Foundations

SUTURING OF THE WOUND

Suturing

Suturing is the process of closing a wound by stitching the wound edges together using a surgical needle and thread.

It is a fundamental technique in wound management and surgical procedures to facilitate healing, prevent infection, and restore tissue integrity.

Purpose of Suturing

The primary goals of suturing are:

To approximate wound edges until healing occurs.
To speed up the wound healing process by stabilizing the tissue.
To minimize the risk of infection by reducing the open surface area.
To improve cosmetic outcomes and minimize scarring.
To provide additional support in high-tension areas or deep wounds.

Types of Sutures

Sutures are broadly categorized into interrupted and continuous sutures.

1. Interrupted Sutures

In interrupted suturing, each stitch is placed individually and tied separately.
This is the most commonly used wound closure technique.
The individual stitches are not connected, reducing the risk of wound dehiscence if one stitch fails.

Advantages:
Easy to place.
High tensile strength.
Individual stitches can be removed if infection occurs without affecting the entire closure.

Disadvantages:
Takes more time to place compared to continuous sutures.
Requires more suture material.
Each knot increases the risk of infection.

2. Continuous Sutures

A single thread runs through the wound in a series of stitches and is tied only at the beginning and end.
The stitches are connected, making it faster for long wounds or surgical incisions.

Advantages:
Faster than interrupted sutures.
Requires less suture material.
Distributes tension evenly along the wound.

Disadvantages:
If the suture breaks, the entire closure may fail.
Increased risk of dehiscence in high-tension areas.

Retention Sutures:
These are large interrupted sutures placed in addition to standard skin sutures.

They support deep incisions, particularly in obese patients or high-risk wounds where dehiscence is likely.
Often reinforced with rubber tubing to prevent the sutures from cutting into the skin.
Retention sutures are typically removed after 14–21 days (longer than regular sutures).

Suturing Patterns

Based on the pattern of suturing, stitches can be classified as:

Suturing Pattern	Description
Plain Interrupted	Single, unconnected stitches; most common technique.
Plain Continuous	One continuous stitch running along the wound, tied at both ends.
Mattress Interrupted	Provides deeper support, with stitches looping through multiple layers.
Mattress Continuous	A continuous version of mattress suturing for stronger wound closure.
Blanket Continuous (Locking Stitch)	Each stitch loops into the previous one, creating a stronger hold.

Suturing Technique Tip: Each suture should be placed as deep as it is wide, and the distance between the sutures should be equal to the depth and width of the wound to ensure proper healing.

Suture Materials

A suture material is the thread used to stitch a wound.

These materials vary in absorption, strength, and application.

Suture materials are classified into:

Type	Examples	Usage
Absorbable Sutures	Surgical gut (catgut)	Used for internal tissues (e.g., beneath the skin) where the sutures dissolve naturally.
Non-Absorbable Sutures	Silk, Nylon, Dacron, Stainless Steel	Used for skin closure, removed after healing.

1. Absorbable Sutures

Absorbable sutures naturally break down and are absorbed by the body over time.

Advantages:
No need for suture removal.
Ideal for internal tissues (e.g., intestines, muscles, and subcutaneous tissues).
Available in multiple sizes (ranging from 0000000 to No. 5).

Disadvantages:
May cause an inflammatory reaction as they degrade.
Not suitable for long-term wound support.

Types of Absorbable Sutures

Type	Absorption Time	Description
Plain Catgut	5–10 days	Rapid absorption, used in fast-healing tissues.
Chromic Catgut	10–40 days	Coated with chromium salts to prolong absorption and reduce irritation.

2. Non-Absorbable Sutures

Non-absorbable sutures do not dissolve and need to be manually removed once the wound has healed.

Advantages:
High tensile strength – they do not easily break.
Minimal tissue reaction, reducing inflammation.
Can be used for ligatures to tie off blood vessels.

Disadvantages:
Requires removal after healing.
Can cause irritation if left in place too long.

Common Non-Absorbable Suture Materials

Material	Properties	Usage
Silk	Soft, flexible, easy to handle	Used in skin closure and ligatures.
Nylon	High tensile strength, minimal reactivity	Used for skin sutures and deep tissue repair.
Dacron/Polyester	Strong, durable	Used in cardiovascular and orthopedic procedures.
Stainless Steel	Extremely strong, resistant to infection	Used for bone repair and surgical staples.

Ligature (Tie Sutures):
A ligature is a free piece of suture material used to tie off blood vessels that have been clamped with artery forceps to prevent bleeding.

Suture Removal Guidelines

The time for removing sutures varies depending on the wound location and type.

Wound Location	Suture Removal Time
Face	3–5 days
Neck	5–7 days
Scalp	7–10 days
Trunk & Upper Limbs	10–14 days
Lower Limbs & Joints	14–21 days
Retention Sutures	14–21 days

Nursing Considerations in Suturing

Choose the appropriate suture material based on wound type, location, and required tensile strength.
Use absorbable sutures for internal tissues to avoid the need for removal.
Use non-absorbable sutures for skin closure, ensuring proper follow-up for suture removal.
Place sutures evenly to distribute tension and prevent scarring.
Monitor for infection (redness, swelling, pus formation) and remove affected sutures if needed.
Ensure wound edges are well-approximated but not overly tight to avoid necrosis.

Suture Needles

Suture needles are essential tools in wound closure and are classified based on their shape, function, and method of attachment to the suture material.

1. Classification Based on Shape

Type of Needle	Description	Common Uses
Straight Needles	Used without a needle holder	Suturing skin layers and easily accessible wounds
Curved Needles	Require a needle holder; allow precise control	Deep wounds, internal tissues, and confined spaces
Half-Circle Needles	A variation of curved needles, providing greater maneuverability	Used in deeper surgical procedures

Straight Needles: Are used for superficial wounds where access is easy. They are often manipulated without a needle holder, making them suitable for skin closure.

Curved Needles: Preferred for deeper wounds or when working in confined spaces. They require a needle holder for precise placement and controlled passage through tissue. Curved needles are further categorized by the degree of curvature (e.g., 1/2 circle, 3/8 circle).

2. Classification Based on Function

Needle Type	Description	Common Uses
Cutting Needle	Three-edged triangular needle; sharp enough to cut through dense tissue	Used for skin, tendons, and the cervix
Reverse Cutting Needle	Has the cutting edge on the outside curve	Reduces risk of sutures pulling through the tissue
Non-Cutting Needle (Round Body Needle)	Rounded tip; does not cut through tissue	Used for delicate tissue like intestines, blood vessels, and subcutaneous tissues

Cutting Needles: Characterized by three-edged, triangular points designed to cut through dense tissues. Commonly used for skin, tendons, and the uterine cervix.

Non-Cutting (Round Body) Needles: Feature a rounded point that separates rather than cuts through tissues. Ideal for delicate tissues beneath the skin, reducing trauma and the risk of tearing.

3. Classification Based on Suture Attachment

Needle Type	Description	Advantages
Traumatic Needle (Eye Needle)	Has an eye/opening at one end to thread the suture	Can use different suture materials; cost-effective
Atraumatic Needle (Swaged Needle)	Suture material is pre-attached to the needle	Minimizes tissue trauma and provides better handling

Traumatic (Eyed) Needles: These needles have an eye through which the suture material is threaded. The suture diameter is larger than the needle, causing more tissue trauma during passage.

Atraumatic (Swaged/Eyeless) Needles: In these needles, the suture is directly attached to the needle during manufacturing. This results in a suture diameter equal to or smaller than the needle, minimizing tissue trauma. Atraumatic needles are preferred for delicate tissues like intestines, brain, mucous membranes, and nerves.

Wound Suturing

In addition to standard dressing materials, the following sterile equipment is required for wound suturing:

Sterile gloves
Sterile drapes (hole sheet)
Sterile needle holder
Sterile round needle(s)
Sterile cutting needle(s)
Sterile suture material (silk, catgut, etc.)
Sterile tissue forceps
Sterile suture scissors
Sterile dressing forceps
Antiseptic solution (e.g., iodine)
Local anesthetic

Nurse’s Responsibilities in Wound Suturing

In most healthcare settings, suturing is the responsibility of doctors. However, in some hospitals, nurses may be responsible for suturing small wounds, depending on institutional policies.

Preliminary Wound Assessment Before Suturing

Assessment Factor	Purpose
Circumstances of injury	Helps determine wound contamination risk.
Nature of the wound	Identifies if it is caused by a sharp or blunt object, influencing suturing decisions.
Time elapsed since injury	Older wounds are at higher risk of infection and may need debridement.
Patient’s medical history	Conditions like diabetes can affect healing.
Previous wound healing history	Assesses abnormal bleeding, keloid formation, or past wound dehiscence.
Medications	Drugs like corticosteroids delay healing.
Allergy history	Checks for allergic reactions to local anesthesia.
Tetanus immunization status	Tetanus toxoid should be given if necessary.
Wound depth and location	Determines whether general anesthesia is required.
Foreign bodies	Must be removed before suturing to prevent infection.
Devitalized tissues	May need debridement before closure.
Bleeding control	Bleeding points should be ligated before suturing.
Associated complications	Identifies fractures, nerve damage, or tendon injuries requiring further intervention.

Preliminary Assessment

Assess the circumstances under which the wound was produced. This will help to evaluate the possibility of wound contamination.
Assess the nature of the wounding object e.g., blunt, sharp, etc. this will help to assess the depth of penetration of the object and also to identify the puncture wounds.
Assess the duration of time after the injury. This will help to assess the healing process. If the wound is exposed for a prolonged period, there always is the possibility of wound infection.
Check the presence of existing illness in the patient that may influence the healing process e.g. Diabetes mellitus.
Prior healing history is to be assessed. This will help us to find out abnormal bleeding time, wound dehiscence in the past, formation of excessive scar tissue etc.
Check the drugs, the injured person has been taking e.g., cortico-steroids. This will delay the healing process.
Take a history of allergies in the past, especially allergic reaction to local anaesthetics.
Date of most recent tetanus immunization. All patients with a roadside injury should be given tetanus toxoid to prevent tetanus.
Wound location and the type of wound. A penetrating wound should be sutured under general anaesthesia. There is the possibility of injury of the underlying organs.
Watch for the presence of foreign bodies, presence of penetrating objects etc. penetrating objects should not be disturbed until everything is ready for suturing, for fear of bleeding.
Assess the presence of devitalized tissues. This necessitates debridement prior to suturing.
Presence of bleeding. The bleeding points have to be ligated before suturing to prevent further bleeding.
Presence of complications such as fractures, shock, tendon injuries, nerve injuries etc. this necessitates further treatment.
Check the consciousness of the patient and the ability to follow.

Preparation of the Patient and the Environment

Explain the procedure to win the confidence and co-operation of the patient. Explain the sequence of the procedure and tell the patient how he can cooperate with you. Reassure the patient and his relatives.
Get the signature of the patient or his guardian in case anaesthesia is to be given.
Prepare the wound area for a surgical procedure. Shave the hairy regions. Clean the surrounding skin thoroughly with an antiseptic. While shaving and cleaning the area, place a sterile cotton pad or gauze piece over the wound to prevent future contamination of the wound.
Give analgesics if the patient is in pain.
Provide privacy with curtains and drapes, if necessary.
Protect the bed with a mackintosh and towel.
Call for assistance if necessary e.g., to hand over the sterile supplies, to restrain the patient etc.
Place the patient in a comfortable position. See that the doctors or the nurse are also in a comfortable position to do the procedure.
Apply restraints in case of children.
See that the unit is in order with no unnecessary articles. Clear the bedside table or over-bed table and arrange the articles conveniently.
See that there is sufficient light. Adjust the spot light to provide maximum light in the wound area.
Turn the patient’s head away from the wound to prevent the patient from seeing the wound and getting worried.

Wound Suturing Procedure

Step	Action	Rationale
1	Explain procedure to patient	To reduce anxiety and gain patient cooperation.
2	Adjust light	To provide optimal visualization of the wound.
3	Wash your hands	To reduce the risk of infection.
4	Clean the wound thoroughly	To remove debris and bacteria from the wound site.
5	Wash your hands again	To further minimize the risk of infection before donning sterile gloves.
6	Put on sterile gloves	To maintain a sterile field.
7	Drape the wound with the hole-sheet	To create a sterile field around the wound and isolate the area.
8	Infiltrate the edges of the wound to be sutured with local anesthesia.	To minimize patient discomfort during the procedure.
9	Approximate the edges of the fascia with the help of the tissue forceps and using the round needle and cat-gut. Suture the fascia layer first.	To close the deeper tissue layers and provide support.
10	Using the cutting needle and silk, suture the outer layer of skin approximating the edges with the help of the tissue forceps.	To close the skin edges and promote healing.
11	Clean with iodine and cover with sterile gauze.	To disinfect the wound and protect it from infection.
12	Remove the hole-sheet	To remove the drapes.
13	Make patient comfortable	To ensure patient well-being.
14	Remove all equipment, wash and return to its proper place or send for sterilization.	To maintain a clean environment and prepare instruments for future use.

After Care of the Patient and the Articles

Following wound closure, clean the wound again and apply a multilayered dressing to absorb drainage and to arrest bleeding by exerting pressure.
Secure the dressings with a roller bandage or adhesive tapes. As far as possible, avoid covering the wound area with adhesive straps, completely, because it may foster accumulation of moisture and subsequent maceration of the wound edges.
Keep the wound as dry as possible.
Remove the mackintosh and towel. Replace the bed linen. Change the garments if necessary. Make the patient comfortable by adjusting his position in bed.
Ask the patient to rest in bed to prevent fainting attacks.
Elevate the injured part above the heart level to minimize the oedema and pain. Mild analgesics may be given to reduce pain.
Take all the articles to the utility room. Discard the soiled dressing and send it for incineration. Wash and clean the articles first in the cold water and then with warm water and soap. Wash them thoroughly and dry them. Reset the suturing tray and send for autoclaving. Replace all articles to their proper places.
Wash hands. Record on the nurses record with date and time the type of the wound, the number of sutures applied, type of drainage tube applied, if any etc.
Return to the bedside to assess the comfort of the patient and to observe the condition of the wound. Watch for any bleeding from the wound area. Change the dressing if there is excessive bleeding. Report to the doctor.
Watch for the vital signs regularly to detect early signs of shock and collapse on the first day and signs of infection on subsequent days.
Unless signs of infection occur, the dressing should be left undisturbed until time for suture removal. Changing the dressing frequently causes friction on the wound edges and increases the possibility of the wound infection.
Inject tetanus toxoid, if it is not given previously.
On discharge of the patient, the patient should be given the instructions about the care of the wound, and the time when he has returned for the removal of sutures.

Suture Removal Guidelines

Sutures should be removed based on wound location and healing progress. In all cases the surgeon gives the written order for the removal of the sutures.
The sutures may be removed by the surgeons or by the nurses according to the hospital customs.

Wound Location	Suture Removal Time
Face & Scalp	2–5 days
Abdominal wounds	7–10 days
Lower limbs	10–14 days

General Instructions

Confirm the doctor’s orders for the removal of the sutures.
The suture removal is done in conjunction with a dressing change.
Toothed dissecting forceps and a pair of scissors with a short, curved, cutting tip that readily slide under the suture are used.
The suture line is cleansed before and after suture removal.
While removing interrupted sutures, alternate ones are removed first. The remaining sutures are removed a day or two later. If wound dehiscence occurs, the remaining sutures may then be left in place.
Suture material that is beneath the skin is considered free from bacteria, and those visible outside are in contact with the resident bacteria of the skin. It is important that no part of the stitch which is above the skin level enters and contaminates the tissues under the skin.
Suture material left beneath the skin acts as a foreign body and elicits the inflammatory response. While removing sutures, care to be taken to remove them completely. Each suture should be examined for its completeness. Every interrupted suture will have one knot and four ends when removed completely. The number of sutures should be counted before and after removal.
If wound dehiscence occurs during the removal of the sutures, inform the surgeon immediately. In case of abdominal wounds, resuturing is imperative to prevent evisceration. In other places, if resuturing is not necessary, adhesive tapes should be applied to approximate the wound edges as closely as possible.
After the removal of sutures, even if the wound is dry, a small dressing is applied for a day or two to prevent infection. The patient should be told about the care of the wound. He is advised to take rest after removal of sutures of an abdominal wound. The patient should be told not to strain the part e.g., not to cough or lift heavy weight after removal of sutures from the abdomen. This will prevent wound dehiscence.
If wound discharge occurs, the patient should be instructed to contact the surgeon. Presence of pain and swelling at the wound line are the signs of complications.
Abdominal belts or many tailed bandages may be applied on the abdomen after removal of abdominal sutures in obese patients to prevent wound dehiscence and evisceration.

Suture Removal Technique

To remove the interrupted sutures, grasp the suture at the knot with a toothed forceps and pull it gently to expose the portion of the stitch under the skin. Cut the suture with sharp scissors between the knot and the skin on one side either below the knot or opposite the knot. Then pull the thread out as one piece. The suture which is already above the skin should not be drawn under the skin.
After removal of sutures, every suture should be examined for its completeness. The number of sutures should be counted before and after removal. (it is not uncommon to find some sutures
laid bury under the skin).
Mattress interrupted sutures have two threads underlying the skin. The visible part of the suture opposite the knot should be cut and the suture is removed by pulling it in the direction of the knot.
If a continuous suture is applied, it is cut through, close at each skin orifice on one side and the cut sections are removed through the opposite side by gentle traction.

Clips (Metal Sutures) in Wound Closure

Clips, also known as metal sutures or surgical staples, are used to close the skin after a surgical procedure or deep wound.

Unlike traditional sutures, clips provide a fast, secure, and uniform wound closure, minimizing tissue trauma.

Purpose of Clips in Wound Closure

The primary objectives of using clips are similar to those of suturing with stitches, including:

To approximate wound edges until healing occurs.
To speed up wound closure and healing.
To reduce the risk of infection by minimizing handling.
To provide a strong and secure closure, especially for long surgical incisions.
To improve cosmetic outcomes by minimizing scarring.
To reduce operation time compared to conventional suturing.

Equipment Required for Clip Removal

In addition to standard equipment for dressing a septic wound, the following specialized instruments are required for removing clips:

Equipment	Purpose
Sterile Clip Removal Forceps	Specially designed to safely remove surgical clips without causing tissue trauma.
Receiver	Used to collect removed clips.
Benzene or Ether	Used to clean the surrounding skin and remove adhesive residue.
Sterile Gauze	To receive and hold the removed clips.
Antiseptic Solution	Used for cleansing the wound.
Adhesive Tape or Bandage	Secures dressing after clip removal.

Procedure for Removing Clips

Pre-Procedure Preparation

Explain the procedure to the patient to gain cooperation and reduce anxiety.
Gather and organize all necessary equipment.
Position the patient comfortably and drape appropriately for privacy.
Protect the bedding with a rubber sheet and cover to prevent contamination.
Remove the old dressing and discard it properly.

Clip Removal Procedure

Clean the wound using an antiseptic solution, starting from the cleanest area to the most contaminated part.
Place a sterile gauze pad near the wound to collect removed clips.
Hold the clip removal forceps in the right hand and the dissecting forceps in the left hand.
Insert the lower blade of the clip remover under the center of the clip.
Use the dissecting forceps to hold the clip in place as the removal forceps are squeezed.
Gently press the forceps together – this action bends the clip outward, disengaging it from the skin.
Carefully remove the clip and place it on the sterile gauze.
Repeat the process until all clips are removed.
Apply iodine or antiseptic to the puncture sites to prevent infection.
Dress the wound if necessary and secure the dressing with adhesive tape or a bandage.
Ensure patient comfort and adjust their position as needed.
Document the procedure, noting the appearance of the scar, wound healing progress, and any complications.
Dispose of all used materials properly and return reusable instruments for sterilization.

Post-Procedure Care and Monitoring

Assess the wound for signs of infection or delayed healing.
Monitor for bleeding or wound dehiscence (reopening of the wound).
Advise the patient to avoid excessive movement that could stress the healing wound.
Provide pain relief if needed.
Instruct the patient on proper wound care and when to seek medical attention.

Clinical Appearance of the Wound Bed

The appearance of the wound bed provides insight into healing progress and potential complications.

Wound Bed Type	Description	Clinical Significance
Granulating	Healthy red/pink moist tissue with newly formed collagen, elastin, and capillary networks. Tissue is well vascularized and bleeds easily.	Indicates active healing and proper blood supply.
Epithelializing	Pink or whitish thin layer forming on top of granulation tissue.	Sign of wound closure and final healing stage.
Sloughy	Yellowish devitalized tissue, composed of dead cells and fibrin, often misinterpreted as pus.	Requires debridement to promote healing.
Necrotic	Black, hard, or dry tissue with greyish dead connective tissue. Prevents healing and may lead to infection.	Needs immediate debridement and intervention.
Hypergranulating	Granulation tissue grows above the wound margin, caused by bacterial imbalance or excessive irritation.	Delays wound healing and requires adjustments in wound care.

SUTURING OF THE WOUND Read More »

Post-Operative Nursing Care

Post-operative nursing care refers to the specialized care provided to patients following a surgical procedure. This care focuses on monitoring, managing, and supporting the patient’s recovery through a variety of interventions and assessments.

Aims or principles of post-operative care

Prevent, Recognize, and Treat Complications: Through skillful observation and application of knowledge, proactively identify and manage potential complications throughout the recovery period, from unconsciousness to discharge.
Ensure Patient Comfort: Prioritize pain management, provide emotional support, and create a comfortable and safe environment to promote healing and well-being.
Restore Maximum Health and Independence: Guide the patient towards optimal physical and functional recovery, enabling them to regain their independence and return to their desired lifestyle.

Immediate care of a patient recovering from anesthesia

Transporting the patient from the operating room to the recovery room

Following the completion of the operation, the operating room staff generally dresses the patient in a clean gown and moves the patient to the stretcher. Care is taken to avoid:

Exposing the patient, which predisposes them to respiratory infections and shock.
Rough handling, which may place a strain on the sutures.
Hurried movements and rapid position changes, which predispose the patient to hypotension.

Recovery Room Care

After arriving, the patient is either transferred to a bed from a stretcher or left on the couch. The patient is positioned supine with the head turned to one side and the chin extended forward. This is done because the patient is unconscious or semi-conscious from anesthesia, and this position helps to avoid respiratory obstruction from a relaxed tongue falling back into the throat, or by aspiration of mucus, blood, and/or vomitus. This positioning also allows secretions to flow out or for easy suctioning.

Baseline assessment of the patient is done, including:

Vital signs: blood pressure, pulse, respiratory rate, airway patency, depth of respirations, chest expansion, and the color of the skin.
Visual assessment of the patient, presence of IV infusions, drains, or special equipment.
The time of admission to the recovery room.
The absence of reflexes, e.g., pharyngeal or swallowing reflex, to ensure proper positioning of the head (lateral head position with the neck extended forward until the patient is swallowing).
The patient’s level of responsiveness upon admission (e.g., touch, pain, sound, movement, etc.).
The temperature and vital signs, which are taken every 15 minutes until stable, then every 30 minutes for the next 2-3 hours. Temperature is taken every 2-4 hours, depending on recovery policy.
The quality and rate of respirations. If in distress, oxygen is given, and the anesthetist is informed of respiratory depression or change in ventilatory pattern. Arterial blood gas is determined, and mechanical breathing aids are employed to resuscitate the patient (e.g., intubation, tracheostomy, ambu-ventilation, suctioning, etc.).
The presence of an airway/mouthpiece meant to keep the tongue from falling back. Sometimes the patient may push this away as they regain consciousness.
Skin color and dryness. A pale, cold, sweating skin is one sign of shock. Also, observe the lips and nail beds for pallor and cyanosis. Run the fluids as prescribed.
The condition of the dressing: if soiled, note the color, type, and amount of drainage.
The presence of drainage tubes (e.g., thoracic, abdominal, gastric catheters). Check if the patent, clamped, whether to be connected to suction apparatus, and whether they are draining.
The IV infusions: note the type of IV infusion solutions, amount left in the bottle, the rate of the drip, infiltrations, and orders for any other fluid to follow. Check if medications have to be added to the IV or if there are orders for any to be added.
The presence of a blood transfusion: note if BT is running or if one is ordered. Watch the rate of the drip and carefully for signs of a reaction.
Any unusual symptoms like airway obstruction, arrhythmias, signs of shock, hemorrhage, marked temperature elevation, and signs of circulatory overload from excess IV fluids.

After the patient stabilizes (i.e., in 2-3 hours) and recovers from anesthesia, they are discharged from the recovery room by the anesthetist or surgeon. The ward nursing staff is informed to come and collect the patient.

Patient is Collected from the Recovery Room Back to the Ward

The ward nurses are informed about the patient to be collected from the recovery room after stabilizing.
A verbal report is given by the recovery room nurse to the two nurses who have come to collect the patient. This report covers the type of operation done, vital signs, the level of consciousness, wound status and drainages, infusions and blood transfusions, resuscitation done, anesthesia, problems the patient had during surgery (such as vomiting or stoppage of breathing), urinary drainage, and other post-operative instructions.
Brief taking of vital parameters is done by the ward nurses to confirm the report from the theater and to prove that the patient is alive.
The patient is rolled back to the ward with the legs in front and the head behind for easy resuscitation by the nurse behind should there be any problem.
The patient is gently lifted from the stretcher to the bed prepared before, and care of the anesthetized patient is instituted immediately.

Immediate Post-Operative Care in the Ward

Care of Anesthetized Patient in the Ward:

The patient should not be left alone during this period because of the danger of asphyxiation, shock, falls, and hemorrhage.

Position:

This varies with the type of surgery. It can be supine with the head turned to one side to prevent the bulky tongue from falling back by gravity over the pharynx and blocking the airway, and to promote drainage of saliva from the mouth.
The head can be made lower than the shoulders to prevent the flow of fluids into the trachea, allowing secretions to pool in the cheek, making removal easier, and preventing obstruction and pneumonia. The usual position is modified Sims.

Respiratory Status: Assess the quality, depth, and rate of respirations, as well as the skin color and temperature, which indicate adequate oxygen exchange.

Neurologic Status/Level of Responsiveness: Determine whether the patient is alert and oriented, unconscious, confused, restless, etc.

Cardiovascular Status: Obtain vital signs, and check the color and temperature of the skin.

Wound:

Check for drainage and bleeding, and connect any drainage tubes to the suction machine or collection bag.
See if the dressings are soiled, and look and feel under the patient to detect pooling of blood.

Tubes: Ensure catheters, NGTs, and infusion lines are patent, check the rate and amount, look for drainage or blockage, and verify proper attachment to drainage systems.

Discharge Advice/Health Education on Home Care of the Patient:

The length of time needed for a patient to recover from surgery depends on the patient’s physical and mental condition prior to surgery, the magnitude of the surgery, and the development of any post-operative complications.
Assess the knowledge and understanding of the patient about the surgery and the preventive measures.
Look for learning readiness and the ability of the patient and/or family members to provide care and skills needed to perform procedures at home.
Teach the patient to report pain in any area, temperature elevation, cough and sputum of abnormal color, loss of energy, nausea and vomiting, change in urine characteristics, difficulty in breathing, abnormal drainage, and sudden weight loss. These are signs of complications.
Emphasize the importance of hand washing prior to meals, performing any procedure of care, and toileting.
Practice together with the patient coughing, breathing, and exercises to prevent pulmonary complications.
Advise the patient to avoid smoking or contact with people with RTIs.
Encourage the patient to continue with physical exercises, increase activity when necessary, and stop when tired. Exercises promote activity to maintain circulation and normal functioning of the systems.
Inform the patient to take plenty of fluids, vitamins, and electrolytes to maintain fluid/nutritional status for health (wound healing, skin integrity, elimination, liquefy secretions).
Teach the patient how to care for the wound: dressing change, cleansing, and skin care. Allow practicing aseptic technique in wound care and protection of the wound when bathing to maintain a clean, dry, healing wound.
Educate the patient on how to take drugs: checking their actions, dose, route, frequency, side effects, and food and drug interactions to ensure compliance.
Instruct the patient to modify their home environment to clear pathways of rugs, provide good lighting, and use articles to hold onto when walking, wearing firm and good-fitting shoes to ensure safety and prevent accidents.
Discuss the care of appliances such as fixators, plaster of Paris, and prostheses for the purpose of safe usage and optimal effect of supportive aids.
Provide information on where to find supplies and equipment for home care.
Give the patient contact information and the phone number of the doctor or other staff for easy follow-up or emergency calls.

POST OPERATIVE CARE

Requirement

As for Postoperative bed

Procedure

Steps	Action	Rationale
1	Two ward nurses (Senior and Junior) collect the patient from the theatre.	To ensure the patient’s safety.
2	Receive full report of the patient’s condition from Surgeon, anaesthetist and theatre nurse.	To promote continuity of quality care and legal purpose.
3	Take the patient to the ward while observing consciousness, color of the patient and maintain a clear airway.	–
4	Screen the patient bed.	To ensure privacy.
5	Pull the prepared bed away from the wall and push the theatre trolley up against the bed. Roll the patient from trolley to bed.	This enables safe lifting of the patient.
6	Position the patient in an appropriate position depending on the surgery done and making sure the airway is maintained clear.	To maintain patient airway and aid free drainage of secretions.
7	Leave the airway piece in position until the patient regains consciousness.	To prevent the tongue from falling back and causing obstruction.
8	Check the surgeon’s post-operative instructions regarding operation and care i.e. intravenous fluid therapy, medicines, nutrition, and positioning.	To promote continuity of quality care.
9	Stay with the patient until the patient is conscious. Take vital observations as prescribed or at intervals ¼ to ½ hourly depending on the patient’s condition.	Monitor and evaluate patient’s conditions and timely interventions.
10	Observe the incision site for bleeding and drainage tubes for functionality.	–
11	Carry out special nursing procedures as prescribed i.e. suction, intravenous fluids.	–
12	Provide warmth to the patient.	To prevent hypothermia.
13	Document all the care provided and report accordingly.	Monitor progress and provide appropriate interventions.
14	Give a pillow to the patient when fully conscious, and more pillows as required.	To aid comfort.
15	Observe fluid intake; give Intravenous fluids as prescribed and encourage oral fluid as indicated; measure and record in fluid balance chart.	Monitor fluid balance.
16	Observe fluid output: Encourage the patient to pass urine or empty the drainage bag, measure and record the amount passed.	–
17	Administer post-operative medicine as prescribed by the doctor.	Promote healing or treat pain.
18	Assist the patient to perform different exercises as taught before operation.	Prevent post-operative complications.
19	Offer general nursing care to postoperative patient.	–

Points to Remember:

Take note of the irregularities in vital observations:
- A rising pulse rate and/or decreasing pulse volume.
- A falling or inaudible blood pressure recording.
- Slowing, rapid, or noisy respirations.
For the skin note; the color, feel of the skin, i.e. cold or clammy.
Dressing; note, any oozing or bleeding from the incision site. In case of bleeding is present add more sterile dressing and bandage in position, and report immediately to the nurse in charge or the doctor.
Special nursing care is given to patients as per operation and condition.

PERI-OPERATIVE CARE (Summary)

PRE-OPERATIVE:

Admission
Explanation to the patient about the nature of the surgery and the possible outcomes.
Informed Consent for admission and surgery.
Vital observations and other lab investigations, radiological investigations to get a baseline.
Preparation of the body and mind through counseling and continuous reassurance. This helps to allay anxiety as well.
Talk to the patient and answer questions of their concerns to reduce fear/anxiety.
Spiritual care if one so wishes; respective church leaders are allowed to come and see the patient.
A baseline Physical examination, e.g., weight, height, nutritional status, needs to be assessed prior.
Site preparation: involves marking/labeling, 48 hours shaving if hairy.
Removal of jewelry and rings.
Removal of dentures and prostheses.
Inserting an IV line.
Rehydration with IV fluids.
Administration of premedication drugs.
Perform required procedures like inserting NGT, catheterization, bowel irrigation.
Ensure enough rest and sleep.
Educate on anticipated activity post-operatively.
Starve the patient prior as per order (nil per os).
Make a post-op bed with all the necessary accessories required, e.g., oxygen, suction apparatus.

POST-OPERATIVE CARE:

Reception from theatre with all the necessary instructions.
Vital parameters monitoring.
Monitoring for bleeding, and signs of shock.
Admission to a warm postoperative bed from the theatre.
Intravenous infusion with fluids and prescribed drugs.
Fluid balance chart recording and monitoring.
Ongoing post-op medication.
Bowel and bladder care.
Rest and sleep.
Proper management of drainages, e.g., abdominals, etc.
Proper positioning to relieve pain.
Diet/nutrition.
Wound care.
Pain management.
Bed hygiene.
Body/skin hygiene.
Physiotherapy, e.g., breathing exercises.
Psychological care.

POST-OPERATIVE COMPLICATIONS:

Hemorrhage; can be primary or secondary.
Pain.
Shock.
Wound infection/sepsis.
Hypostatic pneumonia due to constant lying on the bed.
Delayed healing.
Paralytic ileus.
Adhesions.

Post-Operative Nursing Care Read More »

CARE OF THE PATIENT’S EYES

CARE OF THE PATIENT’S EYES.

Care of the patient’s eyes includes a range of procedures and practices aimed at maintaining the cleanliness, comfort, and health of the eyes.

It Involves:

Cleaning of the Eye: This includes removing debris, discharge, and crusting from the eyelids and eyelashes. It’s done gently using sterile wipes or cotton balls moistened with warm water.
Instillation of Eye Drops/Ointment: This is done to deliver medication directly to the eye, treating various conditions like infection, inflammation, dryness, or glaucoma.
Cold and Warm Compresses: These are used to reduce inflammation, calm irritation, or promote relaxation. Cold compresses are applied for injuries or swelling, while warm compresses are beneficial for dry eye or clogged tear ducts.
Eye Irrigation: This involves flushing the eye with a sterile solution to remove foreign objects, irritants, or excessive discharge.

Indications of Cleaning the eye

Patients with Eye Discharge: This can be a sign of infection, inflammation, or irritation. Cleaning the eye, instilling appropriate drops, and sometimes irrigation can help manage the discharge and promote healing.
Postoperative Care for Patients Following a Cataract Operation: This includes gentle cleaning of the eye, instillation of prescribed eye drops, and monitoring for signs of infection or complications.
Eye Care for the Unconscious Patient: This is crucial for preventing infections and maintaining eye health. It includes cleaning the eye, keeping the eyelids closed, and ensuring the eyes are protected from injury.
To Be Performed Prior to Instilling Eye Drops or Ointment: Cleaning the eye beforehand helps ensure that the medication is delivered effectively and avoids contamination.
Patients with Dry Eye Syndrome: Eye care practices can help manage symptoms by promoting tear production, lubricating the eye, and protecting the cornea.
Patients with Eye Allergies: Cleaning the eye and instilling antihistamine drops can help manage the symptoms of itching, redness, and watery eyes.
Patients with Foreign Body in the Eye: Eye irrigation with a sterile solution is essential to remove the foreign object and prevent damage to the cornea.

Aims/Purposes of Eye Care:

To prevent and treat infections: Cleaning and disinfecting the eye area helps reduce the risk of infections.
To alleviate symptoms and discomfort: Procedures like cold compressions, warm compresses, and eye irrigation can provide relief from pain, itching, and dryness.
To promote healing and recovery: Appropriate cleaning and medication can help facilitate healing after eye surgery or trauma.
To maintain optimal eye health: Regular eye care can help prevent eye diseases and preserve vision.

Cleaning of the Eye

Objectives

Identify the requirements for cleaning the eyes.
Prepare the requirements for cleaning the eyes.
Demonstrate the ability to clean the eyes.

Requirement

Tray containing:

Gallipot of cotton balls
Receiver
Clean/disposable gloves
Mackintosh and towel
Plastic apron
Gallipot of normal saline 0.9% or cooled boiled water

At the bedside:

Hand washing equipment
Screen

Procedure

Steps	Action	Rationale
1.	Observe general rules.	Promotes adherence to standards.
2.	Put the patient in a sitting up position.	To prevent the flow of solution to the healthy eye.
3.	Place protective mackintosh and towel in place.	To prevent soiling/wetting the patient’s clothes.
4.	Wash and dry hands and put on gloves.	To prevent cross infection.
5.	Stand at the right-hand side of the patient.
6.	Dip the swabs/cotton balls in the solution and bathe the eye in the following sequence: – Start from the healthy eye – Swab from the nasal to the temporal aspect, using the swab once and discard. – Use the dry swabs to dry the eye – Do the same for the other eye – Repeat the swabbing until the eye is cleared of all discharge.	Prevents contamination from entering the other eye. Prevent the spread of infection.
7.	Dry excess fluid with a dry swab.	Prevent the spread of infection.
8.	Thank and leave the patient comfortable.	Promotes a sense of well-being.
9.	Clear away.	Maintain the cleanliness of the environment.
10.	Document the procedure.

INSTILLATION OF EYE DROPS/ OINTMENT.

Instillation Of Eye Drops/ Ointment is the process of application of medication into the patients’ eyes.

Objectives

Identify the requirements for instilling eye drops/ointment.
Prepare the requirements for instilling eye drops/ointment.
Instill the eye drops/ointment to the eyes.

Indications:

For Eye Drops:

To treat infections: Antibiotic eye drops are commonly used to combat bacterial infections like conjunctivitis (pink eye).
To keep eyes moist: Artificial tears or normal saline drops are used to lubricate the eye and relieve dryness, often prescribed after cataract surgery.
To anaesthetize the eye: Anaesthetic drops numb the eye surface, used for procedures like cataract surgery or foreign body removal.
To dilate the pupil: Mydriatic drops widen the pupil, facilitating eye exams or helping treat certain eye conditions.
To reduce inflammation: Steroid eye drops are used to reduce inflammation in the eye, often prescribed after eye injury or surgery.
To lower intraocular pressure: Glaucoma medications are often administered as eye drops to control eye pressure and prevent further damage.

For Eye Ointment:

To protect the vision of neonates: Prophylactic antibiotic ointment is routinely applied to newborns’ eyes to prevent infections.
To treat infections: Antibiotic ointments can be used to treat bacterial eye infections, often preferred for overnight treatment due to their longer-lasting effect.
To lubricate and soothe dry eyes: Ointments can provide a longer-lasting lubricating effect than drops, especially helpful for severe dryness.
To treat certain eye allergies: Steroid ointments can be used to reduce allergic inflammation.

Requirements

Patient’s medication chart.

Tray:

Prescribed eye drops/eye ointment
Gallipot of cotton balls
Receiver
Gloves
Eye pad in a sterile bowl
Strapping

At the Bedside:

Hand washing equipment
Screen

Procedure for eye drop

Steps	Action	Rationale
1.	Refer to general rules.	Promotes adherence to standards.
2.	Check the prescription.	Ensures correct administration of medicine.
3.	The patient may be seated or lying down for this procedure.	Provides easy access to the eye for instillation.
4.	Wash hands and put on gloves.	Prevents the spread of microorganisms.
5.	Clean the eyes as before.	Prevents entrance of microorganisms to the lacrimal duct.
6.	Place a folded swab on the lower lid up to the lash margin.	Absorbs medication that escapes from the eye.
7.	Instilling eye drops: Gently pull down the eyelid of the affected eye.	Exposes lower conjunctival sac.
8.	Request the patient to look up; hold the dropper close to the eye and drop the medicine according to the dose into the lower conjunctival sac.	To reduce stimulation of the blink reflex.
9.	Release the lower eyelid after the eye drops are installed.
10.	Request the patient to gently close the eye.
11.	Apply gentle pressure over the inner Canthus.	To prevent eye drops from falling over the inner Canthus to prevent systemic effects from the medicine.
12	Administering eye ointment: – Gently pull down the lid	To expose the inner surface of the lid and conjunctival sac.
13	Squeeze a small amount (1.25cm) of ointment along the exposed sac from in outwards.	Promotes comfort and prevents trauma to the eye.
14	Instruct the patient to close the eyes.	The warmth helps to liquefy the ointment Prevents contamination and entrance of micro-organism into the eye.
15	Instruct the patient to roll the eyeball Patient should keep the eye closed for a few minutes.	Allows even distribution of medication over the eye.
16	Thank and leave the patient comfortable.	Ensures patient’s comfort.
17	Clear away.	Ensures a clean environment.
18	Record treatment given on the chart.	Continuity of care and follow up.

General Principles – Application of Eye Ointment

Ointment may be prescribed in addition to drops. If both are prescribed, drops should be instilled first, followed by ointment after a 3-minute interval.
Ointment may be prescribed for structures other than the eye. This could include wounds on the lids, face, or eye socket.
Ointment may be prescribed for use after the first dressing. This might not happen for up to a week in some oculoplastic surgery cases.
If requested, visual acuity should be recorded before ointment is applied. This is because ointment clouds vision. Any existing ointment excess should be removed before taking the measurement.
A 5-mm strip of ointment should be applied to the inner edge of the lower fornix of the appropriate eye.
The patient should close his eye and remove excess ointment with a swab.
The patient should be advised that the ointment is likely to cause blurring of vision due to its viscous nature.
In the case of wounds on the lids, face, or eye socket, ointment should be squeezed directly onto the wound. It can be dispersed using a moistened swab. If the ophthalmic surgeon requests it, the wound or scar should be massaged using the ointment.

Procedure of Instillation of Eye Ointment

Steps	Action	Rationale
1.	Wash hands and prepare trolley and equipment in accordance with ANTT (Aseptic Non Touch Technique) principles.	Promotes adherence to standards.
2.	Check the patient identification band against the eye-drop medication chart.	Ensures correct patient identification and medication administration.
3.	Prepare the patient for the procedure and obtain consent, giving an explanation of the procedure including any side-effects of the medication.	Informed consent and patient understanding of the procedure.
4.	Assess the patient as before, including ensuring that the drops are not contra-indicated.	Ensures the medication is safe and appropriate for the patient.
5.	The patient should be seated.	Provides easy access to the eye for instillation.
6.	Wash hands or use alcogel.	Prevents the spread of microorganisms.
7.	Prepare equipment and place it in the tray, identifying key parts to be protected during the procedure; in this case, the tips of bottles.	Maintains aseptic technique.
8.	Check drops/ointment against the prescription.	Ensures correct medication is administered.
9.	Check the correct strength (%) of the drops against prescription.	Ensures correct dosage.
10.	Check drops/ointment have not expired. Check clarity of drops, i.e., the fluid in the bottle/minim must be clear and not discoloured.	Ensures medication is safe and effective.
11.	Check packaging/bottle seal is intact when first used.	Ensures sterility and safety of the medication.
12.	Identify any current allergy to the topical medications.	Prevents adverse allergic reactions.
13.	Ensure that the drops are instilled into the correct eye.	Ensures correct administration site.
14.	Examine the eye to be treated for the following: Redness not attributed to surgery or other known causes. No stickiness or pain. No deterioration of vision. Allergies to the prescribed eye drops.	Assesses the condition of the eye to avoid complications.
15.	Check no contact lens in situ unless advised to the contrary by the doctor.	Prevents interference with medication absorption and eye health.
16.	Remove gloves, clean hands with alcohol gel and reapply non-sterile gloves.	Prevents contamination and maintains hygiene.
17.	Open packaging, ensuring key parts remain protected. NB: You may need to open additional packaging if the eye needs cleaning prior to drop instillation, in which case you should proceed to eye cleaning first.	Maintains aseptic technique.
18.	Instruct the patient to slightly tilt the head back and ask the patient to look up. NB: Before using any bottle of eye drops, shake the bottle first.	Facilitates easy access to the eye and proper medication distribution.
19.	Instill only one drop into the lower fornix towards the outer canthus or squeeze 5 mm of ointment along the lower fornix towards the outer canthus. NB: Ointment must only be applied after prescribed eye drops.	Ensures correct medication application.
20.	Ask the patient to gently close his eyes, counting slowly to 60. This helps to minimize systemic absorption.	Promotes proper absorption and effectiveness of the medication.
21.	Wipe away any excess drops/ointment, taking care not to wick away drops from the eye.	Maintains patient comfort and ensures proper dosage remains in the eye.
22.	If further drops are prescribed, wait an interval of 3 minutes before carrying out the procedure. Apply alcogel to hands before instilling the next eye drop.	Prevents contamination and ensures effectiveness of multiple medications.
23.	Make the patient comfortable; patients usually appreciate being given a tissue to dab their cheeks.	Ensures patient comfort and cleanliness.
24.	Dispose of clinical waste, cleanse hands, and then clean the tray.	Maintains a clean and safe environment.
25.	Cleanse hands and document the procedure in the case notes and/or drop chart.	Ensures proper record-keeping and patient safety.

WARM EYE COMPRESS.

A warm eye compress involves applying a warm, moist cloth or compress to the eye area.

Soothe and relax the eye muscles: The warmth helps to relax the eye muscles, which can be helpful for reducing eye strain and fatigue.
Increase blood flow to the area: The warmth dilates blood vessels, increasing blood flow to the eye area, which can promote healing and reduce inflammation.
Loosen eye secretions: Warmth can help loosen mucus and other secretions in the eye, making them easier to remove.

Indications for Warm Eye Compresses

Pain Relief: Warm compresses can help reduce discomfort and pain in the eye area.
Reduce Inflammation: The warmth helps to decrease inflammation and swelling in the eye.
Improve Medication Absorption: Warm compresses can enhance the absorption of eye drops or ointments.
Promote Drainage: Warmth helps to loosen and drain secretions, which can be beneficial for superficial infections.
Dry eye: Warmth can help to stimulate tear production and lubricate the eye surface.
Stye (hordeolum): A stye is a painful red bump on the eyelid caused by a bacterial infection. Warm compresses can help to bring the stye to a head and promote drainage.
Blepharitis: This is a common eye condition that causes inflammation of the eyelids. Warm compresses can help to loosen debris and reduce inflammation.
Conjunctivitis (Pink eye): This is an infection of the conjunctiva, the thin transparent membrane that lines the inside of the eyelid and covers the white part of the eye. Warm compresses can help to soothe inflammation and promote drainage.
Eye strain: Warm compresses can help to relax eye muscles and relieve eye strain caused by prolonged computer use or reading.
Meibomian Gland Dysfunction (MGD): This condition involves a blockage of the oil glands in the eyelids, causing dry eye and other symptoms. Warm compresses can help to loosen and drain the oil glands.

Requirements

Tray	Bedside
Bowl with warm water	Screen
Sterile water or normal saline	Hand washing apparatus
Mackintosh cape and towel/dressing mackintosh
Sterile bowl
Cotton swabs
Receiver

Procedure

Steps	Action	Rationale
1	Identify the eye to be treated.	Ensure the correct eye to prevent error.
2	Follow the general rules.	Promote adherence to standards.
3	The patient may be seated or lying down for this procedure.	To ensure comfort for the patient.
4	Place the bowl with solution in a bowl of warm water.	Cold application is very uncomfortable for the patient.
5	Wash dry hands and put on gloves.	To prevent the chance of cross infection.
6	Place the swab in the warm solution (37°-41°C).	To improve circulation and relieve pain.
7	Squeeze out the excess solution.	To reduce the chance of scalding the patient and wetting patient’s clothes.
8	Instruct the patient to close the eye. Gently apply the swab on top of the affected eye.	To promote patient’s safety and prevent skin damage.
9	Change the compress every 2 minutes for the prescribed length of time.	To maintain a constant temperature for the duration of therapy.
10	Use a dry swab to clean and dry the eyes.	Promote patient’s comfort.
11	If required apply eye drops/ointment.	To prevent infection.
12	Thank and leave the patient comfortable.	Promotes patient’s well-being.

COLD EYE COMPRESS

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

Indications of Cold compress

Reduce inflammation: Cold compresses constrict blood vessels, reducing inflammation and swelling.
Relieve pain: The coldness helps numb the affected area, reducing pain and discomfort.
Reduce bleeding: Cold compresses can help stop minor bleeding by constricting blood vessels.
Control bruising: Applying cold compresses immediately after an injury can help reduce bruising by minimizing blood pooling.
To reduce swelling or bleeding: Cold compresses can help reduce swelling and bleeding in the eye area by constricting blood vessels.
To ease periorbital discomfort: Cold compresses can help ease pain and discomfort around the eye area.
To relieve itching: The coolness of the compress can help reduce itching in the eye area.

Requirements

Tray

Ice cubes/chips
Solution: sterile water or normal saline solution
Mackintosh and towel/Dressing mackintosh
Strapping
Cotton swabs
Clean gloves

At the bedside

Screen
Hand washing apparatus

Procedure of cold compress

Steps	Action	Rationale
1	Follow the general rules of nursing procedure.	Prevent solution from over the nose and into the eye.
2	Identify the eye to be treated.	To prevent errors.
3	The patient should lie down for this procedure.	To prevent the solution from wetting the patient’s clothes.
4	Position the mackintosh and towel to protect the patient’s clothes.	To prevent wetting the patient’s clothes.
5	Place the swab in the bowl of ice chips (18-27°C).	To make it easy to apply and provide comfort.
6	Wash dry hands and put on gloves.	To prevent infection.
7	Place the moist swab over the affected closed eye.	The swab helps to conduct the cold from the ice pack.
8	After 15-20 minutes, remove the cold compress.	To prevent skin change this can occur from vasoconstriction.
9	Use a dry swab to clean and dry the patient’s face.	To ensure comfort.
10	If required apply eye drops/ointment.	To prevent/treat infection.
11	Thank and leave the patient comfortable.	To ensure comfort.
12	Clear away and document procedure.	To ensure proper records are kept.

Eye Irrigation

Eye irrigation involves flushing the eye with a sterile solution to remove foreign bodies, irritants, or discharge. This process helps cleanse the eye, reduce inflammation, and improve visual clarity.

Eye irrigation is the washing of the conjunctiva sack with a stream of fluid(water). The gentle flow of the irrigation solution washes away the offending substance from the eye. The solution is typically sterile and isotonic to minimize irritation.

Purpose/Aims of Eye Irrigation:

To remove foreign bodies from the eye: This includes dust, dirt, small particles, or insects that may have entered the eye.
To remove chemicals which have been accidentally splashed into the eye(s): This includes chemicals, smoke, fumes, or allergens that may cause irritation.
To washout discharge: This includes mucus, pus, or other secretions that may accumulate in the eye.
Reduce inflammation: The flushing action can help reduce inflammation and swelling.
Improve visual clarity: Removal of foreign objects or discharge can improve vision.
Before administration of medication: Irrigation can help prepare the eye for medication application.
In preparation for eye operations: Irrigation can help cleanse the eye before surgery.

Indications for Eye Irrigation:

Foreign body sensation: If a patient feels something in their eye, such as a speck of dust or a small insect.
Chemical or irritant exposure: If the eye has come into contact with a chemical or irritant.
Discharge or secretions: If there is excessive discharge or secretions from the eye.
Eye infections: In some cases, eye irrigation can help remove infectious material and reduce inflammation in certain eye infections.

Requirements

Tray-sterile

Irrigating solution-Normal saline at 37°C or plain boiled cooled water(sterile).
Sterile gloves, patient’s towel
Lid retractor
Litmus paper
Undine or any small container with a pouring spout e.g. feeding cup, bulb syringe or Sterile irrigation set
Eye pad/waterproof pad
Gallipot of cotton balls or facial tissues
2 receivers, mackintosh cape and towel/dressing mackintosh
Boric acid 2 to 4 %
Gallipot of cotton

At the bedside

Wash hand equipment
Screen

Procedure

Steps	Action	Rationale
1	Follow the general rules for all nursing procedures.	Promotes adherence to standards.
2	Have the patient sit or lie down with the head tilted toward the side of the affected eye. Protect the patient and the bed with a dressing mackintosh or waterproof pad and a towel.	Gravity helps the flow of solution away from the unaffected eye and from the inner canthus of the affected eye toward the outer canthus.
3	Put on gloves. Clean the eye as before.	–
4	Place the curved part of the receiver at the cheek on the side of the affected eye to receive the irrigating solution. If the patient is sitting up, request the patient to hold the receiver.	Cavity aids the flow of solution.
5	Expose the lower conjunctival sac and hold the upper lid open with the non-dominant hand.	To avoid injury to the conjunctival sac and prevent reflex blinking.
6	Hold the irrigator about 2.5 cm from the eye. Direct the flow of the solution from the inner to the outer canthus along the conjunctival sac.	This minimizes the risk of injury to the cornea and prevents the spread of infection from the eye to the lacrimal sac, lacrimal duct, and the nose.
7	Irrigate until the solution is clear or all the solution has been used. Use only sufficient force gently to remove secretion from the conjunctiva without touching any part of the irrigating equipment.	To prevent injury to the tissues of the eye, as well as the conjunctiva, and promote comfort for the patient.
8	Tell the patient to close the eye and move the eye periodically.	Helps to move the secretion from the upper to the lower conjunctival sac.
9	Dry the area after irrigation with cotton balls. Offer the towel to the patient if the face and neck are wet.	To provide comfort.
10	Remove gloves and wash your hands.	–
11	Make the patient comfortable.	–
12	Document the procedure or findings.	–
13	Clear away.	–

Points to remember

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 acidic or alkaline or to be sure the eye has been irrigated adequately.
When irrigating both eyes, ask the patient to tilt his head towards the side being irrigated to avoid contamination.
An irrigation fluid may be pre-packed in a disposable set for use or a sterile 50ml syringe may be used.

CARE OF THE PATIENT’S EYES Read More »

BLOOD TRANSFUSION

Blood transfusion refers to the intravenous replacement of lost or destroyed blood with compatible human blood.

TYPES OF BLOOD PRODUCTS

1. Whole Blood: Whole blood is indicated to the patient experiencing acute massive loss or hypovolemic shock. Whole blood restores volume and raises hemoglobin count and therefore oxygen capacity.

Indication: Acute massive blood loss (e.g., trauma) or hypovolemic shock.
Purpose: Replenishes blood volume, increases hemoglobin count (carrying oxygen), and improves oxygen-carrying capacity.

2. Packed Red Blood Cells (PRBCs): Red blood cells are separated from a unit of whole blood. 80% of plasma is removed leaving packed red blood cells which may be transfused to a patient to increase the number of red blood cells without overloading the circulatory system with fluids. Certain types of anaemia such as aplastic anaemia may be treated by this blood product.

Indication:
- Anemia (including aplastic anemia)
- Conditions requiring increased oxygen-carrying capacity without excessive fluid volume.
Purpose: Increases the number of red blood cells to improve oxygen delivery without overloading the circulatory system.

3. Platelet Concentration: Platelets may be administered to aid homeostasis in patients suffering from thrombocytopenia. Platelets assist in initiating the clotting process and other clotting factors such as prothrombin, fibrinogen and thromboplastin.

Indication: Thrombocytopenia (low platelet count), leading to bleeding disorders.
Purpose: Provides platelets to aid in hemostasis (stopping bleeding). Platelets initiate the clotting process, working alongside other clotting factors like prothrombin, fibrinogen, and thromboplastin.

4. Plasma: Plasma is the fluid part of blood after centrifuging in order to remove the red blood cells. Plasma is used to expand blood volume in cases of shock, burns, haemorrhage and while waiting for blood to be cross matched.

Indication:
- Shock (e.g., due to trauma, burns, or hemorrhage).
- While awaiting crossmatched blood for transfusion.
Purpose: Expands blood volume, providing essential proteins and clotting factors.

Indications for Blood Transfusion:

1. Severe Anemia:

Pregnancy
Sickle Cell Disease
Complicated Malaria

2. Preoperative: To address low blood volume levels.

3. Severe Burns: To replace lost fluids and proteins.

4. Postoperative: After major surgeries like:

Laparotomy (abdominal surgery)
Open reduction of internal fractures
Total abdominal hysterectomy

5. Trauma: Following road traffic accidents (RTAs) or other injuries.

6. Blood Clotting Factor Deficiencies: To provide missing clotting factors.

7. Specific Types of Anemia: When other treatment options are inadequate.

Note:

Blood type matching: It’s important to ensure the blood type of the donor matches the recipient to prevent transfusion reactions.
Rh factor compatibility: Rh factor is another important blood group factor that needs to be considered.
Crossmatching: A process to further ensure compatibility between donor and recipient blood.
Potential risks: Blood transfusions can carry risks, including allergic reactions, infections, and transfusion-related acute lung injury (TRALI).
Alternatives to blood transfusion: Options like erythropoietin (for anemia) and medications to increase platelet production are sometimes available.

REQUIREMENTS

As for intravenous infusion with addition of: –

Top shelf

Blood giving set with a filter
Larger needle or cannula

Bottom shelf

Unit of blood.
Normal saline.
Observation chart, fluid balance chart.
Patients chart with details of transfusion.
Medicines as prescribed.

Procedure

The technique of transfusion is similar to intravenous infusion.

On completion of the transfusion the empty bottle must not be washed and should be kept on the ward for 24 hours, in case it is needed for testing in the case of reaction.
Record the following on the patient’s chart: –

Date and time of starting and completing the transfusion.
Number of the blood bottle.
Amount of blood transfused.
Names of nurses or doctor who checked the blood and set up the transfusion.
Patient’s initial response to the transfusion.
Urinary output

Administer normal saline before and after blood transfusion.

Complications of Blood Transfusion

The following are some of the adverse reactions which may occur during blood transfusion:

1. Allergic Reactions:

Cause: Hypersensitivity to components within the blood product.
Signs & Symptoms: Itching, flushing, hives (urticaria), respiratory distress, and anaphylactic shock.
Management:
- Stop the transfusion immediately.
- Notify the doctor urgently.
- Administer antihistamines if prescribed.

2. Febrile Reaction:

Cause: Antibodies in the recipient’s blood reacting to donor white blood cells.
Signs & Symptoms: Fever, chills, and headache during transfusion.
Management:
- Stop the transfusion immediately.
- Inform the doctor.
- Provide symptomatic relief (extra blankets, prescribed antipyretics).
- Reassure the patient.

3. Incompatibility Reaction:

Cause: Mismatched blood types (e.g., giving type A blood to a type B recipient). This is a serious, potentially life-threatening reaction.
Signs & Symptoms: Immediate onset of shivering, chills, headache, low back pain, nausea, vomiting, hemoglobinuria (hemoglobin in the urine), and acute renal failure.
Management:
- Stop the transfusion immediately.
- Notify the doctor.
- Keep the vein open with normal saline.
- Treat shock if present.
- Return the blood unit to the blood bank for rechecking.
- Collect blood samples from the recipient and urine specimen to check for hemoglobinuria.
- Administer diuretics as prescribed.

4. Circulatory Overload:

Cause: Infusion of blood volume faster than the circulatory system can handle.
Signs & Symptoms: Distended neck veins, shortness of breath (dyspnea), dry cough, and pulmonary edema.
Management:
- Stop the transfusion immediately.
- Inform the doctor, who may decide to stop the transfusion completely or slow the infusion rate.
- Administer prescribed medications.
- Monitor and record vital signs frequently.

5. Pyogenic Reaction:

Cause: Bacterial contamination of the blood product or transfusion equipment.
Signs & Symptoms: High fever, chills, nausea, and vomiting.
Management:
- Stop the transfusion immediately.
- Provide tepid sponge baths for fever reduction.
- Inform the doctor and the blood bank.
- Monitor vital signs closely.
- Return the blood unit to the blood bank.
- Administer antibiotics and antipyretics as prescribed.

6. Transmission of Infectious Diseases:

Cause: Blood products can potentially transmit diseases like malaria, syphilis, viral hepatitis, and HIV/AIDS.
Prevention: Careful screening of donor blood is essential to minimize this risk.

THE ROLES OF A NURSE BEFORE, DURING AND AFTER BLOOD TRANSFUSION

Before Blood Transfusion (Nurse’s Interventions)

Verify Prescription: Ensure that a blood transfusion has been prescribed by the doctor as indicated in the patient’s file.
Patient Identification: Properly identify the patient to be transfused.
Explain Procedure: Explain the procedure to the patient to alleviate anxiety.
Counsel and Educate: Counsel, reassure, and provide health education to the patient and their relatives about the benefits of the blood transfusion.
Establish IV Line: Insert a cannula into the identified vein to establish an IV line, maintain it in situ, and obtain a blood sample for laboratory grouping and cross-matching to obtain a compatible donor.
Collect Blood Pack: Collect the compatible blood pack from the laboratory for the patient to be transfused.
Inspect Blood Pack:
- Verify the blood group.
- Confirm the patient’s name on the blood pack.
- Check the expiry date.
- Verify the Rh factor.
- Confirm the reference number.
Check for Leaks and Clots: Inspect the blood pack for leakages and change it if necessary. Check for the color and presence of clots, replacing the pack if clots are present.
Confirm Infusion Set Integrity: Ensure the infusion set is intact.
Take Vital Observations: Record vital signs, including BP, TPR, and maintain a temperature chart.
Patient Positioning: Position the patient’s arm comfortably.
Warm Blood: Warm the blood to room temperature to prevent chills.
Connect Blood Pack: Firmly connect the blood pack to the infusion system on the drip stand.
Fill Air Chamber: Fill the air chamber with a little blood and expel air from the infusion set by running blood through it.
Administer Prescribed Treatment: Administer any prescribed medications.

During Transfusion

Note Start Time: Record the time the transfusion begins.
Monitor Blood Flow Rate: Ensure the blood flow rate is normal.
Watch for Reactions: Observe the patient for any adverse reactions, stopping the transfusion immediately if they occur.
Take Vital Observations: Continuously monitor vital signs to ensure the patient remains stable.
Check Infusion Site: Inspect the infusion site for swelling, leakages, pain, and check the infusion system for blood clotting.
Disconnect After Transfusion: After successful transfusion, disconnect the transfusion system from the infusion line.
Record End Time: Document the time the transfusion ends.
Thank the Patient: Thank the patient for their cooperation.

After Transfusion

Monitor for Reactions: Continuously monitor the patient for post-transfusion reactions.
Monitor Vital Signs: Keep a close watch on vital signs and maintain a temperature chart.
Keep Blood Pack: Retain the empty blood pack at the bedside for 8-12 hours.

Note:

Administer normal saline before and after the blood transfusion.
Administer whole blood and packed red blood cells over 4 hours.
Administer plasma, platelets, and cryoprecipitate over 20 minutes.

BLOOD TRANSFUSION Read More »

INSTIlLING MEDICATION

INSTILLING MEDICATION INTO EAR

Requirements

Tray

Cotton tipped applicators.
Cotton balls.
Bowl with warm normal saline.
Medication bottle with dropper.
Receiver.
Clean gloves.

At the side

Screen
Vomit bowl

Procedure.

Step	Action	Rationale
1	Refer to general rules on nursing procedure and medicine administration.
2	Obtain assistance in case of children or infants.	Prevents accidental injury due to sudden movement during the procedure.
3	Using a cotton-tipped applicator, clean the meatus of the ear canal.	Removes any discharge before instillation.
4	Warm medication container in hands or place in warm normal saline.	Promotes patient’s comfort and prevents vertigo and vomiting.
5	Fill ear dropper, particularly with medication.
6	Straighten auditory canal: – For infants or children under 3 years, pull pinna down and back. – For an adult or child older than 3 years, pull pinna upward and backward.	Straining the canal ensures the solution flows the entire length of the auditory canal.
7	Instill the correct number of drops along the side of the ear canal by holding the dropper ½ to 1 cm above the ear canal.	Reduces trauma to the tympanic membrane.
8	Press gently and firmly a few times on the tragus of the ear.	Pressing assists the flow of medication into the ear canal.
9	Request the patient to remain in a side-lying position for about 5 minutes.	Prevents drops from escaping and enables medication to reach all sides of the canal.
10	Insert a small piece of cotton swab at the meatus of the auditory canal for 15-20 minutes.	Cotton helps to retain medication when the patient is upright.
11	Assess for patient comfort, response, and check for discharge/drainage from the ear.
12	Replace requirements and wash hands.	Reduces the spread of microorganisms.
13	Document medication administration, name of medication administered, and patient’s response.	Ensures accurate record keeping and continuity of care.

Points to remember;

Use sterile technique in administration when administering medication in perforated tympanic membrane.
Consider side effects and toxic effects and contraindications of various medicines.

INSTILLING MEDICATION INTO THE EYES

Requirements

Tray

Sterile gloves sterile cotton balls soaked in sterile normal saline.
Dry cotton balls.
Adhesive strapping.
Receiver.
Dry sterile dressing pad.
Medication.

At the side

Screen.

Procedure

Step	Action	Rationale
1	Refer to general rules on nursing procedure and medicine administration.
2	Check ophthalmic preparation for name, name expiry date.	Prevention medication error
3	Request the patient to look up the ceiling and give the patient a sterile absorbent cotton swab.	If looking up prevents blinking and in this position the cornea is protected by an upper lid.
4	Expose the lower conjunctival sac by pacing thumb or fingers of non-dominant hand just below the eye on the zygomatic arch and gently draw down the skin on the cheek.	Placing fingers on the bony prominence avoids pressure to the eyeball and prevents a person from blinking or squinting.
5	For liquid medication; discard the first drop. For ointment; discard the first ointment bead, hold the tube above the conjunctival sac from the canthus outwords.	It is considered to be contaminated.
6	Approach the eye from the side and instill the correct number of drops into the outer third of the conjunctiva holding the dropper 1-2 cm above the eye.	Patient is less likely to blink if a side approach is used.
7	Request the patient to squeeze on nasolacrimal duct for at least 30 seconds after instilling liquid medication.	Pressure prevents medication running down the duct.
8	Request the patient to close eyes but not to squeeze them.	Squeezing can injure eye and push out medication .
9	Clean the eyelid as needed by wiping from inner canthus to outer canthus.	Prevents spread of infection into the lacrimal duct.
10	Apply eye pad if required and secure it, request patient not to rub the eye.	Reduces risk of injury.

Key points;

If more than one eye drop is ordered, wait 5 minutes between each medication.
If medication for both eyes, place, in the unaffected eye first.

ADMINISTERING NASAL DROPS

Requirements

Tray

Prepared medication.
Pen light.
Receiver toilet paper.
Clean dropper.
Facial flannels.

At the side

Screen
Small pillow.

Procedure

Step	Action	Rationale
1	Refer to general rules on nursing procedure and medicine administration.
2	Inspect the condition of the nose and sinuses using a penlight and palpate sinuses for tenderness.	Provides baseline data to monitor effects.
3	Wash hands and put on gloves.	Promotes infection prevention.
4	Request patient to clear or blow nose gently unless contraindicated (increased intracranial pressure or nose bleeds).	Removes mucous and secretions that can block the nasal passages.
5	Position patient supine, and position head properly for access to the posterior pharynx, tilt patient’s head backward.	Allows medication to flow into affected sinuses.
6	Support the patient’s head with the non-dominant hand and instruct the patient to breathe through the mouth.	Prevents straining of the muscles and mouth breathing reduces the chances of aspirating nasal drops.
7	Hold dropper ½ – 1 cm above nares and instill prescribed number of drops towards the midline of the ethmoid bone.	Avoids contamination of the dropper.
8	Have the patient remain in the supine position for 5 minutes and offer a facial towel to blot the nose but do not blow.	Prevents premature loss of medication through nares and allows maximum dose to be absorbed.
9	Assist patient to a comfortable position after the medication is absorbed.	Restores comfort.
10	Assess patient response, replace requirements, and wash hands.	To detect reactions and maintain a hygienic environment.
11	Document and record administration of medication.	Ensures accurate record keeping and continuity of care.

ADMINISTERING MEDICATION THROUGH NASO-GASTRIC TUBE

Requirements

Tray

All requirements for passing a tube.
Medication.
Mortar or pestle if tablets are used.

At the side

Screen

Procedure

Step	Action	Rationale
1	Refer to general rules on nursing procedure and medicine administration.
2	Position patient and place mackintosh and towel under the chest.	Protects patient from spillage.
3	Elevate the head of the bead 35° -45°	Protects patient from aspiration.
4	Assess placement of the tube, if correct flush 15-30ml of water (adults) or 5-10ml in children.	Helps to maintain tube patency.
5	Administer the prepared medication in the same manner as feeds are administered. Administer each medication and flush with 5ml after each, do not mix medications.	To avoid medicine reactions.
6	After administering the prescribed medications flush the tubing with at least 30 ml of water.	Prevents clogging of feeding tube
7	Assess patient response, replace requirements and wash hands.
8	Document and record administration of medication.

APPLYING TOPICAL MEDICATIONS

Requirements

Tray

Gloves
Water in a bowl
Soap in a dish
Cotton balls or gauze pieces
Medicine (ointment, lotion or liniment) in appropriate container
Adhesive tape and dressing pad

Procedure

Step	Action	Rationale
1	Refer to general rules on nursing procedure and medicine administration.	To maitain Standards
2	Expose only the area where lotion/liniment is to be applied
3	Powders; make sure the skin surface is dry and sprinkle evenly over the area till a fine layer covers the skin. Cover Area if required.
4	Lotions; shake the container and put a small amount of lotion on a gauze dressing pad and apply it evenly in the direction of hair growth.
5	Creams, ointments, and pastes; take a small quantity of medication in gloved hand, smear it evenly over skin using long strokes in the direction of hair growth.
6	Spray; shake the container well to mix the contents, hold the container at 15 – 30 cm away from the area and spray, ensuring that it does not enter the eyes.
7	Transdermal patches; select clean dry area which is free of air, take the patch holding it without holding the adhesive edges and apply it firmly using palm of hand and press it for 10 seconds, remove the patch at the appropriate time.
8	Observe the area carefully for changes in color, swelling appearance of a rash.
9	Document and record administration of medication.

ADMINISTERING RECTAL AND VAGINAL MEDICATION.

Requirements

Tray

Rectal suppository.
Clean gloves.
Application plunger in case of vaginal cream.
Receiver.
Lubricating jelly.
Toilet paper receiver.
Swabs in a gallipot.
Mackintosh and towel.

At the side

Screen

Procedure

Rectal

Steps	Action	Rationale
1.	Refer to general nursing procedures.	Keeps standard.
2.	Review patient’s information about the medicine.	Ensures safe and correct medical administration.
3.	Receive patient knowledge about the intended administration.	Ensures patient privacy and positions ensures easy access to anus.
4.	Screen bed and position patient in left lateral with upper leg flexed.	Provides privacy.
5.	Wash hands and put on gloves.	Reduces transfer of infection.
6.	Keep the patient draped with only the anal area exposed.	Maintains privacy and facilitates relaxation.
7.	Remove suppository from foil wrap and lubricate rounded end with jelly, lubricate gloved finger of dominant hand.	Lubrication reduces friction.
8.	Request the patient to take slow deep breaths.	Facilitating suppository through constricted sphincter causes less pain.
9.	Retract patient’s buttocks with non-dominant hand, with index finger of dominant hand insert suppository along rectal wall to 10 cm in adult and 5 cm in children.	Promotes eventual absorption.
10.	Withdraw your finger and wipe the patient’s anal area with toilet paper.	Promotes comfort.
11.	Request the patient to remain flat or on one side for 5 minutes.	Prevents expulsion of the medication.
12.	Check within 5 minutes to determine the suppository is in place, request the patient to retain the suppository for 30-45 minutes.	Ensures effectiveness of medication.
13.	Clean, remove gloves and wash hands.	Infection prevention.
14.	Record and report all patients’ responses to medication including any reactions.	Ensures the effect of medicine.

Vaginal

Steps	Action	Rationale
1.	Explain to the patient that insertion is painless and will bring relief from itching, pain and discomfort.	Reduces anxiety and ensures cooperation.
2.	Request patient to empty bowel and bladder.	Promotes effectiveness.
3.	Position patient in semi recumbent, cover patient leaving the perineal area only.	Ensures patient privacy.
4.	Prepare requirements, unwrap suppository, for cream, fill applicator as instructed.	Promotes infection control.
5.	Put on gloves, inspect perineal/vaginal discharge.	Prevents infection.
6.	Apply medicine gently into the vaginal wall.	Ensures correct administration.
7.	Request the patient to remain flat or on one side for 5-10 minutes following insertion.	Ensures absorption.
8.	Apply a clean perineal pad if excessive discharge or cream leakage.	Promotes patient’s comfort.
9.	Clean, remove gloves and wash hands.	Infection prevention.
10.	Record and report all patients’ responses to medication including any reactions.	Promotes communication between team members.

INSTIlLING MEDICATION Read More »

Under water seal drainage

UNDER WATER SEAL DRAINAGE

Under water seal drainage is a system that allows drainage of the pleural space using an airtight system to maintain sub-atmospheric intrapleural pressure.

It’s used when air or fluid gets trapped in the pleural space.

Pleural Space: This is the space between the two layers of pleura, which are thin membranes lining the lungs and the inside of the chest wall. Normally, this space has negative pressure, which helps the lungs stay inflated.

Purpose: The water seal drainage system has two main jobs:

To remove air and fluid: It allows air and fluid that have accumulated in the pleural space to escape out of the chest. Under water seal drainage is used to remove blood, air, pus, or serous fluid from the pleural cavity after thoracotomy, chest injury, pleural effusion, or pneumothorax.
To prevent backflow: It stops air and fluid from going back into the pleural space, especially when you breathe in (inhale). This one-way system is nice for proper lung function.

In simpler terms: Imagine a bottle with a straw dipped in water. When you blow into the straw, bubbles escape, but water doesn’t come back up the straw into your mouth. Water seal drainage works on a similar principle for your chest.

The underwater seal acts as a one-way valve.

Conditions necessitating Underwater Seal Drainage

Traumatic Pneumothorax: This happens when an injury to the chest (like a car accident or stab wound) causes air to leak into the pleural space, collapsing the lung.
Hemopneumothorax: This is a combination of air and blood in the pleural space. It can also be caused by trauma.
Spontaneous Pneumothorax: Sometimes, a lung can collapse on its own, without an obvious injury. This is more common in tall, thin young adults or people with lung diseases.
Iatrogenic Pneumothorax: This occurs unintentionally as a result of a medical procedure, such as inserting a central line or during a lung biopsy.
Broncho-pleural Fistula: This is an abnormal connection between an airway in the lung (bronchus) and the pleural space, causing air to leak into the pleural space.
Emphysema: A chronic lung disease where air sacs in the lungs are damaged. In some cases, it can lead to air leaks into the pleural space.
Malignancy: Lung cancers or other cancers in the chest can sometimes cause fluid buildup in the pleural space (pleural effusion).
Pleural Effusion: This is the buildup of excess fluid in the pleural space. It can be caused by various conditions like heart failure, pneumonia, or cancer.
Thoracic or Thoraco-abdominal Surgeries: After surgeries in the chest or upper abdomen, chest tubes are often placed to drain air and fluid and prevent complications.

In short: Any condition that causes air or fluid to accumulate in the pleural space and disrupt normal lung function may require water seal drainage.

Indications of Water Seal Drainage

The goals of water seal drainage are to:

Permit Drainage of Air and Fluid: The most direct purpose is to remove unwanted air, blood, or fluid from the pleural cavity. This helps to relieve pressure and allow the lung to re-expand.
Establish Normal Negative Pressure: The pleural space normally has a negative pressure, which is essential for keeping the lungs inflated. Water seal drainage helps to restore this negative pressure. Think of it like sucking air out of a balloon to make it inflate inside a jar.
Promote Lung Expansion: By removing air and fluid and restoring negative pressure, water seal drainage allows the collapsed lung to re-inflate and function properly.
Equalize Pressure on Both Sides of the Thoracic Cavity: Conditions like pneumothorax can disrupt the pressure balance in the chest. Water seal drainage helps to restore this balance.
Prevent Tension Pneumothorax: In a tension pneumothorax, air keeps getting trapped in the pleural space and cannot escape, leading to dangerous pressure buildup that can compress the heart and major blood vessels. Water seal drainage prevents this life-threatening situation by providing an escape route for the air.
Provide Continuous Suction (if needed): In some cases, gravity alone may not be enough to drain the air or fluid, or to re-expand the lung quickly. In these situations, gentle suction may be added to the water seal drainage system to assist the process.

In essence: Water seal drainage aims to bring the lung back to its normal, healthy state by removing obstacles and restoring the necessary pressure for it to function.

Site for Chest Tube Insertion

Where is the Chest Tube Inserted? The location of the chest tube depends on the reason for drainage:

For Thoracic Surgery (usually two tubes):

Anterior Chest Tube (Front):

Location: Usually placed in the upper and front part of the chest wall.
Intercostal Space: Inserted in the 2nd intercostal space (the space between the 2nd and 3rd ribs).
Purpose: Primarily to remove air. Air rises, so placing the tube high in the chest helps to drain air that has collected in the upper pleural cavity.

Posterior Chest Tube (Back):

Location: Placed in the back of the chest.
Intercostal Space: Inserted in the 8th or 9th intercostal space at the mid-axillary line (roughly in line with the middle of your armpit).
Purpose: Primarily to remove fluid (like blood or serous fluid). Fluid tends to settle at the bottom of the pleural cavity due to gravity, so a lower tube placement is effective for drainage.
Tube Diameter: Tubes for fluid drainage (posterior tubes) are often wider or longer than tubes for air drainage (anterior tubes) to facilitate better fluid removal.

For Pneumothorax (usually one tube for air removal):

Location: In the front or side of the chest.
Intercostal Space: Usually placed in the 2nd or 3rd intercostal space along the mid-clavicular line (in line with the middle of your collarbone) or anterior axillary line (front of your armpit).
Purpose: To remove air from the pleural space, allowing the lung to re-expand. Since air rises, a higher placement is effective for pneumothorax.

Types of Drainage Systems

Water seal drainage systems can be categorized based on the number of bottles (or chambers in modern systems). The basic principle remains the same, but complexity increases with more bottles.

One-Bottle Drainage System (Simple System)

Components:

Drainage Bottle: A single sterile bottle containing a specific amount of sterile water or saline solution.

Two Tubes:

Patient Tube (A): Connects to the chest tube from the patient. This tube is submerged underwater in the bottle, creating the water seal.
Vent Tube (B): A shorter tube that vents to the atmosphere (or suction). This allows air to escape from the bottle.

How it Works:

Air and fluid drain from the patient’s pleural space through tube A into the bottle.
The underwater seal prevents air from being sucked back into the pleural space during inhalation.
Air from the pleural space bubbles through the water and escapes out through vent tube B.
Drainage fluid collects in the bottle.

Limitations:

As drainage collects in the bottle, the water level rises, increasing the positive pressure needed to push out more fluid. This can slow down drainage if a large amount of fluid needs to be removed.
Not ideal for large amounts of drainage or when suction is needed.

Two-Bottle Drainage System (Improved Drainage and Collection)

Components:

Trap Bottle (Collection Bottle): The first bottle to receive drainage from the patient. It’s simply a collection container and doesn’t contain water.
Underwater Seal Bottle: The second bottle, containing sterile water and acting as the water seal, similar to the one-bottle system.

How it Works:

Drainage from the patient first goes into the Trap Bottle, which collects the fluid.
Air then passes from the Trap Bottle to the Underwater Seal Bottle.
The Underwater Seal Bottle functions exactly as in the one-bottle system, providing the water seal and venting air.
The collection of drainage in a separate bottle prevents the increasing water level issue of the one-bottle system.

Advantages over One-Bottle System:

More efficient drainage, especially for larger volumes, as the water seal is not affected by the amount of drainage.
Allows for more accurate measurement of drainage as it’s collected in a separate bottle.

Three-Bottle Drainage System (Suction Control Added)

Components:

Trap Bottle (Collection Bottle): First bottle, collects drainage.
Underwater Seal Bottle: Second bottle, provides the water seal.
Manometer Bottle (Suction Control Bottle): Third bottle, controls the amount of suction applied to the system. It also contains sterile water.
Adjustable Vent Tube: A tube in the Manometer Bottle that is open to the atmosphere.

How it Works:

Drainage flows through the Trap Bottle and Underwater Seal Bottle as in the two-bottle system.

Suction Control: The Manometer Bottle regulates the suction.

The depth of the vent tube in the water in the Manometer Bottle determines the amount of negative pressure (suction). For example, if the tube is submerged 20 cm underwater, the suction will be approximately -20 cm H₂O.
When suction is applied, air is drawn in through the adjustable vent tube and bubbles through the water in the Manometer Bottle. This bubbling indicates that the suction is working and is being controlled at the desired level.
Excess suction is vented to the atmosphere, preventing excessive negative pressure from being applied to the patient’s pleural space.

Advantages of Three-Bottle System:

Controlled Suction: Allows for the application of gentle suction to aid in lung re-expansion and drainage, especially when gravity drainage is insufficient.
Safety: Prevents excessive suction, which could damage lung tissue.
More efficient drainage: Especially useful for persistent air leaks or when rapid lung re-expansion is needed.

Modern Systems: Today, many systems use pre-assembled, disposable plastic units that combine the functions of these bottles into chambers within a single unit. These are often referred to as multi-chamber drainage systems and are more convenient and easier to manage, but the underlying principles are the same as the bottle systems.

Factors Affecting Water Seal Drainage

Several factors can influence how well a water seal drainage system works. Knowing these factors is key for effective nursing care and management.

1. Proper Placement of Chest Catheter (Chest Tube): Rationale: Correct placement is key for effective drainage. As discussed earlier, tubes placed high are for air, and tubes placed low are for fluid.

Considerations:

Intercostal Space: Using the correct intercostal space (e.g., 2nd for air, 8th-9th for fluid).
Anterior/Posterior: Anterior for air, posterior for fluid in surgical cases with two tubes.
Single Tube: If only one tube is used, it’s often placed lower for general drainage of both air and fluid, although its effectiveness for air drainage alone might be less optimal than a higher placed tube in pneumothorax.
Separate Bottles: If multiple tubes are placed, they should be connected to separate drainage bottles to manage drainage from different areas effectively.

2. Proper Placement of Chest Drainage Apparatus: Rationale: Gravity is key. The drainage system must be lower than the chest for drainage to occur effectively and to prevent backflow.

Considerations:

Below Chest Level: Always ensure the drainage unit is consistently below the patient’s chest level, whether the patient is in bed, sitting, or walking.
Gravity Assist: This helps gravity to pull drainage from the pleural space into the collection system.
Prevent Backflow: Keeping it low prevents fluid in the drainage system from flowing back into the pleural space, which could cause infection or other complications.
During Transfer: When moving the patient (e.g., to another bed or for transport), the drainage unit should be held or placed carefully below chest level. It’s also advisable to briefly clamp the tubing (as instructed by protocol or physician order) during transfer to prevent accidental spillage or backflow, but clamping should be brief and tubing must be unclamped immediately after.

3. Length of Drainage Tubing: Rationale: Tubing length affects drainage efficiency and patient mobility.

Considerations:

Not Too Short: Tubing that is too short can restrict patient movement, potentially dislodge the chest tube, or cause tension on the insertion site.
Not Too Long: Tubing that is too long can create loops that impede drainage flow due to increased resistance and potential fluid collection in loops.
Straight Line: Tubing should ideally run in a relatively straight line from the chest to the drainage system, avoiding kinks or dependent loops.
No Loops: Avoid creating loops in the tubing, as these can trap fluid and air, obstructing drainage.

4. Patency of Chest Tubing: Rationale: The chest tube must be open and clear for drainage to flow.

Considerations:

Frequent Checks: Regularly check the tubing for kinks, clamps, or pressure points that might obstruct flow.
No Kinks or Pressure: Ensure the patient is not lying on the tubing, and that bedding or clothing is not pressing on it.
Mucus Plugs/Clots: Clots or mucus plugs inside the tubing can block drainage.
Milking the Tube: If clots or plugs are suspected, gently “milking” or stripping the tubing (following hospital protocol and physician orders) can help to dislodge them and maintain patency. However, routine stripping/milking is generally discouraged as it can create excessive negative pressure and potentially damage lung tissue. Gentle manipulation to maintain patency is preferred.
Avoid Clamping: Never clamp the chest tubing routinely, as this can lead to tension pneumothorax if air is still leaking into the pleural space. Clamping is generally only done briefly in specific situations, such as changing the drainage system, assessing for air leaks, or prior to removal, and should be done per physician order or hospital protocol.

5. Maintenance of Air Tight Drainage System: Rationale: The system must be airtight to maintain the water seal and suction (if used) and prevent air from entering the pleural space.

Considerations:

Air Tight Seals: Ensure all connections in the drainage system (tubing connections, bottle stoppers, connections to the chest tube at the insertion site) are airtight.
Taping Connections: Tape all tubing connections securely to prevent accidental disconnections and air leaks.
Stoppers and Seals: Make sure bottle stoppers (if using bottle systems) are firmly in place and that any seals in modern systems are intact.
Check for Leaks: Regularly check the system for air leaks. Continuous bubbling in the water seal bottle (when not expected) may indicate an air leak in the system rather than from the patient. To check for system leaks, briefly and sequentially clamp sections of the tubing starting close to the patient. If bubbling stops when you clamp a certain section, the leak is likely in that section or closer to the patient. If bubbling continues even when clamped near the patient, the leak is likely from the patient (e.g., lung air leak) or the chest tube insertion site.

6. Position of the Client: Rationale: Patient position can affect drainage, especially fluid drainage.

Considerations:

Fowler’s Position (Semi- or High-Fowler’s): Elevating the head of the bed (Fowler’s position) is often recommended.
Fluid Localization: Fowler’s position helps to localize fluid in the lower pleural space, making it easier to drain through a lower placed chest tube.
Lung Expansion: It can also improve lung expansion and breathing mechanics.
Regular Repositioning: Encourage the patient to change position regularly (within activity limitations) to promote drainage from different areas of the pleural space and prevent fluid from settling in one area.

7. Application of Mechanical Suction: Rationale: Suction, when used appropriately, can enhance drainage but must be applied correctly.

Considerations:

Continuous and Gentle: Suction should be continuous and gentle, not intermittent or high pressure.

When to Use Suction: Suction is typically used when:

Gravity drainage alone is not enough (e.g., persistent air leak, slow lung re-expansion).
The patient’s respiratory effort and cough are weak.
There’s a fast or significant air leak into the pleural space.
Speedier removal of air or fluid from the pleural space is needed.

–

Physician Order: Suction should always be applied based on a physician’s order.
Proper Setting: Ensure the suction is set to the prescribed level (often indicated by the water level in the suction control bottle or the setting on a modern drainage unit).
Bubbling in Suction Chamber: Gentle, continuous bubbling in the suction control chamber (Manometer Bottle) is a sign that suction is being applied correctly. Vigorous bubbling is usually unnecessary and can increase water evaporation and noise.

8. Activity of the Client: Rationale: Patient activity can promote drainage and lung function.

Considerations:

Movement on Bed: Encourage gentle movement in bed (turning side to side, repositioning). Movement helps to shift fluid and air within the pleural space, promoting drainage.
Coughing and Deep Breathing: Encourage the patient to cough and deep breathe regularly.
Intrapleural and Intrapulmonary Pressure: Coughing and deep breathing help to increase intrapleural and intrapulmonary pressure, which can assist in expelling air and fluid from the pleural space and promote lung expansion.
Walking (if appropriate): If medically appropriate and ordered by the physician, ambulation (walking) can also be beneficial, as it encourages deeper breathing and overall lung function.

Requirements for Under Water Seal Drainage (UWSD)

STERILE TROLLEY – Top Shelf

A trocar and cannula, intercostal tubing, and an introducer

Artery forceps in a receiver

Scalpel

Suturing material

Safety pin

A large Winchester bottle containing water or normal saline to a level of about 6cm

A rubber cork pierced by a short and long glass tube or by rigid plastic tubes

Bottom Shelf

A pair of gloves

Chest X-ray investigations and ultrasound scan results

A dressing pack

A patient’s file

Bedside

Hand washing equipment

Suction machine

Screen

Patient’s file

Emergency tray

Procedure for Underwater Seal Drainage (UWSD)

Step	Action	Rationale
Preparation of equipment
1	Preferably a graduated bottle is used	For correct reading of the drainage fluid
2	Assist Doctor to submerge the long tube in the water at 2 to 3 cm but must not touch the bottom of the bottle. The short tube acts as an escape route for air in the vacuum space in the bottle.	To prevent air from going to pleural cavity
3	Assist the Doctor to connect the tube to the top of the under-water to the patient’s intercostal drainage tube.	To drain fluid from the pleural cavity
Procedure
1	Explain the procedure carefully to the patient; to understand the importance of limited movements during the period of UWSD.	Explanation encourages patients cooperation and relieves anxiety
2	Take the trolley to the bedside, screen the bed and close nearby windows.	To provide privacy
3	Wash and dry hands and be ready to assist the doctor.	Promote hygiene measures
4	Position the patient leaning over the bed table supported by pillows. The patient’s arm which is on the side where the tube will be inserted must be placed forward and supported by a nurse.	This position gives best access to the second or third intercostal space
5	Observe the patient’s colour, pulse and respirations throughout the procedure.	To detect any change in patient condition and manage accordingly
6	The doctor cleans the patient’s skin, places a drape in position and injects local anaesthesia. A scalpel is used to make an incision through the skin and muscle of the intercostal space. Using the introducer, the tubing is inserted and secures it with a stitch.	Local anaesthesia helps to relieve pain
7	The nurse connects the tube to the UWSD bottle once the introducer is removed, then clamps the tube with two pairs of clamps until all the connections of the apparatus are sealed.	To be able to clip the tube so as to prevent air going to the lungs
8	Remove the clamps and check the functioning of the apparatus by noting if the fluid in the tube rises and falls in rhythm with the patient’s respirations.	To ensure that the system is air tight and no air leakages and no risk of emphysema.
9	Apply a dressing to the wound.	A dressing makes an airtight seal at the incision site and prevents infection.
10	Wash hands, clear away the equipment and leave the patient comfortable.	To prevent spread of infections
Changing the bottle
11	• Securely clamp off the drain with two clamps but for a short time. • Disconnect the tubing and put used apparatus to one side. • Connect new tubing and bottle and remove the clamps.	Minimise re-infection of the patient.
12	Monitor the fluid in tubing whether it is moving up and down in rhythm with the patient’s respiration rate.	To ensure that the tube is in situ and functioning.
13	Record the amount of drainage on the fluid balance chart and note any abnormalities.	For effective assessment of progress of therapy and the patient
	Wash hands, Clear away and clean the used apparatus and equipment.	To prevent spread of infections

Points to remember

Make sure that all connections are secure to avoid leakages
Check that the patient is not compressing or kicking any part of the drainage system, to avoid obstructing the tube.
The bottle must always remain below the level of the patient’s chest and should preferably be in a stand to avoid being easily knocked over, to prevent back flow of fluid from drainage chamber to pleural cavity and to maintain the water seal.

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Nursing Management Question Approach

Nursing Care Management: Answering Questions with Confidence

As nurses prepare for their nursing exams, it is crucial to develop effective strategies for answering questions related to nursing care management. Nursing exams often include questions that require nurses to demonstrate their knowledge of nursing considerations, Nursing concerns, Nursing issues, and Nursing interventions.

In this comprehensive post, we will dive into each of these areas and provide detailed explanations and examples of how to approach and answer these types of questions with confidence.

Understanding Nursing Considerations

In nursing, considerations refer to the factors that nurses must take into account when providing care to their patients. These considerations encompass various aspects, including patient assessment, specific health conditions, treatments, interventions, and potential complications. By considering these factors, nurses can tailor their care plans and interventions to meet the unique needs of each patient.

Now, let’s apply the question approach to nursing considerations by examining the following question: “What are ten nursing considerations when applying Plaster of Paris on a limb?”

To effectively answer this question, we need to identify and describe ten essential nursing considerations when applying Plaster of Paris on a limb. Let’s explore each consideration in detail:

1. Assessment of Limb Condition

Before applying plaster of Paris, assess the condition of the limb thoroughly. This assessment includes evaluating skin integrity, checking for any open wounds or infections, and assessing neurovascular status.

2. Proper Positioning

Proper positioning is essential to ensure accurate application and alignment of the plaster. Assist the patient in a comfortable position that allows easy access to the limb and facilitates proper molding.

3. Skin Preparation

Preparing the skin before applying plaster of Paris is crucial to prevent skin complications. Clean the skin thoroughly, remove any hair, and ensure it is dry before applying the plaster.

4. Education and Informed Consent

Provide education to the patient and their family about the plaster application process, including the expected duration, care instructions, and potential complications. Obtaining informed consent is also a vital nursing consideration.

5. Selection and Preparation of Materials

Select the appropriate plaster of Paris materials and prepare them according to the manufacturer’s instructions. This involves measuring and cutting the plaster strips to the required length and immersing them in water.

6. Proper Application Technique

Applying plaster of Paris requires proper technique to ensure a secure and well-fitting cast. Apply the wet plaster strips smoothly and evenly, avoiding wrinkles or excessive pressure that could compromise circulation.

7. Patient Comfort and Pain Management

During the plaster application process, continuously assess the patient’s comfort and manage any associated pain. This may involve administering analgesics as prescribed, providing positioning support, and offering emotional support.

8. Monitoring Neurovascular Status

Closely monitor the neurovascular status of the limb after applying the plaster. This includes assessing for signs of impaired circulation, such as changes in color, temperature, sensation, and capillary refill time.

9. Prevention of Complications

To prevent complications, educate the patient and their family about proper care techniques, such as keeping the cast dry, avoiding putting weight on the cast, and recognizing signs of infection or circulation problems.

10. Follow-Up and Evaluation

After applying the plaster of Paris, schedule appropriate follow-up appointments to monitor the limb’s progress, assess the cast’s integrity, and ensure proper healing. Regular evaluation is essential to detect any complications early and provide timely interventions.

Understanding Nursing Concerns

Nursing concerns refer to the specific areas of attention or any issues or problems that a nurse recognizes or identifies as something that has potential impact on the health of the patient. These concerns include the potential risks, complications, and specific care needs associated with the patient’s health condition. Understanding nursing concerns allows nurses to provide holistic and patient-centered care.

Have you ever wondered what nurses are thinking about when they’re caring for a patient? It’s not just about administering medication and taking vital signs. Nurses are constantly on the lookout for potential problems, known as nursing concerns, that could impact a patient’s health.

Nursing concerns are like early warning systems in healthcare. They are potential problems or issues that a nurse recognizes or identifies as something that has the potential to negatively affect a patient’s health.

Think of it like this: Imagine you’re driving a car. You’re paying attention to the road, but you’re also constantly checking the dashboard for warning lights. These lights signal potential problems that could lead to a breakdown. Nurses are like the dashboard, monitoring for early warning signs in their patients.

Now, let’s apply the question approach to nursing concerns by examining the following question: “Explain five nursing concerns to address when caring for a patient with trigeminal neuralgia?”

To effectively answer this question, we need to identify and explain five nursing concerns when caring for a patient with trigeminal neuralgia;

Answer: A nurse would be concerned about:

Risk for Injury: The pain might make it difficult for the patient to move around safely, increasing the chance of falls.
Impaired Oral Intake: Eating and drinking can become painful, leading to malnutrition and dehydration.
Ineffective Coping: Chronic pain can cause anxiety, depression, and social isolation.
Noncompliance with Medication Regimen: The patient may be hesitant to take medications due to side effects or fear of addiction.
Risk for Adverse Drug Reactions: Certain medications used to treat trigeminal neuralgia can have serious side effects.
Risk for Social Isolation: The pain and discomfort can make it difficult for the patient to participate in social activities.
Risk for Impaired Skin Integrity: The patient may have difficulty maintaining oral hygiene due to pain, leading to skin breakdown.

Understanding Nursing Issues

Nursing issues refer to the specific challenges or problems that nurses may encounter when managing patients with certain health conditions. These issues encompass the physical, emotional, and social aspects that can impact patient care and require nursing interventions. Understanding nursing issues allows nurses to anticipate and address potential difficulties in providing holistic care.

Now, let’s apply the question approach to nursing issues by examining the following question: “Outline five nursing issues of a patient with Parkinson’s disease?“

To effectively answer this question, we need to outline five nursing issues encountered when managing a patient with Parkinson’s disease. Let’s explore each issue in detail:

1. Mobility and Gait Disturbances

Parkinson’s disease often presents with mobility and gait disturbances, including bradykinesia, rigidity, and postural instability. Assess and address these issues by implementing interventions such as physical therapy, assistive devices, and fall prevention strategies.

2. Medication Management

Patients with Parkinson’s disease require complex medication categories to manage their symptoms. Educate patients and caregivers about the medications, their dosages, possible side effects, and the importance of adherence.

3. Psychosocial Support

Parkinson’s disease can significantly impact a patient’s mental and emotional well-being. Provide psychosocial support by addressing concerns, facilitating support groups, and connecting patients and caregivers with resources for counseling or therapy.

4. Communication Difficulties

As the disease progresses, patients with Parkinson’s disease may experience speech and swallowing difficulties. Employ alternative communication methods, such as augmentative and alternative communication devices, to facilitate effective communication.

5. Nutrition and Swallowing

Impaired swallowing, known as dysphagia, is a common issue in Parkinson’s disease. Collaborate with dieticians and speech therapists to develop appropriate dietary modifications and swallowing techniques to ensure adequate nutrition and prevent aspiration.

Understanding Nursing Interventions

Nursing interventions refer to the actions and activities that nurses perform to promote health, prevent complications, and manage patient care. These interventions encompass a wide range of activities, including assessment, education, medication administration, wound care, and emotional support. Understanding nursing interventions allows nurses to deliver effective and evidence-based care to their patients.

Now, let’s apply the question approach to nursing interventions by examining the following question: “Explain six nursing interventions performed during the care of a patient with a tracheostomy tube?“

To effectively answer this question, we need to explain six nursing interventions performed during the care of a patient with a tracheostomy tube. Let’s explore each intervention in detail:

1. Tracheostomy Tube Care and Suctioning

Perform regular tracheostomy tube care, including cleaning and suctioning to maintain airway patency and prevent infection. This involves sterile techniques, monitoring secretion consistency, and assessing for any signs of complications.

2. Humidification and Hydration

Patients with a tracheostomy tube often require humidification to maintain proper airway moisture. Ensure adequate humidification and hydration to prevent mucus plugs and support optimal respiratory function.

3. Communication Support

Patients with a tracheostomy tube may face communication challenges. You should provide alternative communication methods, such as communication boards, pen and a paper or electronic devices, to facilitate effective interaction and alleviate patient frustration.

4. Skin and Stoma Care

Assess and care for the tracheostomy site to prevent infection and skin breakdown. This involves regular cleaning, monitoring for redness or irritation, and applying appropriate dressings or barriers.

5. Mobilization and Positioning

Proper positioning is crucial for patients with a tracheostomy tube to ensure optimal ventilation and prevent complications. Assist with positioning changes, mobilization, and providing appropriate support and stability during transfers or ambulation.

6. Education and Support

Provide comprehensive education to patients and caregivers regarding tracheostomy tube care, emergency management, signs of complications, and home care instructions. Emotional support and counseling are also essential to help patients and their families adapt to the lifestyle changes associated with a tracheostomy.

By implementing these six nursing interventions during the care of a patient with a tracheostomy tube, nurses can optimize airway management, prevent complications, and promote patient comfort and well-being.

In conclusion, we explored the question approach for each category, providing detailed explanations and examples. By considering nursing considerations, addressing nursing concerns, understanding nursing issues, and implementing nursing interventions, nurses can excel in their nursing exams and deliver high-quality care to their patients.

Remember, nursing care management is a multifaceted field that requires a combination of knowledge, critical thinking, and compassion. By continuously expanding your understanding of nursing concepts and refining your exam answering skills, you can become a proficient and confident nurse who excels in providing exceptional care to your patients.

WISHING YOU SUCCESS IN YOUR JUNE EXAMS.

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nursing exam Nursing Management nursing exam

Nursing Exam Question Approach

Nursing Exam Question Approach.

In this comprehensive guide, we will explore and provide examples of the Question Approach for nurses preparing for their nursing exams. We will cover question types such as EXPLAIN, OUTLINE, DESCRIBE, MENTION, IDENTIFY, STATE, LIST, WHAT, and GIVE.

Also, we will dive into question approaches specifically related to Nursing Management questions, including specific nursing interventions, considerations, concerns, issues, and interventions.

1. The EXPLAIN Question Approach

The EXPLAIN question requires nurses to provide a detailed explanation of a particular concept, process, or condition. When approaching an EXPLAIN question, follow these steps:

Step 1: Understand the question

Carefully read the question and identify the main topic or concept that needs to be explained. Pay attention to any specific instructions or requirements.

Step 2: Organize your response

Create an outline or mental map of the key points you want to include in your explanation. Start with a concise introduction that provides context and a clear thesis statement. Then, present your main points in a logical order, supporting them with relevant evidence or examples.

Step 3: Provide a thorough explanation

Elaborate on each key point using clear and concise language. Use appropriate nursing terminology and provide examples or case studies to enhance your explanation. Aim to cover all relevant aspects of the topic while maintaining a coherent and structured response.

Example EXPLAIN question:

“Explain the pathophysiology of diabetes mellitus and its effects on the body.”

Diabetes mellitus is a chronic metabolic disorder characterized by high blood glucose levels due to impaired insulin secretion, insulin action, or both. The pathophysiology of diabetes involves multiple factors that contribute to the development and progression of the disease.

Firstly, in type 1 diabetes, an autoimmune process leads to the destruction of insulin-producing beta cells in the pancreas. This results in a deficiency of insulin and requires external insulin administration. On the other hand, type 2 diabetes is primarily characterized by insulin resistance, where the body’s cells become less responsive to insulin.

Insulin is a hormone produced by the beta cells of the pancreas, and its main function is to regulate glucose metabolism. In diabetes, the lack of insulin or the body’s inability to use it effectively leads to hyperglycemia. Persistently high blood glucose levels can have detrimental effects on various organs and systems in the body.

The effects of diabetes on the body are many. It can lead to macrovascular complications, such as cardiovascular disease, stroke, and peripheral vascular disease. Also, microvascular complications may arise, affecting small blood vessels in the eyes, kidneys, and nerves. Diabetes can also increase the risk of infections, slow wound healing, and cause diabetic neuropathy and nephropathy.

2. The OUTLINE Question Approach

The OUTLINE question requires nurses to present a structured overview of a particular topic, process, or care plan. When approaching an OUTLINE question, follow these steps:

Step 1: Analyze the question

Carefully read the question and identify the main components or aspects that need to be outlined. Pay attention to any specific instructions or requirements.

Step 2: Organize your response

Create a clear and logical outline for your response. Identify the main headings or sections that you will include and arrange them in a coherent order. Each section should address a specific aspect of the topic or process.

Step 3: Provide detailed information

Under each heading or section, provide detailed information, explanations, or examples related to that particular aspect. Use concise and informative language, ensuring that your outline is well-structured and easy to follow.

Example OUTLINE question

“Outline the steps involved in the nursing process.”

The nursing process is a systematic framework that guides nurses in delivering patient-centered care. It consists of five essential steps: assessment, diagnosis, planning, implementation, and evaluation.

1. Assessment:
– Gather relevant patient data, including physical, psychological, social, and cultural aspects.
– Perform a comprehensive health history and physical examination.
– Utilize assessment tools and techniques to collect objective and subjective data.
– Document and organize the collected data systematically.

2. Diagnosis:
– Analyze the assessment data to identify health problems, risks, or potential complications.
– Formulate nursing diagnoses based on the identified issues.
– Ensure that the diagnoses are accurate, concise, and specific.
– Collaborate with other healthcare professionals when necessary.

3. Planning:
– Establish patient-centered goals and outcomes in collaboration with the patient.
– Develop a nursing care plan that includes evidence-based interventions and strategies.
– Prioritize nursing actions based on the urgency and importance of each goal.
– Ensure that the care plan is feasible, realistic, and adaptable.

4. Implementation:
– Execute the planned nursing interventions effectively and efficiently.
– Provide safe and compassionate care while considering the patient’s preferences.
– Document the implementation process and any modifications made.
– Collaborate with the interdisciplinary healthcare team to deliver comprehensive care.

5. Evaluation:
– Assess the patient’s response to the nursing interventions and the achievement of goals.
– Compare the actual outcomes with the expected outcomes.
– Modify the care plan if needed based on the evaluation findings.
– Document the evaluation results and communicate them to the healthcare team.

3. The DESCRIBE Question Approach

The DESCRIBE question requires nurses to provide a detailed account or characterization of a particular topic, condition, or intervention. When approaching a DESCRIBE question, follow these steps:

Step 1: Understand the question

Carefully read the question and identify the main topic or subject that needs to be described. Pay attention to any specific instructions or requirements.

Step 2: Provide a comprehensive description

Offer a thorough and comprehensive description of the topic or subject. Include relevant details, characteristics, features, or components. Use clear and concise language to ensure clarity and understanding.

Step 3: Use appropriate terminology

Utilize appropriate nursing terminology to accurately describe the topic or subject. This will demonstrate your knowledge and understanding of the nursing concepts related to the question.

Step 4: Provide examples ( if applicable)

Enhance your description by providing relevant examples. These real-life scenarios will help illustrate the topic or subject and provide a practical way for understanding.

 Example DESCRIBE question:

“Describe the stages of wound healing.”

Wound healing is a complex process that involves several distinct stages. Understanding these stages is essential for nurses to provide appropriate wound care and promote optimal healing.

1. Hemostasis:
– This initial stage begins immediately after the injury occurs.
– Blood vessels constrict to reduce blood flow and prevent excessive bleeding.
– Platelets aggregate to form a temporary clot.
– The clotting process releases various growth factors and cytokines, initiating the subsequent stages of healing.

2. Inflammatory phase:
– This phase typically lasts for 2-3 days.
– Inflammation occurs as a response to tissue injury.
– Vasodilation and increased vascular permeability allow immune cells to migrate to the wound site.
– Neutrophils arrive first to eliminate debris and prevent infection.
– Macrophages then remove dead tissue and release additional growth factors to stimulate healing.

3. Proliferative phase:
– This phase generally occurs between days 3 and 20.
– New blood vessels form to supply oxygen and nutrients to the wound.
– Fibroblasts produce collagen, which provides structural support for wound healing.
– Epithelial cells migrate from the wound edges to resurface the wound.
– Granulation tissue forms, consisting of new blood vessels, fibroblasts, and extracellular matrix.

4. Maturation phase:
– This final phase can last for several months to years.
– Collagen fibers reorganize and remodel, increasing the wound’s tensile strength.
– Scar tissue forms, but it may not possess the same strength and flexibility as the original tissue.
– The scar gradually becomes more refined and fades over time.

4. The MENTION/IDENTIFY/STATE Question Approach

The MENTION/IDENTIFY/STATE question requires nurses to highlight or state specific information or facts related to a particular topic or condition. When approaching a MENTION/IDENTIFY/STATE question, follow these steps:

Step 1: Understand the question

Carefully read the question and identify the specific information or facts that need to be mentioned, identified, or stated. Pay attention to any specific instructions.

Step 2: Provide a direct response

Offer a direct and concise response to the question. Avoid unnecessary elaboration or providing excessive details beyond what is asked.

Step 3: Use precise language

Use precise and accurate language to give the required information. Ensure that your response aligns with the question and provides the requested details.

Step 4: Provide examples if applicable

If the question allows for it or if it helps clarify the information, you can provide relevant examples or scenarios to support your response.

Example MENTION/IDENTIFY/STATE question:

“Mention/ Identify/ State the types of delusions.”

Grandiose delusions; the patient believes s/he is somebody great /important ,knowledgeable or powerful contrary to the social cultural ,religious background and experiences
Delusion of guilty and worthlessness; the patient believes s/he is not worth to live even though there’s nothing to justify this belief.
Delusions of jealousy –the patient believes that spouse/partner is being unfaithful even when there is no evidence to suggest so.
Delusion of persecution: the patient believes they’re being deliberately wronged, conspired or harmed by another person or agency even when there’s no evidence to suggest so.
Religious delusions; the individual believes he or she has a special link with God that is out keeping with people of the same religious belief.
Delusions of control, influence or phenomenon , these are three types ;belief that the person performs activities as a result of an extreme force .

5. The LIST Question Approach

The LIST question requires nurses to present a series of items, factors, or elements related to a specific topic or condition. When approaching a LIST question, follow these steps:

Step 1: Understand the question

Carefully read the question and identify the specific items or factors that need to be listed. Pay attention to any specific instructions or requirements.

Step 2: Organize your response

Create a well-structured list that presents the items or factors in a logical and coherent order. Consider using bullet points or numbered lists for clarity.

Step 3: Provide concise descriptions

Under each item or factor, provide a concise description or explanation. Keep your descriptions clear, informative, and relevant to the question.

 Example LIST question:

“List the risk factors for cardiovascular disease.”

Hypertension: High blood pressure increases the strain on the heart and blood vessels, leading to an increased risk of cardiovascular problems.
High cholesterol levels: Elevated levels of LDL (low-density lipoprotein) cholesterol, also known as “bad” cholesterol, can lead to the formation of plaque in the arteries, restricting blood flow and increasing the risk of cardiovascular events.
Smoking: Tobacco smoke contains harmful chemicals that can damage blood vessels and promote the development of atherosclerosis.
Obesity: Excess body weight, especially when concentrated around the abdomen, increases the risk of hypertension, high cholesterol, and diabetes, all of which contribute to cardiovascular disease.
Sedentary lifestyle: Lack of regular physical activity can contribute to obesity, hypertension, and other risk factors for cardiovascular disease.
Diabetes mellitus: Individuals with diabetes have a higher risk of developing cardiovascular disease due to the impact of chronically elevated blood glucose levels on blood vessels and the heart.
Family history: Having a close relative, such as a parent or sibling, with a history of cardiovascular disease increases an individual’s risk.
Age and gender: Advancing age and being male are additional risk factors for cardiovascular disease.

6. The WHAT Question Approach

The WHAT question requires nurses to provide an explanation or definition of a specific term, concept, or procedure. When approaching a WHAT question, follow these steps:

Step 1: Understand the question

Carefully read the question and identify the specific term, concept, or procedure that needs to be explained or defined. Pay attention to any specific instructions.

Step 2: Provide a clear explanation or definition

Offer a clear and concise explanation or definition of the term, concept, or procedure. Use simple language and avoid unnecessary words.

Step 3: Provide examples if applicable

If the term, concept, or procedure can be further elucidated with examples or scenarios, provide relevant and practical illustrations to enhance understanding.

 Example WHAT question:

“What is sepsis?”

Sepsis is a potentially life-threatening condition that occurs when the body’s response to an infection becomes unregulated, leading to widespread inflammation and organ dysfunction. It is often triggered by bacterial, fungal, or viral infections, but can also result from other sources of inflammation.

Click Here for Nursing Care Management Question Approach, with Nursing Issues, Concerns, Interventions, e.t.c.

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Medical Instruments For Nurses

MEDICAL INSTRUMENTS AND OTHER EQUIPMENTS

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Wound Dressing

WOUND DRESSING

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

Indications for wound dressing

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

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

Classification of Wounds

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

1. Classification by Manner of Production

Abraded Wound (Abrasion)

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

Incised Wound

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

Contused Wound

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

Lacerated Wound

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

Penetrating Wound

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

Punctured Wound

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

2. Classification by Bacterial Content

Clean Wound

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

Contaminated Wound

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

Septic (Infected) Wound

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

3. Classification by Extent

Open Wound

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

Closed Wound

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

4. Classification by Time

Acute Wound

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

Chronic Wound

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

WOUND HEALING

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

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

Factors Affecting Wound Healing

Several factors determine the rate and effectiveness of wound healing:

1. Age

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

2. Nutritional Status

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

3. Type of Wound

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

4. Blood Supply to the Affected Area

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

5. Presence of Foreign Bodies

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

6. Infection and Foreign Bodies in the Wound

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

7. Lack of Rest of the Affected Part

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

8. Hemorrhage (Excessive Bleeding)

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

9. Presence of Dead Space in the Wound

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

10. Malnutrition

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

11. Medications

Certain medications can impair the healing process, such as:

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

12. Stress, Anxiety, and Depression

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

13. Underlying Diseases

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

14. Infection

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

Types of Wound Healing (Wound Closure)

1. Healing by Primary Intention (First Intention)

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

2. Healing by Secondary Intention (Granulation Healing)

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

Phases of Wound Healing

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

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

Includes:

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

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

Key events:

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

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

Key processes:

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

This phase lasts up to 3 weeks.

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

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

Care of Wounds

Dressing Methods

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

Advantages of Dressing

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

Advantages of Non-Dressing Method

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

Disadvantages of Non-Dressing Method

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

Qualities of a Good Dressing

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

Types of Dressings

Dry Dressing

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

Wet Dressing

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

Pressure Dressing

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

General Rules for Wound Dressing

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

Sources of Wound Infection in the Ward

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

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

General Rules for Wound Dressing

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

Wound Dressing Procedures

Dressing a Clean Wound

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

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

Purpose of Dressing a Clean Wound

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

Requirements for Clean Wounds

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

Bed-Side Requirements

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

Procedure

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

Dressing of Septic Wound

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

Purpose of Dressing a Septic Wound

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

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

Additional Items (Top Shelf)

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

Saline 0.9% solution

Receiver containing large syringe and fine catheter

Receiver for used lotion

Procedure

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

Wound Irrigation

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

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

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

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

Essential Steps of Wound Irrigation

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

Indications for Wound Irrigation

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

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

Contraindications for Wound Irrigation

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

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

Wound Cleansing Agents

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

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

Irrigation Solutions for Wound Cleansing

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

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

Requirements

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

Procedure

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

Complications

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

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

Wound Assessment

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

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

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

Key Factors in Wound Assessment

The following considerations are essential for a comprehensive wound assessment:

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

1. Type of Wound

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

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

2. Tissue Loss

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

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

3. Clinical Appearance of the Wound Bed

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

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

4. Wound Measurement

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

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

5. Wound Edges

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

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

6. Exudate (Wound Drainage)

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

Functions of Exudate in Healing

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

Complications Related to Exudate

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

7. Surrounding Skin Condition

The surrounding skin should be examined for:

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

8. Presence of Infection

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

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

Local Signs of Infection

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

Systemic Signs of Infection (Indicating worsening condition)

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

SUTURES and CLIPS

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Instrument/ Appliance	Functions
Sand bags	It prevents movement of a limb in the treatment of special conditions.
Bed block	To elevate the bed
Mouth gag	To open the mouth of unconscious patient

Air ring and its pump	To prevent friction on the bed.
Cardiac table	Used by cardiac patients to lean forward.
Bed pan	Used for toileting of bedridden patients.
Dirty linen container	For collecting dirty bed linen.

Male urinal	For male bladder elimination
Kidney dish	Used for receiving soiled dressings and other medical wastes.
Sponge holding forceps	Used to grasp and hold sponges while conducting medical and surgical procedures.
Cheatle forceps	For picking sterile instruments.

Ampoule	Stores air sensitive medications and solutions.
Vial	Stores liquid or powdered medicine intended for parenteral administration.
Episiotomy scissors	Used for episiotomy
Auriscope/ Otoscope	For examining the ear.
Ear syringe	For performing ear syringing.

Tuning fork	For examination of sense of hearing.
Specimen bottles	For collecting laboratory specimens.
Calibrated medicine cup	For giving oral medication to the patient.
Dental probe	To measure the depth of a tooth’s pocket.

Suturing

Purpose of Suturing

Types of Sutures

Suturing Patterns

Suture Materials

Common Non-Absorbable Suture Materials

Suture Removal Guidelines

Nursing Considerations in Suturing

Suture Needles

Wound Suturing

Nurse’s Responsibilities in Wound Suturing

Preliminary Wound Assessment Before Suturing

Suture Removal Guidelines

Clips (Metal Sutures) in Wound Closure

Purpose of Clips in Wound Closure

Procedure for Removing Clips

Clinical Appearance of the Wound Bed

Post-Operative Nursing Care

Aims or principles of post-operative care

Immediate care of a patient recovering from anesthesia

Immediate Post-Operative Care in the Ward

CARE OF THE PATIENT’S EYES.

Indications of Cleaning the eye

Aims/Purposes of Eye Care:

Cleaning of the Eye

INSTILLATION OF EYE DROPS/ OINTMENT.

Indications:

Procedure for eye drop

Procedure of Instillation of Eye Ointment

WARM EYE COMPRESS.

Indications for Warm Eye Compresses

COLD EYE COMPRESS

Indications of Cold compress

Procedure of cold compress

Eye Irrigation

Purpose/Aims of Eye Irrigation:

Indications for Eye Irrigation:

BLOOD TRANSFUSION

TYPES OF BLOOD PRODUCTS

Indications for Blood Transfusion:

REQUIREMENTS

Complications of Blood Transfusion

THE ROLES OF A NURSE BEFORE, DURING AND AFTER BLOOD TRANSFUSION

INSTILLING MEDICATION INTO EAR

INSTILLING MEDICATION INTO THE EYES

ADMINISTERING NASAL DROPS

ADMINISTERING MEDICATION THROUGH NASO-GASTRIC TUBE

APPLYING TOPICAL MEDICATIONS

ADMINISTERING RECTAL AND VAGINAL MEDICATION.

UNDER WATER SEAL DRAINAGE

Conditions necessitating Underwater Seal Drainage

Indications of Water Seal Drainage

Site for Chest Tube Insertion

Types of Drainage Systems

One-Bottle Drainage System (Simple System)

Two-Bottle Drainage System (Improved Drainage and Collection)

Three-Bottle Drainage System (Suction Control Added)

Factors Affecting Water Seal Drainage

Requirements for Under Water Seal Drainage (UWSD)

Procedure for Underwater Seal Drainage (UWSD)

Preparation of equipment

Procedure

Changing the bottle

Nursing Care Management: Answering Questions with Confidence

Understanding Nursing Considerations

Understanding Nursing Concerns

Understanding Nursing Issues

Understanding Nursing Interventions

Nursing Exam Question Approach.

1. The EXPLAIN Question Approach

2. The OUTLINE Question Approach

3. The DESCRIBE Question Approach

4. The MENTION/IDENTIFY/STATE Question Approach

5. The LIST Question Approach

6. The WHAT Question Approach

WOUND DRESSING

Classification of Wounds

WOUND HEALING

Factors Affecting Wound Healing