General Rules (Enema Administration):

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

Requirements (Enema Administration):

Trolley:

Top shelf:

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

Bottom shelf:

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

At the bedside:

Screens
Hamper if necessary
I.V stand pole

Procedure (Enema Administration - Detailed):

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

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

Carry out relevant investigations (PEX 1.3.6)

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

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

Urine Testing

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

Points to observe and report (“CASDORA”)

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

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

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

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

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

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

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

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

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

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

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

Abnormality: The abnormalities to be detected are;

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

Requirements:

Tray:

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

Or (for testing with litmus/urine sticks)

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

Procedure:

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

Testing Urine Abnormalities

Testing urine abnormalities involves specific chemical tests:

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

Nurses Revision

Perform bladder and bowel care Read More »

Care and Treatment of Pressure Sores

Demonstrate care and treatment of pressure areas (e.g hands and feet) (PEX 1.6.3)

Pressure areas are parts of the body susceptible to developing pressure sores (bedsores) due to prolonged pressure, friction, and moisture. Proper care and treatment are essential for prevention and healing.

This PEX focuses on demonstrating the skills required for:

Identifying patients at high risk for pressure sores.
Inspecting pressure areas (such as heels, elbows, sacrum, etc.) for signs of redness, warmth, or breakdown.
Implementing preventive measures, including repositioning, using pressure-reducing devices, and maintaining skin hygiene.
Providing care for existing pressure sores (if applicable and within scope of practice).
Documenting skin assessments and interventions.

TREATMENT OF PRESSURE AREAS

Pressure areas These are places which are liable to pressure sores due to weight applied heavily and the tissue is compressed between the bed and the bony prominence. The blood supply to the area is interfered with and the skin gives way, this is called a decubitus ulcer.

Pressure sore/bed sore/decubitus ulcer: Is an ulcer occurring on the skin of any bedridden patient particularly over bony prominences or where two skin surfaces press against each other. Due to constant pressure circulation becomes inadequate and finally death of tissues occurs.

Causes:

Direct or immediate cause - the pressure caused by weight of the body continuously remaining in one position e.g. in splints, casts and bandages.
Friction - friction of the skin with rough beddings cause injury to the skin e.g. wrinkles in bed cloths, cramps of food in bed, chipped or rough bed pans, hard surfaces of plaster casts and splints.
Moisture - the skin contact with moisture for a prolonged period can lead to maceration of the skin.
Infections - pressure of pathogenic organisms due to unhygienic condition, pathogenic organisms multiply and the infection settles on the skin.

Common sites for bed sores according to positions:

Supine position: Occiput, Scapular, Supine process (in the presence of lodosis or severe emaciated patients), Elbow, Sacrum and skin folds of the buttocks, Heels

Lateral position: Ear, Acromion process (shoulder), Ribs, Iliac crest, Greater trochanter, Media and lateral condyles, Malleolus (ankle)

Prone position: Cheek and ear, Acromion process, Breast (female patients), Anterior superior supinous process, Genitalia (male patients), Knees, Toes

Patients liable to pressure sore/predisposing factors:

Paralyzed patients - The skin is deprived of its nerve supply and the patient can neither move to avoid pressure nor feel its effect. Sore of paralyzed parts are known as trophic ulcers. These ulcers rise with great speed extending alarmingly and are very difficult to prevent.
Obese/heavy patients - This carry much weight on their pressure areas.
Emaciated and malnourished patient - The skin breaks easily since it’s thin.
Patients with incontinence - The skin is frequently soaked by urine. Urine contains urea which irritates the skin.
Debilitating diseases - These include; diabetes, neoplasms, anemia, edema, due to various causes.
Very ill patients confined to bed or patients with long term illnesses e.g. fractured patients.
Patients with spinal injury
Elderly patients with circulatory problems.

Clinical presentation of a bed sore:

First degree: Redness, heat, tender, discomfort in the affected part, inflamed and painful. The area becomes cold to touch and insensitive. Localized edema
Second degree: Later they are becomes blue, purple, insensitive, circulation cut off, gangrene develops and the epidermis breaks.
Third degree: Suppuration and sloughing occurs which may burrow right down to the bones.

Preventive measures of bed sores:

Daily examination of patients with high risk of pressure sore for signs and symptoms. Routine attention to the pressure areas.
Relieve pressure by good nursing care e.g. bed making practices i.e. use of special mattress (sorbo), beds and comfort devices.
Change position at least 2 hourly for all bedridden patients.
Loosening tight bandages and restraints.
Avoid friction by providing smooth, firm and wrinkle free beds, keep the bottom cloths free from crumbs and foreign bodies.
Prevent moisture by changing linen when it is wet or soiled. Sweat, urine, feces must not be allowed to remain in contact with the skin.
In cases of incontinence of urine, an indwelling catheter should be inserted under very strict sterile procedure.
Give a well balanced diet, high in proteins and plenty of fluids to maintain the general health of the patient.

Requirements (Care of Pressure Areas): trolley

Top shelf:

Soap in a soap dish
A galipot for oil/Vaseline
Flannel
Bowl of warm water
2 jug of hot and cold water if necessary

Bottom shelf:

Bath towel
Mackintosh and towel
Toilet paper
Draw sheet
Bed sheet
Patient’s gown
Receiver for used paper
Clean gloves

At the bed side:

Screens
Hamper
Bedpan

Procedure:

Collect the equipment required for the procedure.
Explain the procedure to the patient.
Screen the bed for privacy.
Position the patient exposing the part to be treated.
Wash hands thoroughly and put on gloves then flannel.
Apply soap to a dump flannel; wash the area in circular movements.
Dry the area and massage with oil/Vaseline in circular motion. Do not massage over reddened or inflamed area itself but start just outside the affected area and move outwards in a circle to stimulate circulation.
The bed is then straightened out and the patient is made comfortable. Bed line is changed if necessary.
Clear away and wash hands and dry.
Record and report the findings to the nurse in-charge or the physician.

Demonstrate Washing of Patient's Hair (PEX 1.6.4)

(Note: While your notes describe bed bath procedures, a specific section for washing patient's hair was not detailed. This PEX would involve demonstrating this practical skill.)

Washing a patient's hair when they are unable to do it themselves is important for hygiene and comfort.

This PEX focuses on demonstrating the skills required to:

Prepare the necessary equipment (basin, water, shampoo, towels, waterproof sheeting).
Position the patient comfortably and safely to protect the bed linen from water.
Wash the patient's hair gently and thoroughly.
Rinse and dry the hair properly.
Ensure the patient is comfortable after the procedure.

Carry out Treatment of Infested Hair (PEX 1.6.5)

(Note: A specific section for treating infested hair was not detailed in your notes. This PEX would involve demonstrating this practical skill.)

Treating infested hair (e.g., with lice) is important for patient hygiene and preventing spread.

This PEX focuses on demonstrating the skills required to:

Identify infested hair.
Prepare and use appropriate treatment products (e.g., medicated shampoo, comb).
Follow isolation precautions to prevent spread during treatment.
Thoroughly comb through the hair to remove nits and lice.
Clean equipment and dispose of waste properly after treatment.
Educate the patient/family on preventing re-infestation.

Care of the Patient's Eyes and Ears (PEX 1.6.6)

Providing proper care for the patient's eyes and ears is essential for hygiene, comfort, and preventing complications.

This PEX focuses on demonstrating the skills required for:

Cleaning the patient's eyes correctly (as detailed in the 'Eye Care' section below).
Providing ear care, including cleaning the external ear canal (as detailed in the 'Ear Care' section below).
Identifying signs of infection or other issues in the eyes or ears and reporting them.
Administering eye drops or ointment (as detailed in the 'Eye Care' section below).
Administering ear drops (as detailed in the 'Ear Care' section below).

Eye Care

EYE CARE Eye care helps to prevent infection and to maintain their function. Hygienic care of the eye is always done as part of the general bathing procedure.

Reasons for eye care:

To maintain the cleanliness of the eyes
To prevent infection
To keep the eyes in normal functioning
To wash out discharge prior instillation of eye drops or ointment.
In preparation for operation.

Common eye problems:

Conjunctivitis (burning, itching, red-watery and painful eyes with increased secretions)
Cataracts
Glaucoma
Strabismus
Squint
Foreign bodies
Trachoma

General rules in eye care:

Unconscious patients are at a risk for eye injury. Daily swabbing of the eyes with wet sterile swab is important.
Cleaning of the eyes is done from the inner canthus of the eye to the outer canthus of the eye.
Use normal saline to remove the crust.
During bath, each eye is cleaned with a spat portion of the wash cloth.
When sterile procedure is required, each eye is cleaned with separate swabs, swabbing each once only.

Requirements (for general eye care): A tray containing;

A galipot of swabs
A galipot of sterile normal saline or plain water
Face towel
Receive for used swabs
A drug if any
A kidney dish with a pair of artery forceps.

Procedure (General Eye Care):

Collect the equipment needed.
Explain the procedure to the patient.
Position the patient flat if the condition allows/permits or in sitting up position.
Wash hands.
Wet the swabs in sterile saline or plain water.
Stand in front of the patient and clean the eyes with sterile swabs.
Squeeze the excessive fluid from the swab and gently wipe the eye lids from the inner to the outer canthus.
Use one swab for one swabbing and separate swabs for each eye.
When the eyes are clean, wipe the face with face towel.
Instill any medication if required.
Leave the patient comfortable.
Clear away and wash hands.
Record and report the procedure to the nurse in-charge.

Instillation of Eye Drops

Reasons: As treatment of bacterial infection, As anesthesia, Diagnostic purpose

Requirements: Tray containing; Pipette in galipot (sterile) or drop bottle, Galipot of swabs, Treatment sheet

Procedure:

Collect the equipment needed.
Explain the procedure to the patient.
Check the prescription and note the eye to be treated.
Position the patient in sitting up or lying down position.
Wash hands.
A swab is placed down the lower lid up to the lash margin.
The patient is asked to look up and drop is instilled onto the lower fornix.
The swab is kept on the lid until the patient closes the eye and any tears are absorbed in the swab.
Patient is left comfortable
Clear away and wash hand
Report and record the procedure on the patient’s chart.

Application of Eye Ointment

Requirements: A tray containing; Eye ointment, Galipot of swabs, Treatment sheet

Procedure:

Collect the equipment needed.
Explain the procedure to the patient.
Position the patient in sitting up or lying down position.
The swab is placed on the lower lid; the upper lid is drawn up.
The nozzle of the eye ointment tube is placed 1cm away from the lower lid and the ointment is pressed horizontally onto the lower lid from within outward.
Any surplus ointment is gently wiped off with a swab.
Leave the patient comfortable.
Clear away and wash hands.
Report and record the procedure on the patient’s chart.

Eye Irrigation

Washing of the conjunctiva sack with a stream of fluid (water).

Purpose: To remove foreign body from the eye, To remove chemicals which have been accidentally splashed into the eye(s), To wash out discharge, Before administration of medication, In preparation for eye operations

Requirements: Tray - sterile

Irrigating solution - Normal saline at 37°c or plain boiled cooled water (sterile).
Eye irrigator (Undine) or rubber bulb /syringe without a needle in bowl
Sterile gloves
Litmus paper
Eye pad
A bottle of ophthalmic irrigation fluid (incase more is needed)
Galipot of cotton balls or facial tissues
2 receivers
Mackintosh cape and towel
Eye lid retractor, if any

Procedure:

Collect the equipment which are needed for the procedure.
Explain the procedure to the patient or care taker incase of the child.
Screen for privacy or close the adjacent windows and door.
The patient is placed in the comfortable position either sitting up or reclining position with the head turned to the affected side.
The mackintosh cape and towel are placed under the patient’s head.
Wash the hand and put on gloves.
The patient is given a receiver to hold placed against the cheek to collect the lotion.
If there is much discharge or ointment this must be removed with moist swabs first.
The undine or bulb is filled with lotion. About 12mls should be used and care taken to see that the level of the fluid does not come above the air outlet.
Some lotion is run onto the inner side of the forearm to test the temperature or use lotion thermometer if available.
The eyelids are held apart with the first and second finger of one hand or use an eye lid retractor (if available). The undine or bulb is held 3 to 5cm away from the eye. The flow is started on the cheek then brought up to the nasal side of the eye. The flow is kept up steadily until all the lotion is used.
The eyelids and the cheek are gently dried by the swab.
Apply eye drop or ointment if prescribed by the physician.
Clear away and make the patient comfortable.
Discard the waste (solution and swabs), sterile and replace the reusable articles for next use.
Wash hands
Record the procedure and report the findings and treatment given to the nurse in-charge/physician.
Refer the patient to the physician if the eyes show evidence of ulceration.

N.B:

When irrigating both eyes, ask the patient to tilt his head towards the side being irrigated to avoid contamination.
For chemical burns irrigate each eye for at least 15 minutes with normal saline solution to dilute and wash out the harsh chemicals.
If the patient cannot identify the specific chemical, use litmus paper to determine if the chemical is acid or alkaline or to be sure the eye has been irrigated adequately.
An irrigation fluid may be pre-packed in a disposable set for use or a sterile 50ml syringe may be used.

Warm Eye Compress

Is the placing of the warm compress/pack over the affected area or eye.

Indications: To relieve discomfort/pain, To reduce inflammation, To enhance absorption of drugs, To promote drainage of superficial infections

Requirement: Tray - sterile

Bowl of warm water
Sterile water/normal saline in a bowl
Mackintosh and towel
Sterile swabs
Sterile gloves
Receiver

Procedure:

Identify the patient and the eye to be treated.
Collect the equipment needed for the procedure.
Explain the procedure to the patient to obtain consent.
Provide privacy to the patient.
Position the patient in sitting up or lying down position for this procedure.
Wash hands and put on gloves.
Place the bowl with the solution in the bowl with warm water.
Place the swabs in the warm water/solution.
Squeeze out the excess solution.
Instruct the patient to close his/her eye, gently apply the swab on top of the affected eye. If the patient complains the compress is too hot, remove it immediately.
Change the compress every few minutes for the prescribed length of time.
Use a dry swab to clean and dry the patients’ face.
If required apply eye drops/ointment.
Leave the patient comfortable.
Clear away and wash hands.
Record and report the procedure /findings to the physician or nurse in charge.

Cold Eye Compress

Is placing of a cold compress/pack over the affected area or eye to relieve discomfort.

Indication: To reduce swelling or bleeding, To ease peri-orbital discomfort, To relieve itching

Requirement: Tray

Small plastic bag or glove
Ice cubes/chips
Strapping
Sterile solution (water or normal saline)
Swabs
Mackintosh and towel
Clean gloves

Procedure:

Identify the patient and which eye to be treated.
Collect the equipment needed for the procedure.
Explain the procedure to the patient or caretaker.
Position the patient to lie down for this procedure.
Place the mackintosh and towel to protect the patient’s clothes.
Place the ice or clips in the plastic bag or glove to make an ice pack (keep the ice pack small to avoid excess pressure on the eye).
Remove excess air from the bag or glove and tie a knot at the end.
Wash hands, dry and put on glove.
Moisten the swab with the solution.
Place the moist swab over the affected closed eye (the swab helps to conduct the cold from the ice pack).
Place the ice pack on top of the gauze and tape it onto the place.
If the patient complains that the compress is too cold, remove it immediately.
After 15-20 minutes, remove the tape, ice pack and gauze.
Use the dry swab to clean and dry the patients face.
If required apply eye drops/ointment if required.
Leave the patient comfortable and clear away.
Wash hand and document the procedure and findings.

Ear Care

EAR CARE

Ear Irrigation/Syringing

Is the washing of the external auditory canal with a stream of fluid.

Purpose:

To remove the ear wax
To remove foreign bodies (except hygroscopic substances)
To cleanse the ear in case of purulent discharge caused by middle ear infection.
For antiseptic effect
To apply heat
To evaluate vestibular functions (e.g. bithermal caloric test).

Solution used:

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

Requirements: Tray - sterile

Ear syringe in a receiver
Prescribed sterile solution e.g. sodium bicarbonate (warmed 37-38°c) in a bowl
Head light and mirror (if available)
Galipot of swabs
Cotton tipped applicators
Water proof pad
Mackintosh cape and towel
Jug of extra sterile solution
Sterile gauze
Clean gloves
Emesis/vomitus bowl
Auriscope

Procedure:

Collect the equipment needed for the procedure.
Explain the procedure to the patient and how he should cooperate.
Bring the equipment to the patient’s bedside or nearer the patient.
Check the physician’s order.
Place the mackintosh cape and towel to protect the patient and beddings.
Wash hands
Have the patient sit up or lie with the head tilted the side of the affected ear. The patient is given a receiver to hold against the cheek under the ear to catch/receive the returning solution.
The uses auriscope to examine the ear to ascertain whether the impaction is due to foreign hygroscopic (attracts or absorbs moisture-if water contacts such a substance it may cause it to swell and produce intense pain).
Fill the ear syringe or irrigator and expel the air out.
The nurse takes the pinna of the ear between the first and second fingers of one hand and draws it gently upwards and slightly backward for adults, upward and back for a child over 3 years of and down and back for an infant or child up to 3 years of age to help straighten the meatus (auditory canal).
Holding the syringe in the other handle, the nozzle is rested against the thumb and the first finger of the hand holding the ear to keep it steady and the flow of lotion is directed along the roof of the meatus using only sufficient force to remove secretions. Do not occlude the auditory canal with the nozzle; allow the solution to flow out unimpeded.
The procedure is repeated several times until the ear is clean.
On completion, place the cotton ball loosely in auditory meatus/canal and have the patient lie on the side of the affected ear on a towel or absorbent pad so as the excess fluid to flow out.
the meatus is then examined to see if it is clear
The returned solution is also examined to see the result.
The outside of the ear and cheek is dried and ear reexamined with the auriscope.
Discard the returned solution and swabs.
Clear away the equipment.
The syringe is disconnected and the nozzle cleaned, dried and replace to safe place for next use.
wash hands
Report and document the procedure, the findings/results and the patient’s response.
Remove the cotton ball and asses drainage after 15 minutes.

N.B:

If the patient complains of pain, the procedure is stopped immediately.
The irrigation solution should at least at room temperature.
If irrigation does not dislodge the wax, instill several drops of prescribed glycerin, carbonide peroxide or other solutions as directed, 2 to 3 times daily which helps to soften and loosen impaction.
Take care not to irrigate an older adult’s ears with cool water, it can cause dizziness.

Instillation of Medication into the Ear

Is the administration or introduction of medication into the ear.

Purpose: To soften the ear wax for removal, To reduce localized inflammation and destroy infective organisms in the external ear canal, To relieve pain, To facilitate the removal of a foreign body.

Contra-indications: Rupture of tympanic membrane

Requirement: Clean gloves, Cotton tipped applicators, Medication bottle with dropper, Cotton balls/swabs, Kidney dish/receiver, Bowl with normal saline (if necessary)

Procedure:

Collect the equipment needed for the procedure.
Identify and explain the procedure to the patient, assess for allergy to certain medication, redness/abrasion in the pinna or meatus, type and amount of discharge, complaints of discomfort specific drug reactions and patient knowledge about the medication to be administered and the purpose.
Check the medication order for the name, dose, time, amount and the ear to be treated.
Position the patient to a comfortable position to assume during and after instillation (lie on the side with the ear being treated uppermost).
Obtain assistance in case of children or infants, to immobilize them.
Clean the meatus of ear canal, using cotton tipped applicators. Use normal saline if necessary.
Warm the container in the hand or by placing it for a short time in warm water. Do not instill cold medicine in the ear (irritation).
Fill the ear dropper partially with medication (prescribed amount).
Straighten auditory canal and instill the correct number of drops along the side of ear canal by holding the dropper 1cm (1/2inch) above ear canal.
Press gently and firmly onto the tragus of the ear.
Instruct the patient to remain in that position for about 5 minutes.
Place a small piece of cotton fluff loosely at the meatus of auditory canal for 15-20 minutes.
Assess the patients’ comfort, response and check for the discharge from the ear.
On completion make the patient comfortable
Clear away and wash hands.
Report and document the procedure, medication given, dose (number of drops and patients’ response).

Nasal Care

Irrigation of the nose

Is the washing out or the nasal cavity.

Procedure:

Collect the equipment needed for the procedure.
Explain the procedure to the patient.
Provide the privacy to the patient
Position the patient in recumbent position if the condition allows.
Inspect the condition of the nose and sinuses, clean the patient’s nose.
The easiest and safest way is to ask the patient to sniff in an alkaline solution into the nose and spit it out.
Repeat the procedure until the nose is clear.
Instill the medication if prescribed.
Make the patient comfortable
Clear away, clean, dry and replace the re-useable article in safe place for the next use.
Wash hands
Report and document the procedure, medication given, dose (number of drops) and the patient’ response.

Nasal Instillations

Is the process by which a liquid is introduced into the nasal cavity drop by drop.

Purpose: To treat allergies, To treat sinus infection, To treat nasal congestion, To give local anaesthesia

General rules:

Medications are instilled only on written order from the doctor.
Avoid oil base solutions as nasal drops since it interferes with normal cilliary action and may cause aspiration pneumonia.
Avoid the use of decongestant drops for a long period, because they become ineffective.
Administer drugs in correct concentration.
Identify the drug correctly and follow the rules for administration of medication.
Medical asepsis should be observed carefully throughout the procedure.

Requirement: Prepared medication with clean dropper, Penlight, Clean gloves, Facial tissues/face towel, Small pillow, Receiver, Tissue paper, Medical card/patient’s chart

Procedure:

Identify the patient to be given medication and review the physician’s order.
Collect the equipment needed for the procedure.
Explain the procedure to the patient to obtain consent and help alley anxiety. Tell the patient what to expect e.g. burning sensation or stinging of mucosa or choking sensation as the medication trickles into the throat.
Bring the equipment to bedside or near the patient.
Provide privacy to the patient.
Position the patient in a comfortable position.
Determine which sinus is affected by referring to medical record, assess the patient’s medical history (hypertension, heart disease diabetes and hyperthyroidism and ask about known allergies to nasal instillations.
Wash hands and put on gloves if the patient has nasal discharge.
Inspect the condition of the nose and sinuses using penlight. Palpate sinuses for tenderness.
Instruct the patient to clear or blow nose gently unless contraindicated (increased intracranial pressure or nose bleeding).
Tilt the head backwards and support with a non dominant hand
Instruct the patient to breathe through the mouth
Hold the dropper 1cm above the nares and instill/administer the number of drops towards the midline of ethmoid bone.
Ask the patient to remain in that position for 5 minutes and then offer face tissue to blot the running nose but caution the patient against blowing for several minutes.
Assist the patient to a comfortable position after absorption of medication.
Clear away and discard off the used supplies and then wash hands.
Record the procedure, finding, medication, number of drops, the nostril used, time given and patient’s response.
Observe the patient for 15-30 minutes for side effect after administration of drug.
Ask if the patient is able to breathe through the nose, if not administer the nasal decongestant and ask the patient to occlude one nostril at a time and breathe deeply.

Perineal Care

PERINEAL CARE Is the cleaning the perineum from the cleanest to the less clean area including external genitalia and surrounding areas, the urethral orifice to the anal orifice.

Purpose:

To prevent sepsis
To remove discharge and prevent bad odor
To relieve itching
To promote healing of stitches
To promote comfort

Patients who need perineal care:

Unable to do self care or bedridden patients
After surgery on the genitourinary system
Patients with indwelling catheters
Patients with excessive vaginal discharges
Post partum patients
Incontinence of urine and stool
Genitourinary tract infections

Requirements: A trolley containing;

Top shelf:

Basin of warm water or antiseptic solution
Soap in a soap dish
Sterile swabs and pads if required
Long artery forceps in the kidney dish

Bottom shelf:

Mackintosh and towel
Receiver for used swabs
Gloves
Clean personal clothes/patient’s gown
Clean Bed linen if needed
Flannel/ Wash cloth and towel, if able to help him/herself
Lotion thermometer/bath thermometer
Bedpan and urinal with covers

At the bedside:

Screens
Hamper if necessary

Procedure:

Collect all the equipment needed
Explain the procedure to the patient
Provide privacy
Position the patient in dorsal recumbent position.
Wash hands thoroughly and put on gloves.
Fold back the bed clothes to the foot of the bed, leaving the patient covered to the waist with top sheet.
Place the mackintosh and towel under the buttocks.
Remove soiled pad if any for the case of female patients and place in a receiver on the bottom of the trolley.
Wash abdomen, inside the thighs and buttocks using soap, water and flannel. Rinse and dry thoroughly with the patient’s towel.
Wash hands and put on gloves.
Put the bed pan in position.
Holding the jug at the level of symphysis pubis, pour water/lotion over the perineum to wash off the discharge (females). For the male patient cleanse the penis.
Hold the swabs with forceps or sterile gloved hand and clean from above downwards towards the anal canal.
Use one swab for one swabbing.
For female patient clean the perineum from the middle outward in the following order; the vulva, the labia majora on both sides, inside of the labia minora on both sides, then vestibule and dry thoroughly. Clean the perineal region and anus well. Gently visualize vulva for debris
If male patient clean the fore penis using circular motions from underneath upwards and the rest of it using up- downwards sweeps to scrotum and clean the anal area thoroughly and dry. Carefully examine gluteal folds, scrotal folds.
Remove the bed pan by supporting the hips. Turn the patient to one side and dry the buttocks.
Apply the medicine and pad if necessary.
Remove the mackintosh if any extra one is used, if not dry the mackintosh and remake the bed, leave the patient comfortable.
Clear away, clean and replace the equipment to the appropriate place of storage.
Remove the gloves and Wash hands.
Record the procedure and report any abnormality seen on the patient to the nurse in-charge or physician.

Catheter Care/Hygiene

CATHETER CARE/HYGIENE Is the maintenance in the cleanliness of the surrounding area around the urethra to decrease contamination of the catheter by bacterial flora.

Before procedure you should:

Assess the catheter patency and urine color, consistency and amount while performing the care to determine if the catheter and drainage system are functioning correctly.
Determine the condition of the urinary meatus and perineal area to monitor for redness swelling or drainage, stool or vaginal discharge as indicator of infection. External infections may migrate up the catheter and lead to urinary tract infection.
Determine the clients emotional reaction and feelings related to the catheter (nurse-patient relationship)

Requirements: Trolley

Top shelf:

Galipot of sterile swabs
Soap in a soap dish
Galipot of lotion/antiseptic or warm water in basin
Clean gloves
Wash towel in bowl

Bottom shelf:

Mackintosh and towel
Measuring jar
Receiver for used gloves
Adhesive tape and scissors
Receiver for used swabs
Clean bed linen

At the bed side:

Screens
Hamper

Procedure:

Collect all equipment needed.
Explain the procedure to the patient.
Provide adequate privacy by screening the bed and closing the adjacent windows if any.
Position the patient in supine position.
Wash hands and put on gloves.
Place the mackintosh and towel beneath the buttocks
Carry out perineal care and after the perineal care, cleanse meatus if there is excessive purulent drainage with non-irritating antiseptic lotion.
Cleanse catheter from meatus out to end of catheter, taking care not to pull out the catheter.
Repeat catheter care any time it becomes soiled with stool or other drainage.
On completion, make the patient comfortable.
Clear away, clean and replace the equipment. Remove gloves and wash hands thoroughly and dry.
Record the procedure in the patient’s chart and report the findings to the nurse in-charge of physician.

Nurses Revision

Care and Treatment of Pressure Sores Read More »

Bed Bath

Topic: Carry out proper patient's hygiene (PEX 1.6.1 - 1.6.6)

Carry out bed bath (PEX 1.6.1)

BED BATH Is bathing of a patient who is confined to bed and cannot or has no capability of self bathing.

Purpose:

To cleanse the body off dirt, debris and perspiration (sweating) and toxic substances.
To refresh (relieve fatigue) and provide tactile stimulation.
To stimulate circulation.
To provide comfort and relaxation.
To enhance self-concept (self esteem)
To regulate body temperature.
To induce sleep.
To prevent bed/pressure sores by minimizing skin irritation.
To give health instruction to the patient.
To prevent contracture by giving exercise-stretching of body muscles.

Types of patients needing a bed bath:

Unconscious or semi-conscious patients.
Post-operative patients
Patients with strict bed rest.
Paraplegic patients
Orthopedic patients in plaster cast and traction
Seriously ill patients

Types of cleansing bath:

Bed bath; it is the bathing of a patient who is confined to bed.
Therapeutic bath; doctor specifies the temperature of the water, medications to be added and the body part is to be treated.
Partial bath; it is the act of cleaning particular areas in the body for example face, axilla, genitalia, upper and lower limbs.
Self-administered bath; this is the same as in bed bath except the patient is assisting in taking the bath.
Tub bath or bathroom bath; this bath is allowed to the patient only if h/she has enough confidence for self help and is able to withstand the procedure.

Factors Affecting the Skin (Relevance to hygiene and pressure areas)

Impaired self care
Immobilization
Exposure to pressure and moisture
Vascular insufficiency
Reduced sensation
Nutritional alterations
Constrictive external device

Equipment for bed bath:

Top shelf:

Basin
2 large jugs (1 for hot water, 2^nd for cold water)
2 flannels (wash cloth)
Soap in soap dish
Nail brush and razor blade/nail cutter
Tooth brush/stick and tooth paste
Mug of clean water and receiver
Face towel
Comb and oil/Vaseline
Tray of pressure areas
Bowl of swabs or toilet paper
Bath thermometer

Bottom shelf:

2 bath towels
Clean bed linen
Clean patient’s gown/dress (depend on the sex)
Draw mackintosh and towel
Receiver for used swabs
Pail or bucket for dirty water
Gloves
Nurse’s apron

At the bedside:

Bedpan or + urinal with cover
Soiled linen container
Screens

Procedure:

Collect all the equipment needed always before beginning the procedure
Explain the procedure to the patient
Maintain the privacy of the patient by screening and closing the adjacent windows; and to prevent draught.
Give the patient a bedpan or urinal if required
Remove the top bed clothes and pillows, except the sheet and one pillow to maintain the position.
Remove the gown, wash and dry each part separately uncovering only the part to be washed.
Mix hot and cold water in a basin half full and check the temperature using the back of the hand or bath thermometer (temperature should be 110°F to 115°F)
Spread the face towel around the neck. Wet the sponge towel/flannels and remove excessive water then clean the body in the following order;

Face:

Wash the forehead, face, over and behind the ears and neck.
Clean the eyes from inner to outer end. Rinse the sponge towel and wipe the face.
Dry with the face towel thoroughly well to prevent chills.

Arms:

Place the towel lengthwise under the furthest arm. If there is I.V line do not disturb it.
Take soapy sponge and soap the arm and axilla.
Massage the pressure areas.
Rinse and dry well, paying attention to the skin under the breast.
Cover the finished parts to prevent draught.

Chest:

Expose only the part to be washed.
Wet and apply soap to the chest in rotator movement, paying attention to skin creases (folds)
Remove soap thoroughly by wiping from neck to chest and dry with a bath towel.

Abdomen:

Fold the top sheet to the suprapubic region and cover the chest with a bath towel.
Wet and clean the abdomen with soap.
Clean the umbilicus and dry it with a bath towel.
Cover the patient with the top sheet and remove the towel.

Back:

Turn the patient on side or lateral position close to the edge of the bed, with the back towards the nurse.
Expose the back and buttocks; spread the bath towel on the bed, close to the patient’s back.
Wet the area and apply soap with rotator movements, clean and remove soap and dry the area.
Treat pressure areas.
Straighten the under bed linen and in-put clean linen and mackintosh if necessary.
Help the patient to return to supine position.

Legs:

Uncover the furthest leg 1^st and place a towel and mackintosh under the leg.
Apply soap to the leg and make sure to give special attention to the groin.
Treat pressure areas/points.
Place the foot in the basin to wash.
Rinse and dry well, paying special attention in between the toes.
Repeat the procedure on the next/other leg.

Pubic region:

Clean the pubic region with swabs or toilet paper (for helpless patient), if able permit the patient to clean by him/herself.
Give perineal care and dry the perineum thoroughly well, apply Vaseline to provide comfort.
Clean the mouth if the patient is unable to do it. If able give a stick or tooth brush with tooth paste and mug of water. Hold the receiver for the patient.
Cut the nails if necessary and comb the hair.
Make the bed and leave the patient comfortable.
Clear away and wash hands.

Record the procedure and report any abnormality seen on the patient to the nurse in-charge.

Baby Bath

BABY BATH Is the washing of the baby’s body to maintain its hygiene. The nurse/midwife helps the parents in bathing the baby and teaches them to do it, highlighting on infant’s reaction to various stages of bathing.

Purpose:

To maintain the baby’s hygiene.
To teach the mother (parents) or care-takers on how to bath the baby.

Requirements:

Top shelf:

2 jugs (1 with hot water and 2^nd with cold water)
Baby’s soap in a soap dish
Galipot of sterile swabs
Normal saline
Bath thermometer
Temperature tray (containing; galipot of swabs, thermometer, galipot of solution/disinfectant, TPR chart and pen plus second hand ticker watch)
Tray for cord care (galipot of swabs, cord scissors in a receiver, N/S, cord ligature, 2 receivers: - for used swabs and used instruments)
A pair of sterile gloves

Bottom shelf:

Receiver for used swabs
Plastic apron for the nurse/midwife
Clean baby clothes
Two baby towels (bath towels)
Napkins/diapers
Draw mackintosh and towel
Barrier cream and powder if necessary
Weighing scale

On the stool or table:

Basin

On the floor next to the bath area:

2 pails (for soiled clothing and soiled napkins)
If diapers, a large receiver is required

NB. The requirements can be laid on a trolley or a table. The nurse/midwife may bath the baby while; sitting on a low stool or chair with the baby on his/her laps. Or Standing with the baby on the table.

Procedure:

Prepare/collect the necessary equipment.
Arrange the equipment on the trolley or the table for easy reach.
Explain the procedure to the parent(s) or care-taker.
Provide privacy by closing nearby/adjacent windows and doors in the vicinity of the bath.
Put on the apron and wash hands.
Check the baby’s temperature and record on the chart.
Put cold then hot water in the basin.
Test the temperature with bath thermometer if available (T° 37-38°C) or test using the elbow, it should feel warm not hot, if no thermometer is available.
Undress the baby leaving the napkin on or diaper if dry.
Weigh the baby
Wrap the baby firmly in a towel leaving the head exposed.
Put dirty linen/clothes and napkins in a bucket respectively.
Hold the baby firmly under the left arm supporting the head with left hand.
Lower the head over the basin and wash face using clear clean water without soap.
Clean the eyes and ears with cotton swabs and water. If there is a discharge, use normal saline to clean them using a swab once working from inside outwards for each eye or ear.
Discard the used swabs in the receiver.
Dry the face with a towel.
With the right hand, using soap/baby shampoo, make lather/foam and apply to the baby’s head. Massage gently and then rinse off the foam thoroughly taking care not to splash water in the baby’s face.
Dry the baby’s head with bath towel.
Unwrap the baby and remove the napkin or diaper and clean the buttocks with a swab if necessary.
Hold the baby across your lap with the left hand holding firmly while grasping the shoulder around the axilla/armpit at the same time supporting the head.
Soap the baby’s body, arms and legs, taking care on the skin folds. Turn the baby and soap the back and in between the buttocks.
As the skin is now slippery, great care should be taken in handling the baby. Hold the baby firmly with the left hand under the right axilla and the right hand supporting the buttocks and grasping the left thigh (legs), with the baby’s head resting or supported by the nurse’s left arm, then gently lower the baby into the basin.
While continuing to support the baby with left hand, using the right hand to rinse the baby thoroughly well paying attention on skin folds, in between the buttocks and groins.
Place the bath towel neatly over the laps or on the table and lift the baby onto it. Wrap the baby well to prevent from getting cold.
Dry gently and thoroughly seeing that all skin folds e.g. fingers, arms, neck, axial, groin, in between the buttocks are dry.
When the skin is dry, apply barrier cream e.g. petroleum jelly to the whole body. If necessary apply powder at the groins and in between the buttocks.
Clean the umbilical cord stamp with normal saline and shorten the ligatures if necessary.
Dress the baby in clean napkin/diapers and clothes, keeping the baby warm.
Discard the towel in the bucket
Give baby to the mother to feed before taking him/her to sleep.
Clear away the used articles.
Document the bath, family participation, condition of the baby, urine and bowel movement and report any abnormalities noted during the procedure e.g. bruises, rashes, excoriation (peeling of the skin)

General Rules (Baby Bath):

Safety should be observed by keeping the baby warm, lying in safe place.
Prevent falls, burns and aspiration of water.
Before bathing the baby, assess the family’s preference and home practices.
Allow parents to make their own decisions as much as possible and retain control.
Baby should be bathed prior feeding to reduce the risk of vomiting and aspiration.
Bathing should be postponed in cold weather unless the room is heated.
Powder is not recommended on baby’s skin especially when broken.

Carry out oral care/mouth care (PEX 1.6.2)

MOUTH CARE/ORAL HYGIENE Mouth care is the maintenance in the cleanliness of the mouth. It is important because the mouth is the portal entry of food and digestion starts from the mouth and the entry of any pathogen in the mouth directly affects the health of the person.

Purpose:

To maintain oral hygiene among bedridden patients.
To prevent and treat mouth infections.
To keep the mouth fresh and clean.
To prevent dental carries and tooth decay.
To prevent the mucous membrane from becoming dry and cracked, hence keeping mouth moist.
To prevent sordes and sores which result into ulceration.
To prevent infection of parotid glands.
To stimulate salivation and increase appetite.
To prevent complications such as stomatitis, glossitis, pyorrhea, parotitis etc.
To stimulate circulation in the gums thus maintaining healthy teeth.
To remove food debris
To prevent halitosis.
To create a feeling of general well being.

Patients who require frequent mouth care:

Unconscious, semi-conscious patients
Helpless or very ill patients
Patient with higher body temperature/high fevers
Malnourished and dehydrated patients
Patients having local diseases of the mouth
Paraplegic patients
Post-operative patients

Solutions commonly used for mouth wash:

Potassium permanganate (KMNO₄); 1 crystal to a glass of water
Sodium chloride; 1 teaspoon to a pint of water
Potassium chloride; 4 to 6 percent
Hydrogen peroxide (H₂O₂); 1:8 solution

Dentifrices used:

Glycerin with lime juice; equal parts
Sodium bicarbonate paste
Reliable tooth paste or powder

Emollient/lubricant commonly used:

Cream or butter
White Vaseline
Liquid paraffin
Glycerin borax
Olive oil

Requirements for mouth care: A tray containing;

Mackintosh and towel
Small jug/glass of warm water
Patient’s towel to protect the patient
Two receivers; for waste water and used swabs
Paper bag if a second receiver is not available
A bowl for dentures if necessary
A galipot with moistener/lubricant
A galipot with swabs
A galipot of sodium bicarbonate solution; 5g in ½ liter of water
Kidney dish containing; a pair of artery forceps, anon-toothed dissecting forceps, mouth gag, tongue depressor.
Face towel
Galipot of gauze
A towel to cover the tray

N.B: If the patient can clean his/her own tooth brush and paste or the nurse may give him or her a soft stick /tooth brush with tooth paste to clean his/her teeth and a glass of warm normal saline to gargle with or plain clean water.

Procedure:

Collect the equipment required and bring to the bedside of the patient.
Explain the procedure to the patient.
Position the patient and protect his clothes with the patient’s towel.
Place the small mackintosh with a towel underneath the patient’s chin to protect the bed (if on lying down position)
Position the pillow according to comfort of the patient.
Wash hands and remove patient’s dentures if any, keep safely.
Inspect the mouth, note and report any abnormality detected.
Pour antiseptic solution into the galipot.
Soak the swab in solution and squeeze out excess solution by using artery clamp or press against the side of the galipot to prevent dripping.
Clean using up and down movements from gums to crown, clean oral cavity (inside of cheeks) from proximal to distal, outer and inner aspect of the teeth and clean the tongue gently from inner to outer aspect, avoid touching the palate which may make the patient feel sick and want to vomit.
Change swabs as often as needed and discard used swabs into the receiver or paper bag.
Give the patient a glass of water if he can rinse his mouth. Instruct him to gargle and spill it to the receiver. If not able cleanse the mouth till it’s thoroughly clean.
Dry the face using a face towel.
Wipe the lips with dabbing movements and apply a lubricant using gauze.
Leave the patient comfortable, clean and replace the equipment to the storage place.
Wash hands
Document the time, solution used, date, condition of oral cavity, abnormalities noticed and patient’s condition to the chart and give/inform the findings to the nurse in-charge or physician.

Mouth Irrigation

MOUTH IRRIGATION It is the washing out or removal of plaque or food debris in between the teeth using streams of pulsating water jets.

Indications:

Fractures of the jaw in conscious patients only
Bleeding tooth sockets
Food debris

Requirements: Tray

Jug of lotion (1/2 - 1 litre) sodium bicarbonate
Large syringe (10-20ml)
Fine catheter in a kidney dish
Galipot of swabs or tissues (hand wipes/tissue)
Receiver for used lotion
Mackintosh and towel
Lotion thermometer
Gloves

Procedure:

Collect the equipment needed.
Explain the procedure to the patient.
Provide privacy to the patient.
Position the patient in a comfortable position (sit the patient up if possible or turn onto the side).
Wash hands and put on gloves.
Place the mackintosh and towel around the neck.
Draw up the lotion in the syringe and connect to the catheter.
Place the end of the catheter into the patient’s mouth and ask him/her to hold it about 1” from the mouth.
Hold the end of the catheter close to the syringe and inject the lotion slowly into the mouth.
Pinch the catheter between the finger, disconnect the syringe and refill it.
Reconnect the syringe and inject the lotion as before.
Remove the catheter and the syringe and place in the receiver and ask the patient to rinse the lotion around the mouth.
Hold the second receiver under the chin and ask the patient to spit the lotion into it.
Repeat the procedure until the mouth is clean.
On completion, make the patient comfortable, dry around the mouth with the tissue/swabs and smear a little moistener on the lips.
Clear away and wash hands.
Report and record the procedure and findings.

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Bed Bath Read More »

Bed Making

Topic: Demonstrate bed making (PEX 1.4.1 - 1.4.9)

BED MAKING Bed making is a key nursing skill that is essential for the promotion of patient care, comfort, hygiene and wellbeing.

Bed making requires technical and practical skills and consideration should be given to issues of safety, moving and handling and infection control practices.

There are many types of beds to suit the different conditions of the patient.

Two nurses should work together to make a bed and should face each other. Work from top to bottom of the bed except when putting on a counter pane (bed cover.)

Purpose of Bed Making

To keep the ward neat and tidy.
To keep/make the patient comfortable.
To prevent cross infection and complications such as bed sores.
For treatment of certain conditions e.g. shock or quickening of healing of the patient.

Rule of Bed Making

All equipment should be collected before starting the procedure.
Any conversation during bed making should not be on personal matters between the nurses but should be focused on the patient.
Close adjacent windows to protect the patient from draught on a cold day.
Patient must never be exposed, screen the bed and close the ward to visitors.
The bed should be made free from crumbs and creases, so as to give maximum comfort to the patient.
Sheets have to be smooth and when tucking in, MITRE the corners.
Pillows and other bed accessories should be well arranged to give support and comfort where necessary.
When pillows are being shaken, the nurse should turn away from the patient and not over the patient.
The bed should be made in a way suitable for treating certain conditions such as shock and to prevent complications as a result of bad nursing.
Always use clean beddings and linen for each patient.
Always wash hands after making beds of infectious or septic patients before moving to the next bed.
Do not put any linen of another patient to the next patient’s bed.
If linen is dropped on the floor, it should not be used.
Always have a dirty linen container or hamper at hand in which to put dirty linen, never put it on the floor or carry the across the ward to prevent cross infection.
The patient’s face should not be covered with sheets or blankets.
The open end of a pillow case should face away from the main door or entrance of the ward.
Two nurses are required and they should work in harmony avoiding unnecessary movements of the bed and themselves.
Extra assistance should be available and if necessary, one should be called upon to help lift the patient.
Do not make a bed when a sterile procedure is in progress in the ward.
Beddings from the infectious patients should first be soaked in a disinfectant e.g. jik (3.5%=3.5/0.5-1=6) 1.6,(6%=6/0.5-1=11)1.11 for 24 hours before washing.
Use large mackintoshes for incontinent patients to protect the beddings.
Use small mackintoshes at the head of the bed for unconscious or post operative patients.
Use a bed cradle over leaking wounds e.g. in burns.
Beds should be made in such a way that the patient can be put in without difficulty.
Allow room for the patient’s feet for free movement or turning when placing the top sheet over the patient.
Always wash hands before and after bed making.

Types of Beds

Unoccupied bed/hospital bed
Occupied bed
Admission bed
Admission bed for burns
Operation/post-operative bed
Bed for complete rest
Cardiac bed
Divided bed
Plaster and fracture bed

Appliances Used in Bed Making

Mackintosh/plastic sheet: Protects the beddings during procedures. Protects the beddings in case of vomitus, urine, blood, faeces from soiling the bed sheets and the mattress.
Hot water bottles: To provide added warmth to the patient. The hot bottles must always be covered and the cover tight enough before use. Never place it directly on the patient’s skin to avoid burns.
Bed cradle: To keep the weight of the bed sheets away from the patient’s affected area e.g. in burns.
Bed blocks/bed elevators: To elevate the top or bottom of the bed e.g. in patients with shock, cardiac problems etc. To promote drainage in case of chest drainage.
Backrest/bed rest: To help the patient sit up-right for those with chest problems (breathing difficulties), cardiac problems etc. different degrees of elevation can be made with pillows placed on top of the backrest.
Sandbags: To prevent movement of limbs in the treatment of some conditions like fracture of the limbs.
Air rings: These are place under the buttocks to relieve pressure so as to prevent bed sores.
Foot rest: A small piece of wood or cloth rolled neatly at the foot of the bed for the patient to support his/her feet in-order to prevent slipping/falling down the bed.
A cardiac table: It is the table place in front of the patient over the bed for meals, medicine or any leisure activity e.g. a magazine newspaper or work etc. it is used in patients with cardiac conditions in cardiac bed.
Fracture boards: To make a firm surface for support and it is placed across the bed springs under the mattress.

Prepare and Make an Unoccupied Bed (PEX 1.4.1)

Is an empty bed and is fully covered with a counter pane to protect it from dust and dirt while waiting for the new patient for admission.

Purpose:

To protect the bed from dust and dirt
To keep a ready bed for the admission and emergency.
To give the room/ward a neat and tidy appearance.

Requirements: trolley

Items on the trolley:

Spring cover
2 bed sheets
1 mackintosh/draw mackintosh
1 ground mackintosh
1 draw sheet
1 pillow and pillow case
1 blanket
1 bed cover/counter pane

Items in the ward:

2 chairs/stools for stripping the bed
A dirty linen container/hamper
Hospital bed
Mattress and mattress cover

Appliances needed for the unoccupied bed:

Foot rest
Bed blocks
Bed cradle
Fracture board

Procedure:

Collect 1^st all the requirements needed.
Bring always the hamper with you.
Clear the room 1^st of unnecessary equipment e.g. kidney dishes, bed pans and the belongings of the patient or from the family.
Pull the bed from the wall.
Place the 2 chairs at the foot of the bed.
Wash hands.
Turn the mattress to see whether the spring cover is straight or complete springs (not broken.)
Replace the ground mackintosh then the bottom sheet and start to tuck in from the top (see that the right side is up). Mitre the corners, tuck in at the bottom and then the sides.
Replace the mackintosh/draw mackintosh, put at the height of the patient’s buttocks. Place the draw sheet covering the mackintosh completely.
Put on the top sheet, tuck in the bottom, mitre each corner and leave the top free.
Place the blanket on the bed then turn back the blanket and top sheet on top of the blanket.
Replace the pillow(s) to the bed (open ends away from the entrance) after shaking them.
Put the bed cover to the bed, tuck in the bottom only, mitre corners and leave the sides hanging down but make sure it is covering the whole bed.
Push back the patient’s bed to the original position.
Clear away and wash hands.
Document the procedure and replace the equipment to their place of storage.

Demonstrate Stripping and Changing of Patient Linen (PEX 1.4.2)

STRIPPING THE BED This means undressing the bed or removing the bed linen from the in preparation to lay/make afresh.

Requirements: trolley

As for the unoccupied bed (requirements list above).

Procedure:

Collect 1^st all the requirements needed.
Bring always the hamper with you.
Clear the room 1^st of unnecessary equipment e.g. kidney dishes, bed pans and the belongings of the patient or from the family.
Pull the bed from the wall.
Place the 2 chairs at the foot of the bed.
Wash hands.
Un-tuck all the beddings first.
Take away the pillows and undress.
Fold the bed cover, blanket, top sheet in three, the bottom part should be on top and put on the chairs provided one by one. Fold the draw sheet and mackintosh, put on the chairs. Bottom sheet is also folded in three, bottom part 1^st as the top will be tucked in first when putting it on again.
Remove the ground mackintosh by rolling if off the bed and put to the chairs.
Re make the bed as required (refer to procedures for occupied or unoccupied bed).

Prepare and Make an Occupied Bed (PEX 1.4.3)

OCCUPATION BED Is a suitable, comfortable and appropriate bed for hospitalized patients. It is made as usual and one corner of the linen is folded back at 90° to let the patient in.

Open bed: Patient is allowed out of bed.

Purpose:

To provide clean bed
To provide comfort to the patient.

Requirements: trolley

The requirements needed are as for the hospital bed/unoccupied bed
In addition: gloves

Procedure:

Collect all the equipment needed.
Explain the procedure to the patient.
The patient is allowed out of bed when able.
Pull the bed from the wall.
Wash hands thoroughly and put on gloves.
Strip the bed and replace with clean linen.
The bed is made in the same way as the unoccupied bed except for the bed cover. Fold 1^st the blanket, then put the bed cover over the blanket and fold the top sheet back over the bed cover.
Fold half of the beddings back in a corner of 90° at the side of the locker, so that it is easy for the patient to get into the bed.
Push back the patient’s bed to the original position.
Clear away and wash hands.
Document or record the procedure.

Prepare and Make a Closed Bed (with patient in bed)

With the patient in bed/closed bed The bed is made with the patient in, for a patient who is not able to get out of bed. It is usually done by two nurses.

Purpose:

To provide comfort to the patient
To change the soiled bed linen.

Requirements: trolley

As for the unoccupied bed
In addition: gloves

Procedure:

Collect the equipment needed.
Explain the procedure to the patient.
Screen the bed and close adjacent windows for privacy.
Pull the bed from the wall.
Wash hands thoroughly and put on gloves.
Place 2 chairs at the foot of the bed.
Remove all the pillows except one for the patient to rest his head.
Loosen the beddings on all sides and then strip the bed.
Turn the patient on his left, placing one pillow under his head. The nurse towards the side the patient is facing should support the patient so that he does not feel afraid of falling down.
Roll the draw sheet and mackintosh to the center of the bed near the patient’s back.
If the bottom sheet needs changing, roll it to the center of the bed near the back of the patient.
Place the clean bottom sheet to halfway the bed over the mattress. Make sure that the middle fold is in the middle of the bed. Tuck the head end first, mitre the corner at the top, bottom and then sides.
Bring back the mackintosh and draw sheet if clean, tuck them under the mattress.
Turn the patient on his right side, placing one pillow under his head, the nurse towards the side the patient is facing should support the patient.
The 2^nd nurse removes the soiled linen and puts the linen in the dirty linen container. Straightens out the bottom sheet, mackintosh, draw sheet and tuck them separately and firmly. Mitres the corners beginning from top then bottom and sides.
Turn the patient back to the center of the bed and support him whilst his pillows are plumped and arranged. Position the patient comfortably.
As soon as the top sheet has been replaced over the patient, the sheet or blanket covering him may be removed and replace the top bed clothes.
Ensure that the bed clothes are loose enough over the patient’s feet. A bed cradle may be used to support their weight if needed but in the absence of this, the patient is asked to cross one foot over the other whilst the bed is being made, ensuring plenty of room for his feet.
Push back the patient’s bed to the wall/original position.
Replace the patient’s locker and open the windows.
Clear away and wash hands.
Document the procedure.

Prepare and Make an Admission Bed (PEX 1.4.4)

ADMISSION BED FOR NEW PATIENTS The bed is made for the newly admitted patients. It contains the pack that can be lifted off the bed or fixed on one side.

Requirements: trolley

As for the hospital bed
Additional: 2 admission sheets

Procedure: Admitting the patient in a clean bed

Collect the equipment needed.
Pull the bed form the wall.
Wash hands thoroughly.
Place the 2 chairs at the foot of the bed.
Turn the mattress to check the springs and spring cover.
Place the bottom sheet, mitre corners from top to bottom.
Add the mackintosh and draw sheet, tuck in firmly the place the bottom admission sheet, mitre corners from top to bottom and tuck in the sides.
The top admission sheet is placed over the admission bottom sheet and left hanging. The other top sheet and blanket are added on top of the admission sheets and then the bed cover.
Turn back the bed cover, blanket and the two top sheets to make a pack. Tuck one side or don’t, roll the beddings to the other side while the top admission sheet is rolled together to the pack.
Push the bed back to its original position.
Place the chair at the top side of the bed and put the pillow whilst waiting for the patient.
On completion, clear away and wash hands.
Document the procedure.

N.B:

Admit the patient between the admission sheets.
Cover the whole bed with a bed cover if the patient is not yet admitted to prevent dust and dirt.
Remove the admission sheets after the bed bath has been given to the patient.

Prepare and Make Bed for Burns (PEX 1.4.6)

ADMISSION BED FOR BURNS It is the bed made for new patient with burns only.

Requirements: trolley

As for the unoccupied bed
Additional:
- 2 old sheets and if possible sterile sheets
- Mackintosh pillow cover
- A mosquito net
- Bed cradle
- Bed locks
At the bedside: Infusion stand.

Procedure:

Collect all the equipment needed.
Pull the bed from the wall.
Wash hands thoroughly.
Place the 2 chairs at the foot of the bed.
Make as an admission bed instead of admission sheets, use old or sterile sheets and make a pack.
Cover the pillows with the mackintosh covers before putting on the pillow cases.
Push back the bed to the original position.
Put/hang the mosquito net to protect the patient from flies.
Place the bed cradle over the affected area to relieve weight of the beddings over the affected part.
Bed blocks are used to elevate the foot of the bed if the patient is in shock.
If the patient is bathed on admission, the sheets are removed when it is completed. If patient is still in shock or the burns are extensive, then the sheet should be left until the patient has recovered from shock and the admission bath is then given.
Clear away and wash hands.
Document the procedure

Prepare and Make Post-Operative Bed (PEX 1.4.7)

POST-OPERATIVE BED This bed is prepared to receive the patients who have undergone surgical procedures, recovering from the effects of anesthesia.

Purpose:

To place the patient in bed with minimum discomfort.
To make a comfortable and safe bed for the patient who is recovering from the effects of anesthesia.
To prepare to meet any emergency.

Requirements: trolley

As for the unoccupied bed
Additional:
- A small mackintosh and towel.
- Be elevator
- Emergency tray (mouth gag, air way piece, tongue depressor, drugs (e.g. adrenaline), swabs)
- Hot water bottles
At the bedside: Infusion stand.
On the locker: Post-operative observation tray (BP machine, stethoscope/pulsometer or watch, thermometer and observation chart.)

Procedure:

Collect all the equipment required for the procedure.
Pull the bed from the wall.
Wash hands thoroughly.
Place the 2 chairs at the foot of the bed.
Strip the bed in the usual way.
Put all the dirty linen into the hamper.
Make a clean bed with clean linen, making it as the hospital bed but with a pack which can easily be removed when lifting the patient onto the bed.
Instead of the pillows, put the small mackintosh and towel across the top of the bed and tuck in at the top.
Push the bed back to the wall.
Put the pillow(s) on the chair/stools, which will be used later when the patient recovers.
Clear away and wash hands.
Document the procedure.

Prepare and Make a Cardiac Bed (PEX 1.4.5)

CARDIAC BED Is used to help the patient to assume a sitting up position; which can afford him great comfort with least strain. Cardiac bed is used for patients with heart diseases, those with dyspnoea to provide easy breathing.

Purpose:

To relieve dyspnoea
To assist recovery of the patient
To provide comfort and prevent complications

Requirements: trolley

As for the unoccupied bed
Additional:
- Back rest
- At least 4-6 pillows and pillow cases
- Air cushion/air ring and cover if required
- Bed blocks
- Sand bags and cover/foot support i.e. small board, a pillow, rolled cloth etc; may be necessary to support the feet
- Cardiac table
On the locker: Sputum mug, a bell: so that the patient can reach it easily.

Procedure:

Collect the equipment needed.
Wash hands thoroughly.
Place the 2 chairs at the foot of the bed.
Prepare the bed as the open bed with the patient but in a sitting up position.
When making the bed, take care to see that the patient’s shoulders are covered if possible. It is better to use a bed jacket or shawl or a small blanket - the bed clothes will be restricting.
Place the back rest and pillows so as to support the patient in upright position and use a bed elevator or bed blocks to prevent the patient from slipping down the bed.
Place sandbags/board/small pillow/rolled cloth against the feet where necessary as foot support.
Push the bed back to its original position.
Place the cardiac table over the bed for the patient to use whilst reading or performing any tolerable activity.
Clear away and wash hands.
Document the procedure.

Prepare and Make a Divided Bed (PEX 1.4.8)

DIVIDED/AMPUTATION/STUMP BED The bed is used for the patients who have had an amputation of the leg or have had a fractures lie in extension or for pelvic examination or treatment. It is commonly used for patients whose leg(s) has been amputated in order to keep the stump visible and elevated.

Purpose:

To keep the stump in a good position.
To help in the observation of the stump for bleeding constantly and apply tourniquet instantly if necessary.
To ensure safety and comfort to the patient by preventing soiling and staining of the linen.
To prevent jerking movements of the amputated leg, causing complications

Requirements: trolley

As for the unoccupied bed
Additional:
- 1 sheet
- 1 blanket
- 2 sandbags and covers
- Mackintosh and dressing towel
- Tourniquet and towel, only if ordered by the doctor in charge of the case.
- An emergency dressing trolley
- Bed cradle

Procedure:

Collect the equipment needed for the procedure.
Pull the bed from the wall.
Wash hands thoroughly.
Place the 2 chairs at the foot of the bed.
Make the bed in two halves; across the middle or for the amputation bed at the level of amputation. The top half having a sheet, blanket and counter pane and then the bottom half having a sheet and the blanket. This may be too hot for the patient at day time, so the top blanket may be omitted. At night, however it is much colder and both blankets may be needed.
On completion push back the bed to its original position.
Clear away and wash hands.
Document the procedure.

Prepare and Make a Fracture Bed (PEX 1.4.9)

PLASTER AND FRACTURE BEDS Is used for a patient with fracture of the trunk or extremities to provide firm support by use of a fracture board placed under the mattress. Fracture bed is a hard firm bed designed for the patient with a fracture particularly of the spine, pelvis or femur.

Purpose:

To make the patient comfortable.
To maintain the position and give support to the fracture.
To aid in immobilizing the fracture.
To prevent unnecessary pain.

Requirements: trolley

As for the unoccupied bed
Additional:
- Fracture board
- Bed cradle
- Sandbag with cover
- Extra pillows (at least 3)

Procedure:

Collect the equipment needed.
Pull the bed from the wall.
Wash hands thoroughly.
Place 2 chair at the foot of the bed.
This bed is made as the occupied bed.
The fracture boards are made the same width as the bed, and their purpose is to make a firm surface for placed support. They are place across the bed springs under the mattress.
Put the bed cradle over the affected part, so as to lift the weight of the beddings from the patient.
Push back the bed to the original position.
Clear away and wash hands.
Document the procedure.

TO CHANGE THE BOTTOM SHEET FROM SIDE TO SIDE

This method is used for changing the bottom sheet for most patients in the hospital especially those not able to move out of bed.

Requirements: trolley

1 air ring and cover
1 draw sheet
1 draw mackintosh
A tray for treating pressure areas may be required
1 sheet
Gloves

At the bedside:

2 stools/chairs
Hamper
Screen

Procedure:

Collect all the equipment needed.
Explain the procedure to the patient.
Bring the equipment needed to the bedside.
Close the windows if necessary. Screen the bed if the ward is not closed.
Pull the bed from the wall.
Place the stools/chairs at the foot of the bed.
Wash hands thoroughly and put gloves.
Place the clean linen on the stools/chairs at the foot of the bed and the hamper besides the chairs/stools.
Fold the clean sheets across the width in three or roll them for easy placement.
Strip the top bed clothes as usual, leaving the sheet covering the patient on a hot day or a blanket and sheet on a cold day. Back rest and air ring, foot support are also removed.
Both nurses lift the patient carefully down the bed off the draw sheet.
One nurse supports the patient, while the other removes the draw sheet and mackintosh, and then rolls the soiled bottom sheet down as far as the patient’s back and straightens the mattress cover and ground mackintosh.
The same nurse puts in the clean sheet, tucking it at the top and on her side as far as the dirty linen. She then puts in the draw mackintosh and draw sheet, tucks on her side. Replace the backrest, pillows and air ring. Treat pressure areas if necessary.
Both nurses lift the patient back up the bed and make sure that the pillows are comfortable. Then tuck in the mackintosh and draw sheet, top side of the bottom sheet on the second side.
Draw the soiled sheet to the bottom of the bed from under the patient’s legs and put it in the hamper.
With the hand, brush any crumbs and creases from the mackintosh if present and the mattress and straighten them both. Pull the clean sheet down to the bottom of the bed and tuck in, mitre corners.
Put on the top bed clothes as usual, make the patient comfortable.
Push back the bed to its original position.
Clear away, remove the gloves and wash hands.
Document the procedure.

NB. Some means should be used to prevent the patient in this position from slipping down the bed. This may be achieved by putting a sand bag or a pillow (with mackintosh cover) against the feet. This will also prevent foot drop or the foot of the bed may be raised on a bed elevator/bed blocks.

TO CHANGE THE BOTTOM SHEET FROM TOP TO BOTTOM

This method is used for changing the bottom sheet when the patient is nursed in an upright position and must not be flat e.g. chronic heart disease.

Requirement: trolley

1 air ring and cover
1 draw sheet
1 draw mackintosh
A tray for treating pressure areas may be required
1 sheet
Gloves

At the bedside:

2 stools/chairs
Hamper
Screen

Procedure:

Collect all the equipment needed.
Explain the procedure to the patient.
Bring the equipment needed to the bedside.
Close the windows if necessary. Screen the bed if the ward is not closed.
Pull the bed from the wall.
Place the stools/chairs at the foot of the bed.
Wash hands thoroughly and put gloves.
Place the clean linen on the stools/chairs at the foot of the bed and the hamper besides the chairs/stools.
Fold the clean sheets across the width in three or roll them for easy placement.
Strip the top bed clothes as usual, leaving the sheet covering the patient on a hot day or a blanket and sheet on a cold day. Back rest and air ring, foot support are also removed.
Both nurses lift the patient carefully down the bed off the draw sheet.
One nurse supports the patient, while the other removes the draw sheet and mackintosh, and then rolls the soiled bottom sheet down as far as the patient’s back and straightens the mattress cover and ground mackintosh.
The same nurse puts in the clean sheet, tucking it at the top and on her side as far as the dirty linen. She then puts in the draw mackintosh and draw sheet, tucks on her side. Replace the backrest, pillows and air ring. Treat pressure areas if necessary.
Both nurses lift the patient back up the bed and make sure that the pillows are comfortable. Then tuck in the mackintosh and draw sheet, top side of the bottom sheet on the second side.
Draw the soiled sheet to the bottom of the bed from under the patient’s legs and put it in the hamper.
With the hand, brush any crumbs and creases from the mackintosh if present and the mattress and straighten them both. Pull the clean sheet down to the bottom of the bed and tuck in, mitre corners.
Put on the top bed clothes as usual, make the patient comfortable.
Push back the bed to its original position.
Clear away, remove the gloves and wash hands.
Document the procedure.

Nurses Revision

Bed Making Read More »

General Principles in Patient Care

Topic: Perform general nursing care

Demonstrate appropriate methods of lifting/positioning a patient (PEX 1.3.8)

Safe and effective patient lifting and positioning are crucial skills for nurses to prevent injury to both the patient and themselves, promote patient comfort, and facilitate various procedures and recovery.

This PEX focuses on demonstrating:

Using proper body mechanics when lifting and moving patients.
Selecting the appropriate method for lifting or moving based on the patient's condition and ability.
Positioning patients correctly in various therapeutic positions (as detailed in the 'Positions Used in Nursing' section).
Using assistive devices (if available) for lifting and transferring.
Communicating with the patient during the lifting/positioning process.
Ensuring patient safety and comfort throughout the procedure.

POSITIONS USED IN NURSING

Positioning is placing the person in a proper body alignment for the purpose of preventive, promotive, curative and rehabilitative aspect of health.

Purpose of position:

To provide comfort to the patient.
To relieve pressure on various parts of the body.
To improve circulation
To prevent formation of deformity
To carry out investigations (medical and surgical)
To prevent pressure sores
To provide proper body alignment
To conduct delivery
To carry out nursing interventions

Types of positions commonly used in nursing:

Recumbent/supine position
Dorsal recumbent position
Semi-recumbent position
Lithotomy position
Prone position
Lateral or sim’s position
Fowler’s/sitting up position
Knee-chest or genupectoral position
Trendelenburg’s position

Types of patients who need special care:

Unconscious patients
Infants and children
Hemiplegics and paraplegic patients
Immediate post-operative patients
Orthopedic patients
Cardiac patient etc

Specific Positions

Recumbent/supine position

One or two pillows may be used for this position. The patient lies on the pack with his head and shoulders are slightly elevated on the pillow(s). His legs should be slightly flexed and a small pillow under the knees or the legs are left straight.

One pillow: This is used to provide full relaxation for acutely ill patients and for patients on complete bed rest. It is also used when examining the trunk.

Two pillows: The patient lays in bed with 2 pillows under his head. This is commonly used both medical and surgical nursing.

Indications:

It is a common position used by most patients
used for examination of the trunk (chest and abdomen)

Contraindications:

Elderly patients
Patients with operation on abdomen, breast and thorax
Prone to hypostatic pneumonia
Patient’s with long standing illness and neurological conditions

Semi-recumbent position

The patient is half sitting up, supported by three or more pillows. This is a comfortable position for patients who are recovering from an illness and who wish to be able to read in bed.

Indications:

Recovering patients
To obtain good drainage in the pelvis
To prevent straining of abdominal muscles

Prone position

The patient lies on the front of the body and has his head turned to one side. A pillow is provided on which to rest the side of his face, a small soft pillow is placed under the abdomen and pelvis, the knees are flexed and the lower leg supported on a pillow, under the ankles. It is useful when there is danger of bed sores forming on the back or for change of position when the patient is in a plaster bed with a fractured supine.

Indications:

Post-operative patients
Prevention of bed sores
Relieve abdominal distension
Patients having injuries and burns of the back

Contraindications:

Not tolerated by the elderly
Patients with cardiovascular conditions
Patients with respiratory problems

Lateral/sim’s position

The patient lies on the right or left side of his body with legs flexed at the highs. The left lateral is the most commonly used and the patient lies on the left side. A pillow is kept in front of the abdomen, the back and one under the upper leg.

Indications:

Used for giving of an enema
Examination of the rectum
Inserting suppositories
Taking of rectal temperature
It is used as change of position from the semi-recumbent position
Colonic irrigation
Giving back care

Sitting up position

The patient is sitting nearly upright at least at an angle of 45° attained by means of a special bed or use of a back rest and pillows. Asorbo foam cushion/air ring to relieve weight at the sacrum and ileum is usually place under the buttocks and it is necessary to use some means to prevent the patient from slipping down the bed. This may be done by using a foot rest or elevating the bed on bed blocks. The position is used in cases where there is dyspnoea e.g. heart disease, pneumonia, bronchitis.

Indications:

Dyspnoea
Improve thrombosis
Post-operatively to assist drainage form abdominal or pelvic cavity
To relax the muscles of the abdomen and thighs
To relieve tension on abdominal sutures
To promote comfort
To relieve edema of the chest and abdomen

Semi-prone position

The position is similar to lateral except with the upper knee flexed and the upper part of the trunk turned so that the patient lies almost prone, one arm behind the back, the other arm flexed at the shoulder and elbow lying in front of the patient’s face. The head is turned on one side, no pillows are used. This position ensures the greatest safety for the unconscious patients because it prevents danger of the tongue falling and blocking air passage, and also allows any secretions run out of the mouth (drain).

Indications:

Unconscious patients,
Those returning from operating theatre,
Rectal examination
Relaxation in antenatal exercises

NB. The patients who have had an abdominal operation are placed in recumbent position but all other cases are put back into bed on the semi-prone position unless otherwise ordered.

Contraindications:

Patients with deformities of the hip or knee may be unable to assume this position.

Dorsal recumbent position

Patient lies on the back with the knees fully flexed, thighs flexed and externally rotated feet flat on the bed. The patient is placed on the back in bed with two or more pillows under the head and one pillow under the knees or the bed is elevated at the top to maintain the position.

Indications:

Catheterization
Vaginal douche
Vulva, vaginal and rectal examination
Vaginal operations
Insertion of tampons
Patients with abdominal or pelvic operations unless erect/sitting position is indicated.

Lithotomy position

The patient lies on her back, the legs are separated and supported on the stirrups, thighs are flexed on the abdomen and the patient’s buttocks are kept at the edge of bed or table. One pillow is placed under the patient’s head.

Indications:

Gynaecology examinations, treatments and operations on the genitourinary system
For delivery
Rectal examination and operations

Contraindications:

Patients with arthritis or joint deformity

Knee-chest position

The patient rests on the knees and the chest, the head is turned to one side with one cheek on a pillow and another pillow places under the chest. The weight is on the chest and knees.

Indications:

Used for sigmoidoscopy
Vaginal and rectal examination
First aid treatment in cord prolapsed or retroverted uterus.
As exercise for postpartum and gynaecology

Contraindications:

Patients with cardiovascular and respiratory problems

Trendelenburg’s position

The patient lies on his back, the head is lower than the trunk, the foot of the bed is elevated at 45° angle, the body is on an inclined angle and the legs hang downward over the end of the table.

Indications:

Used in emergency situations like shock and hemorrhage (arrest bleeding from lower limbs)
Used in vaginal surgeries
Used to displace intestines from the pelvic cavity the upper abdomen
Operations on the pelvic organs

Jack knife or Kroaske/Bozeman position

The patient is placed on a prone position with the hips directly over the band of the examining table. Tip the table with the head lower than the hips. Lower the foot part of the table so that the patient’s feet are below the level of his head. Place the pillow under the pelvis and abdomen to relieve the strain.

Indications:

Operation on the rectum and coccyx
Drainage

Walchers position

The patient is place flat on his back with the sacrum resting on the edge of the table. Lower the legs slowly towards the floor. Elevate the buttocks slightly if the table permits.

Indications:

To increase the diagonal conjugate of the pelvis in high forceps delivery and in breech presentation
To relax the perineum

Standing/erect position

The patient stands with the knees separated about ten inches with one foot on a low stool. Instruct her to place one hand on the back of the chair for support and the other hand on her hip.

Indications:

Vaginal examination for determining the degree of uterus prolapsed
Examination of hernia

LIFTING AND TURNING OF PATIENTS

A good nurse always knows how to lift and turn her patient gently. Great strength is not necessary to do this, it will need much practice.

To Lift a Patient Who Is in Sitting up Position in Bed

Procedure I: Orthodox lift

Two nurses are necessary
Move the patient forward from the pillows, each nurse placing a hand under the patient’s axilla.
Ask the patient to fold the arms across the chest and bend the head forward (chin on chest) and bend the knees a little.
Place the arm nearest the head of the head of the bed behind the buttocks at the patient’s back, grasping each other’s wrist firmly.
Slip the other hand under the patient’s high up at the junction of the thighs and buttocks, grasping each other’s wrist firmly
Each nurse should grip with one hand and be gripped on the other hand by the second nurse.
They then lift the patient down the bed and off the draw sheet.

Procedure II: Australian/shoulder lift

Both nurses face the head of the bed.
Bend down and place shoulder nearest to the patient under the axilla to act as a crutch.
Place the hand of the same arm under the thighs as in method I/procedure I.
The free hand is placed flat on the bed behind the patient’s back and is used to take the weight when doing the lifting.
Lift the patient down the bed and off the draw sheet.

To Turn a Patient onto the Side

See that the patient’s knees are flexed, and put arms and legs in position for turning.
Place one hand behind the shoulder furthest away and the other over the hips.
Then turn the patient onto the side towards you.

To Lift a Patient onto the Bed from the Stretcher

Three nurses are necessary.
Put the head of the stretcher to the foot of the bed.
Three nurses stand on the side nearest the bed, one lifts the head and shoulders, one the hips and the third at the legs.
All lift the patient together then move to the right and place the patient very carefully on the bed.
Make the patient comfortable in the bed.

To Lift a Patient onto the Bed from the Theatre Trolley

Wheel the trolley up beside the bed.
Then lift the patient onto the canvas stretcher and place him on the prepared bed.
Remove the poles and put them back on the trolley.
Remember the patient returning from theatre is usually unconscious; handle him very gently and carefully.
Place the arms and legs in position for turning and turn patient to the left side and roll the canvas and mackintosh up to the back.
Roll the patient back to the middle of the bed and then to the right side as above and take out the canvas and mackintosh, put on the theatre trolley.
Put the patient into the position which is used for the condition e.g. semi-prone or lateral.

NB. The patient should lie facing the locker side of the bed because the post-anesthetic tray should be ready on it and the nurse will remain by the bedside (on this side.)

To help a patient Out Of Bed Onto A chair

Requirements:

Patient’s gown
Slippers/sandals
Pillow from the bed
Arm chair
Blanket to put over the knees may be required
A bell

Procedure:

Help the patient into the gown and slippers.
Bring the chair to the side of the bed.
Place the patient’ legs over-side of the bed and help him to stand.
Support the patient while he turns to sit into the chair.
Place a pillow comfortably behind the back and fold a blanket over the knees if necessary.
Give the patient some activity to do e.g. a book or knitting material and if he is alone a bell to ring incase he feels faint.

Perform tepid sponging (PEX 1.3.9)

TEPID SPONGING Is the process of sponging with tepid water to cool the skin/reduce fever by evaporation and the temperature of the water used is 80-90°F (22-28°C)

Purpose:

To reduce the high temperature in a febrile state to normal
To stimulate circulation
To decrease toxicity
To relieve nervousness and delirium and hence soothe the nerves and promote sleep

Requirements:

Trolley:

Top shelf:

A large basin of Luke warm water
Jug of tepid water 6 sponge cloths/face towels in a bowl
Face towel in iced water in a bowl for a compress
Bath thermometer

Bottom shelf:

Clean linen/bed sheets
Patient’s gown
Mackintosh and draw sheet
2 bath towels
Temperature tray
Bucket for used water

At the bed side:

Screens
Hamper
Cold drink for the patient
Drugs with adrenaline

Procedure:

Collect all the equipment needed.
Explain the procedure to the patient.
Provide adequate privacy by screening and closing the adjacent windows.
Wash hands thoroughly.
Take the temperature of the patient and chart it.
Strip the bed up-to the top sheet and take off the patient’ gown.
Soak the face cloth in the ice cold water.
Apply the cold compress to the forehead of the patient.
Sponge the face and dry with a face towel (the face and back are the only parts to be dried to avoid chills)
Place the cold sponge in each axilla and groins, change if necessary.
Sponge the neck, expose the arms and sponge using long slow sweeping movements for 3 minute on each arm. Pour water over the hands and change the compress o the fore head.
Change the water if necessary and check the temperature again.
Cover the upper half of the body and expose the lower half of the body. Sponge the legs with long slow sweeping movements and pour water over the feet.
Remove the compress from the forehead and face cloths from the axillae and groins.
Turn the patient gently on the side, sponge the back using two face towels/cloths with long strokes/sweeping movements and dry.
Remake the bed using clean linen, give the patient a clean gown and leave him/her comfortable.
Give the patient a cold drink. The patient is left for 20 -30 minutes, then the temperature is taken again and charted in the TPR/BP chart. It should fall by 1°C.
Clear away and wash hands.
Report and record the procedure to the patient’ chart.

N.B:

If the patient shows any sign of collapse during the procedure, the procedure is stopped at once, dry the skin and report to the nurse in-charge. Remake the bed. Clear away. The procedure should be left for 20 minutes before commencing.
The patient must be observed carefully throughout the procedure for signs of chills or any abnormality.
The patient is moved as little as possible.

Nurses Revision

General Principles in Patient Care Read More »

Taking Vital Signs or Observations

Topic: Take vital observations (PEX 1.5.1 - 1.5.4)

Vital signs are measurements of the body's most basic functions. They should be looked at in total, to monitor the vital functions of the body. They help reflect changes in the body and determine the patient’s usual state of health.

There are four primary vital signs: body temperature, blood pressure, pulse (heart rate), and breathing rate (respiratory rate), often noted as BT, BP, HR, and RR.

Purpose of Taking Vital Observations

To assess the health status of an individual.
To plan and implement the nursing care.
To modify or change the mode of treatment.
Routine part of complete physical assessment.
It helps to understand the present problem; assists in diagnosis
To understand the effectiveness of the treatment.

Timing of Taking Vital Observations

On the patient’s admission to the hospital or health unit.
On routine schedule according to the physician’s order or hospital policy e.g. 6:00am to 6:00pm.
During patient’s visit to the clinic or physician’s office.
Before and after any invasive diagnostic procedure.
Before and after a surgical procedure e.g. 1^st 48hrs postoperatively or 4hrly with very ill patients or with fever.
Before and after administration of medication that affects the cardio vascular, respiratory and temperature control function.
When the patient’s general physical condition changes e.g. loss of consciousness, increase in intensity of pain.
Before and after nursing interventions influencing anyone of the vital signs e.g. before ambulating a patient who has been previously on bed rest or before the patient performs range of motion exercise, blood transfusion and tepid sponging.
Whenever the patient reports to the nurse about any non specific symptoms of physical distress e.g. “feeling funny or different”

Normal Values and Ranges of Vital Signs

Temperature:

Normal value: - 98.4°F or 37°C in adults.
Normal ranges: - 97°F-99°F or 36°C-37.2°C.

Pulse:

Normal value: - 72 b/m in adults
Normal ranges: -
- Adult: 60-90 b/m (18yrs +)
- Children: 90-120 b/m (1-18yrs)
- Infants: 120-140 b/m (1 month-1yr)
- Neonate (newborn): 140-160 b/m (0-28ays-1month)
- Old age - may be slower
- Extremely old age - may be more rapid

Respiration:

Normal value: 16 breaths/minute (adults)
Normal range:
- 16-20 breaths/minute (adults)
- 30-44 breaths/minute (neonates)
- 20-22 breaths/minute (children)
- Old age - 10 to 24 breaths per minute.

Blood pressure:

Normal value: 120/80 mmhg (in adults)
Normal range: 90/60 - 120/90 mmhg.
Newborn (neonates): - 30-50 / 10 mmhg
Infants: - 70-90 / 50 mmhg
Adult: - 90-120 / 60-90 mmhg (Note: This is the same as the general adult range, but listed again here).

Guidelines for Taking Vital Signs

The primary nurse caring for the patient is the best one to take vital signs, interpret their significance and make decisions about the care.
Equipment used to measure vital signs must be appropriate and working properly to ensure accurate findings.
Knowing the normal range for all vital signs helps the nurse to detect abnormalities.
A client’s normal range may differ from the standard range for that age or physical state.
A normal value for the client serve as a baseline for comparing in conditions over time.
Know the client’s medical history and therapies or medications, for vital sign changes.
Control or minimize environmental factors that may affect vital signs. For example measuring pulse after the patient experiencing pulse upset, will give unclear results for the client’s current state.
An organized, systemic approach when taking vital signs ensure accuracy of findings.

Take Patient's Temperature (PEX 1.5.1)

Temperature Is the degree of heat maintained by the body monitored/measured using a clinical thermometer.
Or
Is the degree of warmth or balance maintained between the heat produced (thermogenesis) and heat lost (thermolysis) in the body.
Or
Is the degree of heat of substance or body as measured by a thermometer.

Purpose:

To determine the body temperature
To assist in diagnosis
To evaluate the patient’s recovery from illness.
To plan immediate nursing interventions.
To evaluate the patient’s response.
To recognize any variation from the normal and its significance.

Normal body temperature from different sites (adult):

Oral: 37°C or 98.4°F (36°C-37°C)
Rectal: 37.6°C or 99.6°F or 1° higher than mouth temperature.
Axilla: 36.4°C or 97.6°F (36°C-37°C or 1° lower than mouth temperature.)
Groin: as for the axilla.

N.B:

Temperature varies at different times of the day, the evening temperature being about 1° (one degree) higher than that of the morning because of muscular and metabolic activity.
The temperature also varies according to the site used for taking it. E.g. the skin temperature i.e. axilla in a healthy person may be 36.1°C while the oral/mouth temperature is usually a degree higher and the rectal temperature may be 37.2°C or 99°F. The rectal temperature is the most accurate temperature.
When taking temperature, never be satisfied with anything but accurate result. Incorrect results do mislead diagnosis, prescription and treatment.

Factors that affect temperature:

Times of the day e.g. morning, evening.
Site used.
Gender, women normally have a higher temperature than men especially during ovulation.
Age, the temperature is highest in neonates and lowest in the elderly.
Emotional conditions.
Environment.

N.B: The mouth, axilla, groin, rectum and vagina are suitable places in taking temperature but as the reading varies according to the site, the same place must be used each time for the same patient.

Factors that influence heat production:

Metabolism, oxidation of food.
Muscle activity, exercise
Strong emotions, excitement, anxiety and nervousness.
Change in atmospheric temperature.
Diseases/conditions; bacterial invasions or infections.
Sympathetic stimulation; epinephrine and nor-epinephrine.

Factors that influence heat loss:

Sleep; body temperature is low
Fasting; leads to decreased heat production
Illness and lower vitality; due to depressed nervous system, the heat production is lowered.
Prolonged exposure to cold
Use of narcotic drugs; suppress the temperature centre.

The body heat is lost through the following;

Conduction- Transfer of heat from body to substance (air, water and cloths) directly in contact.
Radiation- Transfer of heat from the body to heat waves which travel through the space.
Evaporation-Transfer of heat from the body in form of vapor (liquid is converted into vapor)
Convection-It is transfer of heat from the surface of one subject to the surface of the other; such as skin by movement of heated air or fluid particles.

General rules for taking temperature:

The mouth is the usual place to take temperature but it must not be used for the following;
- A child under 5 years
- If there is difficulty in breathing or much coughing
- Unconscious or mentally confused patients.
- If there is disease of the mouth or nose.
- It should not be taken immediately after hot or cold fluids, because the factors affect the temperature recorded on the thermometer.
Wait for 10 minutes after the patient has eaten or drunk.
Grasp the thermometer securely by the upper end of the stem; never hold it by the bulb as it will easily be broken or contaminated.
If the patient bites or breaks a thermometer in the mouth, quickly give cold water to rinse and inform the in charge for further management.
If taking temperature by rectum, always hold the thermometer for the patient in place (children)
Report to the supervisor the temperature below 35°C or above 38°C
Always wash the used thermometer with cold water and soap or disinfect with a disinfectant.
Never take oral and rectal temperature at the same time.
Shake it by quick movement of the wrist below 35°C or 94°F.
Care should be taken when shaking the thermometer near an object or articles to avoid breakages.
Patients are never told what the vital sign reading is but simply explain to the patient i.e. “you are fine, okay, don’t worry.”

Types of thermometer:

Clinical thermometer: It is an instrument used for recording body temperature. It is made of glass with a hollow tube running through the centre. At one end is bulb containing mercury which rises into the center tube when heated. The mercury remains stationary at registration point until shaken down due to a constriction in the tube which prevents this. Degrees of temperature are marked on the clinical thermometer from 35°C-43°C or 94°F-110°F.

Electronic or digital thermometer: It consists of battery powered display unit, a thin wire cord and a temperature sensitive probe covered by a disposal plastic sheath to prevent transmission of infection. Separate probe are available for oral and rectal insertion.

Disposable thermometer: It is a single use thermometer, made of thin plastic strips with chemically impregnated paper, they are used for children to take oral and axillary temperature only. 45 seconds are needed to record the temperature, it is less accurate.
Tympanic membrane thermometer: These are small held devices similar to hodoscopes with disposable speculum. Infrared-sensing electronic and liquid crystal displays. Results are displayed 1-2 seconds after placing their speculum in the outer third of the ear canal, it is accurate.

Oral Temperature

Temperature checked by the oral cavity.

Requirement: Temperature tray containing the following;

Oral clinical thermometer in a jar containing a disinfectant solution e.g. hibitane cetrimide 1-20.
Galipot of swabs
Galipot of water
A receiver for used swabs
Watch with second hand ticker
Temperature chart
A pen

Procedure:

Collect the equipment needed.
Explain the procedure to the patient.
Position the patient and give privacy.
Wash hands.
Hold the colour coded end or system glass thermometer with finger tips.
If the thermometer is stored in disinfectant solution, rinse in cold plain water and dry before use. Inspect for cracks and if broken do not use.
Read mercury level while holding thermometer horizontally and gently rotating at the eye level. If the mercury is above a desired level, grasp at the tip of thermometer securely and sharply flick the wrist downward, continue shaking until reading is below 35°C or 94°F.
Ask the patient/client to open the mouth and gently place the thermometer under the tongue in posterior sublingual, lateral to center of the lower jaw.
Ask the patient to hold thermometer with lips closed. Caution against biting the thermometer and talking whilst the thermometer is in place.
Leave the thermometer for 3 minutes in place or according to agency policy. Carefully remove the thermometer, read at eye level while holding horizontally.
Wipe the thermometer in rotating movements with a wet swab, place it back in its jar and chart the readings and report any unusual variations to the in charge nurse.
Clear away, make the patient comfortable and wash hands.

N.B:

If the ward temperatures are taken orally, individual thermometers should be used.
When taking the temperature the patient should be sitting or lying down.

Contraindications (Oral Temperature):

Disease, injuries, inflammation and surgeries of the oral cavity.
Infants, children below 5 years, mentally disturbed patients; delirious, no-cooperative and unconscious- cannot retain the thermometer in place.
Patients with breathing problem/difficulty in breathing, convulsions, patients with oxygen masks, frequent and severe cough.
Should not be taken immediately after hot bath, after smoking, taking hot or cold drinks - because these factors affect the temperature recorded on the thermometer.

Axillary Temperature

The temperature is sometimes taken by axilla when it cannot be taken by mouth or contra indicated to oral temperature.

Requirements: As for oral temperature.

Procedure:

Collect the equipment needed for the procedure.
Explain the procedure to the patient.
Position the patient and provide privacy.
Wash hands.
Inspect the axilla and dry it thoroughly with a dry swab.
The thermometer is dried on swabs and shaken with a flick of wrist until the mercury falls below 35°C or 94°F mark. Inspect for cracks.
Insert the thermometer into the center of the axilla with the bulb in contact with the skin folds, care should be taken in that clothing should not interfere. The elbow is kept at the side and place arm across client’s/patient’s chest to retain the thermometer in position.
Leave the thermometer in place for 3 min.
Remove the thermometer from the axilla, read it at the eye level. Wipe the thermometer using a swab soaked is a disinfectant or plain water from stem to bulb using a firm twisting motion. Place it back in its jar and chart the findings and report any variations to the in charge nurse.
Clear away, make the patient comfortable and wash hands

Contraindications (Axillary Temperature):

If there are sores or burns at the site
Emaciated or thin patients

NB. The patient should be in sitting or lying position.

Groin Temperature

The rules apply as for the axilla, but one leg is flexed over the other.

Requirements: As for the oral temperature.

Procedure:

Collect the equipment needed for the procedure.
Explain the procedure to the patient.
Position the patient and provide privacy.
Wash hands.
Inspect the groin and dry it thoroughly with a dry swab.
The thermometer is dried on a swab and shaken with a flick of the wrist until the mercury falls below 35°C or 94°F mark. Inspect for cracks.
Insert the thermometer in the center of the groin by asking the patient to abduct the thigh and flex the upper leg over the other.
Leave the thermometer for 3 minutes.
Grasp the end of the thermometer and remove it from the groin, read it at the eye level.
Wipe the thermometer using a swab soaked in a disinfectant or plain water from the stem to bulb using affirm twisting motion.
Place it back in its jar and chart the findings and report any variations to the nurse in-charge.
Clear away, make the patient comfortable and wash hands.

Contraindications (Groin Temperature):

Sores or burns at the site.
Emaciated or thin patients.

Rectal Temperature

Rectal temperature measurement is a technique used to measure body temperature by placing a thermometer in the rectum.

This method is used for head injuries, head operations and for children under 5 years. The rectum thermometer has a blunt end colored blue, to prevent inadvertent use in other situations. The thermometer must be kept in a jar containing a disinfectant solution.

Requirements:

Rectal thermometer
Galipot of swabs
Galipot of water (2); Lukewarm and cool water
Receiver for used swabs.
A watch with a second hand ticker
Temperature chart
A pen
Vasciline or other lubricant
Gloves

Procedure:

Collect all the equipment needed.
Explain the procedure to the patient.
Screen the bed to provide privacy.
Position the patient in sim’s position with the upper leg flexed to expose only the anal area.
Wash hands and put on gloves.
Swab the area.
Remove the thermometer from the jar, clean it/dry it, check for cracks and shake below 35°C.
Squeeze liberal portion of a lubricant on a swab and dip the thermometer’s bulb end into the lubricant covering 2.5-3.5 cm (1-1.5 inches) for adult or 1.2-2.5cm (0.5-1 inch) for infant.
With a non-dominant hand, separate the patient’s buttocks to expose the anus and ask the patient to breathe in slowly and relax.
Gently insert the thermometer into anus along the rectal wall towards the umbilicus so as to register the hemorrhoid artery temperature instead of the faecal temperature. Insert it about 1.2-2.5cm for infants and 2.5-3.5 for adults. Do not force the thermometer to prevent perforation of anus or rectum and breakage of the thermometer.
If resistance is felt during insertion withdraw the thermometer immediately and report.
Hold or leave the thermometer in place for 3 minutes.
Carefully remove the thermometer and wipe off secretions with a swab, wiping in rotating movements towards the bulb.
Read the thermometer at eye level and chart the findings in the patient’s chart.
Wash the thermometer in Lukewarm water or disinfectant, rinse in cool water, dry and replace it in its container or jar.
Clear away, remove the gloves and wash hands.
Report any unusual variations to the nurse in-charge

Contraindications (Rectal Temperature):

Injuries, disease, inflammation and surgeries of the rectum
Patients with faecal impaction
Patients with chronic diarrhea
Patients requiring bowel wash/enema.

Conversions (Temperature)

The Fahrenheit scale ranges from 32°F to 212°F whereas centigrade scale ranges from 0°C to 100°C.

When converting Fahrenheit to centigrade, the formula is (F-32) * 5/9 = C
And in converting centigrade to Fahrenheit, the formula is (C * 9/5) + 32 = F.

Rigors

Is a sudden attack of intense shivering when the heat regulating center in the brain is disturbed. It is seen in certain infections like malaria, allergic reactions i.e. after intravenous infusion.

Stages of rigors:

Cold stage: The patient feels chill, extreme shivering and hyperpyrexia.

Management:

Provide rest and supplementary oxygen.
Offer hot drinks and use hot water bottle to provide warmth.
Provide with an extra blanket.
Give more fluids to take.

Hot stage: The patient feels extremely hot.

Management:

Remove extra blankets and hot water bottles.
Cold sponge/tepid sponge and give ice pack compresses.

Sweating stage: Here the patient is sweating profusely.

Management:

Wipe the patient with a wet towel and cover with a sheet.

N.B: During all the three stages, take temperature and record in the patient’s chart.

Take Patient's Pulse Rate (PEX 1.5.3)

PULSE Is the wave of expansion and recoil of an artery in response to the pumping action of the heart. This can be felt by the examining fingers.

Purpose:

To determine the number of heartbeats acquiring per minutes created.
To evaluate amplitude (strength) of the pulse.
To assess the vascular status of the limbs.
To assess the response of the heart to cardiac medication, activity, blood volume and gas exchange.
To assess the heart’s ability to deliver blood to distant areas of the body.
To obtain information about the heart rhythm and patterns of beats.

Normal pulse rates:

Newborn - 140 b/m
Infant - 120 b/m
2-3 years - 100 b/m
4-10 years - 90 b/m
11 years and above - 70-80 b/m (average - 72 b/m)
Old age - may be slower
Extremely old age - may be more rapid

Normal ranges of pulse rate:

Neonate (newborn) - 140 to 160 b/m (0-1 month)
Infant - 120 to 140 b/m (28 days/1 month - 1 year)
Children - 90 to 120 b/m (1 year - 18 years)
Adults - 60 to -90 b/m (18 years and above)

Common Sites of Taking Pulse:

Site	Location
Radial artery	In front of the wrist at the thumb side.
Brachial artery	Medially above the elbow.
Carotid artery	At the side of the neck where the carotid artery runs between the trachea.
Temporal artery	Over the temporal bone.
Facial artery	Above the lower jaw.
Femoral artery	In the groin.
Tibial artery	Behind the medial malleolus.
Dorsal pedis	On the foot.
Apical	At the left side of the chest in the 4^th 5^th and 6^th intercostals’ space.
Popliteal	Medial or lateral to the popliteal fossa with the knees flexed.
Ulnar pulse	Outer aspect of the wrist along the little finger side.
Fontanelles of infants	Head.

Observations made on taking pulse:

When taking the pulse the following should be noted;

Rate: Is the number of beats per minute. Corresponds with the age, average for adults is 72 b/m.
Rhythm: It is the regularity of beats. The distance between beats is equally spaced (regular)
Volume: It is the fullness of an artery. It is the force of blood felt at each beat (full/large/small/weak). Amount of blood distending the artery with each beat.
Tension: It is the degree of compressibility (high/low). The pulse should be felt soft under the nurse’s fingers, it should not feel hard. If it is difficult to compress or stop the tension, it is high and if it is easy to compress or stop, then it is low.

Factors that affect the pulse:

Age - children have faster beats and very old persons have a slow pulse rate.
Sex - it is slower in men than women.
Stature - It is slower in tall people than in short people.
Position - The pulse rate is slower at rest and sleep than in a standing position.
Emotions - Anger or excitement increases the pulse rate temporarily.
Exercise - It is much faster during exercise.
Fever increases the pulse
Extreme heat and cold - increase
Drugs - may increase the pulse rate e.g. morphine, digitalis.
Shock and hemorrhage (cerebral vascular accident)
Diseases e.g. thyrotoxicosis, myocardial failure (increase)
Fasting (increases)
Head tumors (increase)

Abnormal pulse:

Tachycardia: Is the rapid heart action indicated by a rapid pulse rate. The pulse rate is more than 100 b/m. It is commonly found in patients with fevers, thyrotoxicosis, organic heart disease, nervous disorders and intake drugs like morphine, caffeine and alcohol.
Bradycardia: It is an abnormally slow heart rate indicated by a slow pulse rate of less than 60 b/m. Commonly caused by opium poisoning heart muscle disorder, cerebral tumors and myxedema.
Dicrotic pulse (abnormal volume): There is a one heartbeat and two arterial pulsations giving the sensation of a double beat due to flabby weak arterial pulse.
Abnormal rhythm: There is intermittent pulse and extra systoles e.g. cardiac irritability, hypoxia, digitalis overdose, potassium imbalance, arrhythmias.
Water hammer or Corrigan’s pulse: It is a full volume pulse. This type of pulse is found in aortic regurgitation, when blood is forced into the artery then leaks back into the ventricle due to non closure of the aortic valve.

General rule for taking pulse:

Count the pulse for one full minute especially when there is irregularity.
Observe the rate, rhythm, volume and tension of the pulse.
Pulse should not be taken immediately after the exercise, in emotional stress or after a painful treatment. Check 10-15 minutes of exercise.
Record the pulse immediately.
Choose a suitable site for taking the pulse.
Be aware or take note if the patient is on any medication that can interfere with the heart rate e.g. morphine, digitalis.
Notify the physician when the pulse rate is below 60 b/m or above 100 b/m, abnormal patterns (missing beats).
Assess the pulse again by having another nurse to conduct measurement, if the pulse is abnormal or irregular.

Requirements (Radial Pulse - most common):

In a small tray;
Watch with a second hand ticker
A pen
TPR chart

Procedure (Radial Pulse):

Collect the equipment needed.
Explain the procedure to the patient
Position the patient either sitting or lying down position. Bend the patient’s elbow at 90° and support lower arm on a chair or table or nurse’s arm and slightly extend the wrist with palm downwards.
Wash hands and dry thoroughly.
Place the tips of the 1^st two or middle three fingers of the dominant hand over the groove along radial or thumb side of the patient’s wrist applying slight and steady pressure.
When the pulse is easily palpable, look at the watch’s second hand ticker and begin to count the rate.
If the pulse is regular count the rate for 30 seconds and multiply by 2 and if irregular count for a full minute.
Assess the regularity, the strength (volume), rate and the tension of the pulse.
Assist the patient to return to a comfortable position.
Record the findings to the patient’s chart.
Clear away and wash hands.
Report abnormal findings immediately to the nurse in-charge or physician.

N.B. Record immediately the pulse at the same time the thermometer is placed into the patient’s mouth or any site when the patient is unaware of the counting.

Take Patient's Respiratory Rate (PEX 1.5.4)

RESPIRATIONS Is the act of breathing in /taking in oxygen (inspiration/inhalation) and breathing out/ expelling out of carbon dioxide (expiration/exhalation). The exchange of gases between the blood and lungs is called external or pulmonary respiration and the exchange of gases between the blood and cells is known as internal respiration.

Purpose:

To determine the respiratory status of the patient.
To determine the number of respirations occurring per minute.
To gather information about the rhythm and depth.
To assess response of a patient to any related therapy/medication.

Normal respiration rates:

At birth (neonate) - 30 to 44 breaths per minute.
1 year (infant) - 26 to 30 breaths per minute.
2 to 5 years - 20 to 26 breaths per minute.
Adolescent - 20 to 22 breaths per minute (average 20 breaths per minute.)
Adults - 16 to 20 breaths per minute.
Old age - 10 to 24 breaths per minute.

Factors that influence respiration:

Sex - female have slightly rapid respiration than the male.
Exercise - exertion of any type increases the metabolic rate and stimulates respiration.
Rest and sleep - during rest and sleep metabolism is decreased, so respiration rate is normal or decreased.
Emotions - sudden stressful condition such as fear and anxiety, excitement influence the respiratory rate (rapid)
Change in atmospheric pressure.
In high altitudes the content of oxygen in the atmosphere is very low, the rate of respiration in increased and the increased demand of oxygen is fulfilled.
Disease - in some heart diseases, respiration increases and it is decreased when there is pressure on the brain due to tumors.

Characteristics of a normal respiration:

Normal breathing is effortless.
It is painless, quiet and automatic
It consists of rhythmical rising and falling of the chest wall.
Respiratory rate in a resting adult is 16 to 18 b/m.
Eupnoea; it is regular, even and produces no noise.

Abnormal respirations:

Stridor respiration: It is a noisy shrill and vibrating inspiration occurring in obstruction of the upper airway or may be whistling sound. It is commonly seen in laryngitis and foreign body in the respiratory tract.
Wheezing: It is a difficult and louder/noisy expiration due to partial obstruction of the smaller bronchi and bronchioles and this is seen in asthma and emphysema.
Apnoea: This is a temporary cessation of breathing due to excessive oxygen and lack of carbon dioxide e.g. very ill patients, CNS disorders.
Dyspnoea: It is forced, painful, difficult or labored breathing and it may be accompanied by cyanosis, it is seen in heart diseases, respiratory diseases, obstruction of the airway due to infection, new growth and foreign body, convulsions.
Orthopnoea: Is inability to breathe except when sitting up or in upright position. It is found in congestive heart failure.
Cheyne-strokes breathing: Is the breathing which starts with slow and shallow respirations and gradually increases in rate and depth (volume) until it reaches the maximum (climax) and then a slowly pause occurs and breathing stops/ceases for 5- 30 seconds and the cycle begins again. It is a periodic breathing usually common in patients who are near death, this should be reported at once.
Asphyxia: It is a state of suffocation when the lungs fail to get sufficient supply of oxygen to supply the vital organs.
Rale: An abnormal rattling or bubbling sound caused by the mucus obstructing the airway, which is seen in bronchitis due to pneumonia.
Hyperpnoea/kussumauls breathing/hyperventilation: Is the abnormal forced breathing in which the respiration are deep though regular but rapid or with increased rate and it is seen in diabetic ketoacidosis.
Croup: Is a difficult, noisy breathing due to laryngeal spasms.
Stertorous breathing: Is a noisy breathing which occurs in the unconscious patients.
Biot’s respiration: It is a shallow breathing interrupted by irregular periods of apnoea, usually seen in central nervous system disorders.
Cyanosis: It is the blueness or discoloration of the skin and mucous membranes due to lack of oxygen supply to the tissues.
Bradypnoea: Is slowness of breathing or respirations.
Tachypnoea: Rapid breathing or respiration rate

General rules in counting respirations:

The patient should be placed in a comfortable position (sitting up position)
Respirations should be counted when the patient is unaware of the counting, immediately after counting the pulse before the nurse removes her fingers from the patient’s wrist. The patient may involuntarily increase or decrease the respirations.
Look at the chest wall. The respiratory cycle consists if inspiration, expiration and a pause.
Children’s respiration rate should be counted before disturbing the child to take the temperature.
Inform the physician in case of bradypnoea, tachypnoea or other abnormal respiratory patterns.
Maintain half ½ hourly checking of respiration when indicated.
Make sure the patient’s chest movements are visible, if necessary remove bed linen or gown.
If the patient or client has been active, wait for 5-10 minutes before assessing respirations.

Observations made on respiration counting.

The following should be observed when counting the respiration;

Rate - the number of times the patient breathes in and out per minute. The rate may change in health.
Depth - the nurse should notice whether the respiration are shallow or deep. When they are shallow, the patient is only taking little breaths perhaps because it hurts to breathe as is seen in infections of the respiratory tract or fractured ribs. When the respirations are deep, the patient is taking big breaths and the respirations are usually slow and noisy.
Discomfort - the nurse should notice any discomfort that the patient may have when breathing e.g. pain as in fractured ribs or respiratory diseases or heart diseases.
Movements - it is important to note the muscular movements that take place during breathing. Normally there should be some movements in the abdominal wall as well as in the thoracic muscles.

Requirements:

Wrist with second hand ticker
A pen
TPR chart/patient chart

Procedure:

Collect the equipment needed.
Explain the procedure to the patient.
Position the patient, place the patient’s arm in relaxed position across the abdomen or lower chest.
Observe complete respiratory cycle (one inspiration, one expiration and pause.)
After the cycle is observed, look at the watch’s second hand ticker and begin to count the rate. Count one with a first full respiration cycle.
If the rhythm is regular in adults, count number of respirations in 30 seconds and multiply by 2.
In infants or young children count respirations for a full minute.
If adult has irregular rhythm or abnormally slow or fast rate, count for one full minute.
Note the depth of respirations. This can be assessed by observing the degree of chest wall movement while counting the rate.
Note the rhythm of ventilatory cycle. Normal breathing is regular and uninterrupted. Infants breathe less regularly. Young children breathe slowly and then suddenly the breathe fastens.
On completion replace the patient’s clothes /gown and cover with bed linen to make him/her comfortable.
Record the findings to the patient’s chart and any accompanying signs and symptoms of respiratory alterations. Compare with the previous findings.
Clear away and wash hands.
Report any abnormal findings to the physician or a nurse in charge.

Take Patient's Blood Pressure (PEX 1.5.2)

Blood pressure Is the force or pressure that the blood exerts on the walls of the blood vessels (artery) in which it is contained.

Purpose:

To obtain the baseline rate for diagnosis and treatment
To compare with subsequent changes that may occur during care of the patient.
To assist in evaluating status of the patient’s blood volume.
To evaluate patients’ response to change in physical condition as a result of treatment with fluids or medications.

Types of pressure:

Systolic pressure: Is the highest degree of pressure exerted by the blood against the arterial wall as the left ventricle contracts and forces the blood from it into the aorta.
Diastolic pressure: Is the lowest degree of pressure when the heart is in its resting period just before contraction of the left ventricle.

Factors that influence blood pressure:

Exercise - this will increase blood pressure.
Age - adults’ blood pressure tends to increase with advancing age. The older adults’ blood pressure is 140/80 to 160/90 mmhg.
Stress - anxiety, fear, pain; emotional stress increases blood pressure.
Medication - narcotic and analgesics lower the blood pressure.
Diurnal variation - it is lowest in early morning and higher in late evening.
Sex - in men it is higher than in female.
Bleeding - it causes low blood pressure.

General rules of taking blood pressure:

Assess the arm on which the blood pressure is to be taken. Do not take blood pressure reading on a patient’s arm if;
- The arm has an intravenous infusion line.
- The arm is injured or diseased.
- The arm has a shunt or fistula for renal dialysis.
- On the same side of the body where a female patient had a radial mastectomy.
Postpone blood pressure taking on the patient who is anxious, angry or in pain or crying child.
Check the diagnosis, reason for taking blood pressure, schedule and frequency of obtaining the blood pressure.
Find out the patient’s current emotional status before taking blood pressure; since exercise, emotions, anxiety, fear, tension and worry cause temporary rise in blood pressure. Allow the patient to rest at least 5-10 minute prior to taking blood pressure.

Requirements:

Sphygmomanometer
Stethoscope
Observation/patient’s chart
A pen

Procedure:

Collect the equipment needed.
Explain the procedure to the patient in order to gain co-operation of the patient and to alley anxiety.
Place the patient in a comfortable position either lying down with the arm resting on the bed or sitting up with arm resting /supported on the table/chair arm at the heart level to ensure accurate reading.
Wash hands.
Bring the equipment to the bedside or near the patient.
Apply deflated cuff evenly with rubber ladder over the brachial artery, the lower edge being 2 inches above the antecubital fossa. The two tubes turning towards the palm.
Palpate the brachial artery with the finger tips. Place the bell/diaphragm of the stethoscope on the brachial pulse. The stethoscope must hang freely from the ears.
Close the valve on the pump by turning the knob clockwise. Pump up air in the cuff until the sphygmomanometer registers 20mm above the point at which the radial pulsation disappears.
Open the valve slowly by turning the knob anti-clockwise. Permit the air to escape very slowly. Note the number on the manometer where the 1^st louder sound begins, this is the systolic pressure. Continue to release the pressure slowly and also note the point on the manometer where the 2^nd (last) sound ceases, this is the diastolic pressure.
Allow the air to escape and the mercury to fall to zero. Wait for one minute with the cuff to deflate.
Repeat the procedure if there is any doubts about the reading.
Do not take blood pressure more than 3 times in succession on reading on the same arm.
Make the patient comfortable.
Record the findings immediately with the date and time on the patient’s chart; as systolic/diastolic e.g. 60/90 mmhg.
Clear away, wash hands and report any abnormalities to the physician or nurse in-charge.

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General Principles and Rules of All Nursing Procedure

Topic: General principles and rules of all nursing procedures

These are guidelines that should be observed as a nurse carries out all nursing procedures:

Show interest and devotion to duty and be alert and prompt in all your assignments.
Make the patient the focus of attention, as she/he is the sole reason for the existence of the nursing profession.
Be clean in appearance and behave with an apparent ease and assurance in all-nursing procedures.
Demonstrate and inspire confidence, knowledge of and efficiency in techniques at all times.
Use the available equipment and nursing appliances, which should be collected quickly, quietly and methodically.
Trays and trolleys must be neat and complete to give an adequate nursing procedure.
Thoroughly test all equipment to make sure it is in good condition, before preparing the tray or trolley.
Display a high sense of responsibility in administration and custody of drugs and in the dispensation of any kind of treatment.
Keep up to date with new methods, techniques, drugs and lotions; know exactly their use, dosage, toxic effects and calculation of the dosage.

Patient's Comfort (Principles related to Procedures)

Ensuring maximum comfort for the patient during any procedure is essential and reflects respect for their privacy. Key aspects include:

Ensure maximum comfort to the patient and respect his/her privacy by:
- Telling him/her what is to take place, explaining the procedure as simple as possible.
- Protect the patient from draught and avoid undue exposure, make sure that windows are closed and screens appropriately placed.
- Establish a good nurse/patient relationship to secure the patient’s confidence and to induce their tranquility of mind.
- Observe any change in the patient’s general condition during the procedure.
Always prepare everything that will be required and have it by the patient’s bedside before beginning the procedure.
Lift and handle the patient as gently as possible exhibiting courtesy, efficiency, and skill.

General Rules for Carrying out Nursing Procedures (Detailed Steps)

Collect the equipment needed and prepare the tray /trolley.
Explain the procedure to the patient.
Screen the bed and close adjacent windows.
Bring the tray / trolley to the bed side.
Position the patient.
Wash hands.
Carry out the procedure.
On completion of the procedure leave the patient comfortable.
Leave the surroundings dry and tidy.
Clean and replace the equipment.
Wash hands.
Report and record procedure.
Send any specimens obtained to the Laboratory as soon as possible.

Topic: Hospital Economy

Understanding how resources are managed efficiently in the hospital setting is part of the introductory aspects of the nursing profession.

Note: Detailed information specifically titled "Hospital Economy" or elaborating on its principles and rules was not present in the provided lecture notes document beyond the initial curriculum outline. However, understanding the responsible use of resources, such as equipment and supplies, as mentioned in other sections (e.g., equipment maintenance, preparation for procedures), is a practical aspect of hospital economy.

Topic: Cleaning Methods

WARD MAINTENANCE PRACTICES

Daily Cleaning

A. Ward Maintenance

Collect all equipment necessary on the trolley.
Make the patient’s beds and pull bed and lockers away from the wall.
Collect and put away all the equipment not necessary on the ward for immediate use.
The floor is swept and mopped.
Carry out dump and dry dusting of all ward furniture and equipment, using the ward cleaning trolley.
Return beds and lockers to their position.
Replace sputum mugs with clean ones empty the used ones, rinse well in the sluice room, leave soaked in the disinfectant.
Give out clean drinking mugs and feeding cups. Refill bottles for drinking water if required.
Clean used equipment and keep in the proper place.

In dressing and treatment rooms:

Shelves - Wash daily and whenever necessary
Sinks and wash basins - wash daily and after use with vim or hebitane.
Sterilizers - empty, clean inside with hebitane when necessary, refill with clean water.
Trolleys - wash daily and after with soap and water, dry thoroughly. Do not use gumption or vim on food trolleys.
Lifting forceps - boiled daily and whenever contaminated forceps jars cleaned, boiled and lotion changed daily. Lotion jar inspected daily and more lotion added if required. Or boiled or autoclaved daily and kept in a dry sterile container.
Soiled dressing buckets - keep lid on at all times, keep the outside clean. And they should be thoroughly cleansed after emptying.

Hygiene in Special Areas (Operating theatre, Intensive care unit (ICU), Pre-mature unit and Labour suit.)

Operating theatre:

Operating tables, trolleys and shelves - dump dust daily using water and detergent.
Walls - dump cleaning 2.5-3m downward daily with water and detergent.
Floors - scrub with water and detergent daily and whenever soiled and leave to dry.
Floors where there are spillages of body fluids - apply 1% hydrochloride for 15min and spot clean. Clean after every operation. Do weekly cleaning of all equipment and areas.

Note: The same method of cleaning applies to all the rest of the special areas mentioned above (intensive care unit, pr-mature unit and labour suit.)

B. Equipment Maintenance (Detailed Procedures - extracted from your notes):

It is the responsibility of every health worker in the hospital to see that all equipment is very well looked after, serviced regularly and given immediate attention when there is any defect.

Equipment should be handled with care and breakages reported immediately, this will definitely keep the hospital expenditure very low.

1. Electric machine

Have regular servicing of the machines and as soon as they are out of order, make a requisition to the maintenance department, have them inspected and repaired.

Refrigerators: These are regulated in order to be effective, regulators should be regularly checked and temperatures recorded every day. Defrosting should be carried out weekly, and then the interior is thoroughly washed with hot soapy water, rinsed and the shelves replaced. Ice trays are taken out and washed with cold water.
Suction machines: Wash with soap and water daily and whenever used. Replace the lotion in the bottles.
Autoclaves: Dump dust them daily, check the functionality of the water and pressure gauges. Always unplug from the mains when not in use.
Boilers and sterilizers: Empty, clean inside with gumption/hebitane. When necessary refill with clean water and always unplug from the mains when not in use.
Hot plates: Any substance spilt on it should be wiped off immediately using a dump cloth. Always unplug from the mains when not in use.
Oxygen concentrators: Dump dust daily; make sure there is water in the wolf’s bottles and check the regulator daily. Always unplug from the mains when not in use and clean the filter.
Lamps: Dump then dry and dust shades and bulbs daily.

2. Oxygen cylinders

Dump dust them daily. Check whether the flow meters are working; check whether there is oxygen in the cylinder and the far the water level in the wolf’s bottles. Label the empty cylinders boldly with the word ‘Empty.’

3. Drainage under water seal gadgets

Disinfect, clean and sterilize.

4. Beds

Make them and dump dust the rails daily. On discharge of the patient; wash with soap and water.

5. Bed rests/backrests

Dump dust daily, wash with soap and water, rinse and dry when necessary and on discharge on an infectious patient disinfect.

6. Bed blocks/elevators

Dump dust daily. On discharge of the patients, scrub with soap and water.

7. Bed cradles

Wash with soap and water, rinse and dry when necessary and in discharge of the patient, scrub with soap and water.

8. Fracture boards

On discharge of the patients, scrub with soap and water.

9. Drip stands

Dump dust daily, wash with soap and water whenever necessary and keep them dry.

10. Trolleys

Wash daily and after use with soap and water, dry thoroughly. Do not use vim on food trolleys.

11. Enamel ware

Wash with soap and water after use, if stained use vim or hebitane/gumption, rinse and dry.

12. Stainless steel ware

Wash with soap or detergent and water, rinse and dry. Do not use vim.

13. Plastic ware

Wash with soap or detergent and water, rinse and dry. Use vim if necessary.

14. Shelves

Wash daily and whenever necessary.

15. Sinks and hand washing basins

Wash daily and after use with vim.

16. Crockery and glass ware

Wash daily with soap or detergent and water, rinse and dry.

17. Cutlery

Wash with soap or detergent and water, rinse and dry.

18. Soiled dressing buckets

Keep the lid on at all times, keep the outside clean. And they should be thoroughly cleansed after emptying.

N.B: Use large basins for dusting; do not use receivers and bowls.

19. Infusion stands

Dump and dust daily, wash with soap and water, dry when necessary.

Weekly Cleaning

In the ward:

Move the beds from one side of the ward to the other
Put lockers outside the ward

Proceed on the empty side as follows;

Brush walls and ceiling and wire gauze of ventilators with long handled brush.
Wash painted walls with soap and water, cleaning any edges and corners carefully.
Wash lamp shades.
The sweeper then sweeps and scrubs the floor.
Clean windows.
Replace beds

Repeat the same procedure on the other side.

Scrub lockers and return to the ward when dry.
Turn out and scrub all cupboards.
Polish furniture if necessary.

In the ward annexes (kitchen, bathroom, linen room etc)

Turn out and clean both the room and equipment.

Refrigerators:

Defrosting should be carried weekly, when the interior is washed thoroughly with hot soapy water, rinsed and the shelves replaced. The ice trays are taken out and washed with cold water.

Bedding and linen:

Care of mattress foam-rubber with cotton and plastic:

Do not remove the plastic mattress cover, wash with soap and water, rinse and dry whenever necessary.

Pillows:

May be protected by plastic cover under cotton cover, to avoid soiling. The cover is removed for laundry whenever dirty, do not remove the plastic cover, wash with and soap, dry and put on the cover.

Rubber goods:

Use only soap and cold water. Before hanging to dry wipe off excess water, do not fold if they are to be out of use for a long time, powder them before storing away.

Do not hang on hot pipes or boiling sterilizers or in the sun.

All linen from the infectious patients should be soaked in disinfectant and soiled linen should be sluiced before sending to laundry.

If linen has been stained with blood soak in cold water for 2-3 hours then rinse.

On discharge of patients all linen should be removed and sent to laundry.

Rubber sheets:

Mackintoshes are washed in soapy water and rinsed, hang out to dry, but never folded.

Rubber tubing:

Rubber tubing-catheters and long tubing; these should be washed in soapy water, and under running water, rolled in the hands immediately after use. Rinse and roll and hang to dry.

Woolen blankets:

Bed blankets; avoid frequent washing, but they should be sent to laundry whenever soiled.

Ward linen:

To avoid cross infection in hospitals great care should be taken in handling of soiled linen contain discharges from patients.

During bed making soiled linen should be separated and be put in a special dirty container/hamper.

A trolley should be used for clean linen.

DAMP DUSTING

Is the cleaning/brushing off, of the dust from a surface using a slightly wet cloth e.g. as of a table, chair, floor or wall etc.

Requirement (prepare a trolley):

Top shelf:

Basin of clean water
Soap and vim
2 Clean dusters in bowl
A jar of clean water

Bottom shelf:

Container for rubbish
Bucket for dirty water
Gloves
Apron
Gumboots

Procedure:

Wash hands and put on gloves. Put on apron and gumboots.
Always start to dust from the highest points or things first and work downward so you do not dirtied surfaces already cleaned.
Remove items from the surface to be cleaned.
Dampen or rinse the cloth in cleaning water.
Wipe away the dust with the damp cloth/duster.
Flat surfaces, wipe in straight lines beginning with the edges once each time.
Turn the cloth on each side 2^nd pass and rinse regularly in clean water.
Take care to damp dust the edges and undersides of the surfaces after the tops.
Where there are extendable items, such as bedside tables, are to be damp dusted extend the before beginning to work.
Polish with the dry duster to clean and dry.
Change the cleaning water when it becomes soiled (dirty)
Greasy or stubborn deposits may require repeated passes.
Replace any items moved on the clean surface when it is dry.
On completion, clean and dry all equipment and store safely and tidily in a secure storage area.
Remove gloves and wash hands.
Document the procedure

N.B: The basin used for dusting should be large one, receivers and dressing bowls are not to be used.

RULES ON CARE OF ALL TYPES OF LINEN

Linen should be used only for the purpose it is intended for.
Avoid frequent laundering of woolen articles.
All linen should be marked, checked before and on retuning from laundry.
Check all linen after laundry for any repairs
Lending and borrowing is avoided, lending book may be necessary
Removal of stains;
- Blood- soak immediately in cold water, if it fails to come off, use hydrogen peroxide or ammonia and rinse it well with cold water afterwards.
- Ink- put immediately in cold water or milk, until the stain fades, later use methylated spirit.
- Coffee and tea stains- wash in cold water, then put in hot water.
- Iodine stains- use hot water or ammonia the rinse.
- Stains caused by drugs- use hot water or ammonia the rinse.

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