Foundations of Nursing III

🍽️A gastrostomy feeding tray should be meticulously prepared by the nurse at Nurses Revision Uganda to ensure safe and effective administration of enteral nutrition. Specific requirements to include are:

1. Prescribed Enteral Formula:🍼Requirement: The correct type and amount of prescribed enteral feeding formula, at room temperature (or warmed slightly if indicated by policy, but never hot). Check the expiry date and integrity of the container. Rationale: Ensures the patient receives the specific nutrition ordered by the physician or dietitian, tailored to their individual needs. Administering formula at room temperature minimizes gastrointestinal upset. Verifying expiry and integrity prevents administration of spoiled or contaminated feed.
2. Appropriate Feeding Syringe (Enteral Syringe):💉Requirement: A large-tipped catheter syringe (typically 50-60 mL capacity), specifically designed for enteral feeding (often color-coded purple or labeled "Enteral Use Only" to prevent accidental connection to IV lines). Rationale: Enteral syringes have a tip that is incompatible with IV luer lock systems, preventing accidental intravenous administration of enteral formula, which can be fatal. The large volume allows for efficient administration of bolus feeds or for flushing.
3. Water for Flushing:💧Requirement: A container of clean water (sterile water for immunocompromised patients or as per hospital policy, otherwise tap water may be acceptable for stable patients at home) at room temperature, typically 30-50 mL for flushing before and after feeding, and before and after medication administration. Rationale: Flushing the gastrostomy tube before feeding ensures patency and clears any residual feed or medication. Flushing after feeding and medication administration prevents tube blockage and ensures the full dose of feed/medication is delivered. Water also contributes to the patient's hydration.
4. Measuring Container/Graduate:📏Requirement: A clean graduated measuring container if the formula needs to be decanted from a larger container or if water for flushing needs to be precisely measured. Rationale: Accurate measurement of formula and flush volumes is essential to ensure the patient receives the prescribed amount of nutrition and hydration, and to maintain accurate intake records.
5. Clean Gloves and Protective Cover/Towel:🧤Requirement: Clean, non-sterile examination gloves for the nurse to wear during the procedure, and a clean towel or disposable protective cover to place under the gastrostomy tube connection or over the patient's clothing/bedding. Rationale: Gloves maintain medical asepsis and protect the nurse. The protective cover prevents soiling of the patient's clothes or bed linens from accidental spills of formula or flush water.
6. pH Indicator Strips (if checking gastric placement):🧪Requirement: pH indicator strips if hospital policy requires checking gastric aspirate pH to confirm tube placement before initiating feeding (though for established gastrostomy tubes, this may be less frequent than for newly inserted NG tubes). Rationale: Verifying gastric placement (pH typically <5.5) helps to ensure the feed is delivered into the stomach and not into an inadvertently displaced tube, reducing aspiration risk, although visual inspection of the G-tube site and length is also key for G-tubes.
7. Stethoscope (for auscultation if indicated by policy):🩺Requirement: A stethoscope may be included if auscultation of an instilled air bolus is part of the institutional protocol for checking G-tube placement (though this method's reliability is debated and often superseded by pH testing or other methods for NG tubes; less common for established G-tubes). Rationale: Historically used to listen for a "whoosh" of air in the stomach, but this is not a definitive or primary method for confirming placement of gastrostomy tubes.
8. Clamp (if not already on the G-tube extension set):🔒Requirement: A tube clamp may be needed to clamp the gastrostomy tube or extension set during connection/disconnection of the syringe or feeding bag to prevent leakage of gastric contents or air entry. Rationale: Prevents spillage and maintains a closed system when not actively feeding or flushing.

🩹Providing colostomy care is a vital nursing intervention at Nurses Revision Uganda that promotes patient comfort, hygiene, skin integrity, and psychosocial well-being. Effective care involves several key steps:

1. Assess the Stoma and Peristomal Skin:👀Intervention: Before and during the pouch change, carefully assess the stoma for color (should be moist and beefy red/pink), size, shape, and any signs of complications (e.g., necrosis, retraction, prolapse, stenosis). Inspect the peristomal skin (skin around the stoma) for redness, irritation, breakdown, rash, or signs of infection. Rationale: Regular assessment detects early signs of stoma complications or peristomal skin problems, allowing for prompt intervention and prevention of further issues. A healthy stoma and intact peristomal skin are crucial for successful ostomy management.
2. Gentle Cleansing of the Stoma and Peristomal Skin:🧼💧Intervention: Gently cleanse the stoma and the surrounding peristomal skin with warm water and a soft cloth or disposable wipe. Avoid using harsh soaps, alcohol-based solutions, or oily substances unless specifically indicated, as these can irritate the skin or interfere with pouch adherence. Pat the skin thoroughly dry. Rationale: Gentle cleansing removes any fecal matter and maintains hygiene, reducing odor and the risk of skin irritation or infection. Ensuring the skin is completely dry before applying a new pouch is essential for good adhesion and to prevent skin maceration.
3. Measure the Stoma and Ensure Proper Pouch Fit:📏Intervention: Use a stoma measuring guide to accurately measure the size and shape of the stoma, especially in the early postoperative period when it may change size. Cut the opening in the new skin barrier (wafer) of the ostomy pouch to be just slightly larger than the stoma (typically 1/16 to 1/8 inch or 2-3 mm larger) to ensure a snug fit without constricting the stoma or exposing too much peristomal skin. Rationale: A properly fitting pouching system is critical. An opening that is too small can cut or irritate the stoma. An opening that is too large will expose the peristomal skin to fecal effluent, leading to skin irritation, breakdown, and leakage. Stoma size can change, so regular measurement is important initially.
4. Apply the New Pouching System Securely:🩹✅Intervention: Apply the new skin barrier/pouch carefully, ensuring it adheres smoothly and securely to the dry peristomal skin without wrinkles, especially around the stoma. If using a two-piece system, ensure the pouch is securely attached to the skin barrier flange. Use skin barrier paste or rings if needed to fill in uneven skin surfaces and create a better seal. Rationale: A secure, leak-proof seal is essential to protect the peristomal skin from irritation by fecal output, prevent leakage and odor, and provide the patient with confidence and comfort. Wrinkles in the skin barrier can create channels for leakage.
5. Provide Patient Education, Emotional Support, and Encourage Self-Care:🗣️❤️Intervention: Use the opportunity during colostomy care to educate the patient (and/or caregiver) about stoma care techniques, signs of complications to report, diet and fluid management, odor control, and available resources. Provide emotional support, encourage verbalization of feelings about the ostomy, and actively involve the patient in their care as much as possible to promote independence and positive body image. Rationale: Living with a colostomy requires significant adjustment. Education empowers the patient to manage their ostomy effectively. Emotional support helps them cope with changes in body image and lifestyle. Promoting self-care fosters independence, control, and adaptation.
6. Appropriate Emptying and Disposal of the Old Pouch:🗑️Intervention: Before removing the old pouch, empty its contents into a toilet or designated receptacle if it's a drainable pouch. Dispose of the used pouch and supplies hygienically according to facility policy or home care guidelines (e.g., in a sealed plastic bag). Rationale: Proper emptying and disposal minimize odor, reduce the risk of spillage, and maintain hygiene and infection control.
7. Manage Odor Effectively:🌬️Intervention: Advise on and use odor-reducing strategies, such as ensuring a good pouch seal, using pouch deodorizers (liquid or tablet), and dietary advice regarding foods that may increase gas or odor (though individual tolerance varies). Rationale: Odor can be a major concern for patients with colostomies and can impact their social confidence. Effective odor management improves quality of life.

⚕️Caring for a patient with a tracheostomy at Nurses Revision Uganda requires specialized knowledge and meticulous attention to detail to maintain airway patency, prevent complications, and ensure patient comfort and safety. Here are ten important points nurses should remember:

1. Maintain a Patent Airway at All Times:💨 This is the absolute priority. Ensure the tracheostomy tube is not kinked, dislodged, or obstructed by secretions. Regular assessment of breath sounds, respiratory effort, and oxygen saturation is crucial. Rationale: The tracheostomy is the patient's artificial airway. Any blockage can rapidly lead to hypoxia, respiratory arrest, and death.
2. Perform Tracheostomy Suctioning As Clinically Indicated:🌬️ Suction the tracheostomy tube only when necessary (e.g., audible secretions, signs of respiratory distress, desaturation) using sterile technique. Hyperoxygenate before and after suctioning (if indicated). Limit suction passes and duration to minimize trauma and hypoxia. Rationale: Suctioning clears secretions that the patient cannot expel, maintaining airway patency. However, it's an invasive procedure with potential risks, so it should be based on assessment, not routine.
3. Provide Meticulous Tracheostomy Site and Tube Care:🧼 Regularly clean the stoma site with sterile saline or other prescribed solution as per protocol. Assess for signs of infection (redness, swelling, discharge, odor). Clean or replace the inner cannula (if present) regularly according to policy to prevent obstruction from dried secretions. Change tracheostomy dressings and ties when soiled or damp, ensuring ties are secure but not too tight (allow one to two fingers underneath). Rationale: Proper site and tube care prevents infection, skin breakdown around the stoma, and tube obstruction, ensuring the integrity and functionality of the artificial airway.
4. Ensure Adequate Humidification of Inspired Air:💧 Since a tracheostomy bypasses the natural warming, filtering, and humidifying functions of the upper airway, inspired air must be humidified (e.g., via a heat and moisture exchanger - HME, nebulizer, or humidified oxygen). Rationale: Humidification prevents drying and thickening of respiratory secretions, reduces the risk of mucus plugging, maintains ciliary function, and prevents tracheal irritation or damage.
5. Maintain Emergency Equipment at the Bedside:🚨 Always have essential emergency equipment readily accessible at the patient's bedside. This includes:
   • A spare tracheostomy tube of the same size.
   • A spare tracheostomy tube one size smaller.
   • An obturator for the current tube size.
   • A tracheal dilator or spreader.
   • Suction catheters and suction source.
   • Ambu bag with mask and tracheostomy adapter.
   • Oxygen source and delivery devices.
   • Sterile gloves, saline, and dressings.
   Rationale: In case of accidental decannulation (tube dislodgement) or acute obstruction, immediate access to this equipment is life-saving for re-establishing the airway.
6. Monitor for and Prevent Complications:⚠️ Be vigilant for potential complications such as tube obstruction, decannulation, bleeding, infection (stomal or respiratory), subcutaneous emphysema, tracheoesophageal fistula, or tracheal stenosis (long-term). Rationale: Early detection and prompt management of complications are crucial to prevent serious adverse outcomes. Regular assessment and adherence to best practices minimize these risks.
7. Facilitate Effective Communication:🗣️📝 Patients with tracheostomies (especially those with cuffed tubes or on ventilators) may be unable to speak. Provide alternative means of communication, such as a pen and paper, whiteboard, picture board, communication apps, or facilitate consultation for a speaking valve if appropriate and the patient is a candidate. Rationale: Inability to communicate can be extremely frustrating and isolating for the patient. Facilitating communication enhances their well-being, safety, and participation in care.
8. Address Nutritional and Hydration Needs:🍎💧 Assess the patient's ability to swallow. Some patients with tracheostomies may have dysphagia or be at risk of aspiration. Collaborate with the speech therapist and dietitian. Ensure adequate hydration to help keep secretions thin. Rationale: Safe and adequate nutrition and hydration are vital for recovery and overall health. Aspiration is a significant risk that needs careful management.
9. Provide Psychological and Emotional Support:❤️ Having a tracheostomy can be frightening and can significantly alter body image and self-esteem. Acknowledge the patient's fears and concerns. Provide reassurance, involve them in their care, and offer support. Rationale: Addressing the psychosocial impact of a tracheostomy is essential for the patient's overall well-being and adaptation to their altered airway.
10. Educate the Patient and Family/Caregivers:🧑‍🏫 Provide comprehensive education on all aspects of tracheostomy care, including suctioning, stoma care, emergency procedures (e.g., what to do if the tube comes out), signs of complications, and when to seek help. This is especially important if the patient is being discharged with a tracheostomy. Rationale: Education empowers the patient and their family to manage the tracheostomy safely and effectively at home, promoting independence and reducing anxiety and the risk of complications.
11. Ensure Tracheostomy Tube Security:🔒 Check tracheostomy ties regularly to ensure they are secure, clean, and correctly fastened. Accidental decannulation is a medical emergency. Rationale: Prevents the tube from being accidentally dislodged, which can lead to acute respiratory distress and loss of airway.
12. Assess Cuff Pressure Regularly (if a cuffed tube is in situ):🎈 If the patient has a cuffed tracheostomy tube, monitor cuff pressure regularly (e.g., every 8 hours or per protocol) using a manometer, maintaining it within the recommended range (typically 20-30 cm H2O or 15-25 mmHg). Rationale: Over-inflation of the cuff can cause tracheal mucosal ischemia, necrosis, and long-term complications like tracheomalacia or stenosis. Under-inflation can lead to air leakage (if on a ventilator) or increase the risk of aspiration.

💧🧑‍⚕️Abdominal paracentesis is an invasive procedure to remove ascitic fluid from the peritoneal cavity for diagnostic or therapeutic purposes. Nurses at Nurses Revision Uganda have crucial responsibilities before, during, and after the procedure to ensure patient safety, comfort, and optimal outcomes.

Before the Procedure:

1. Verify Informed Consent and Patient Understanding:✅🗣️Responsibility: Ensure that a valid informed consent form has been signed by the patient (or legal guardian). Reinforce the explanation of the procedure, its purpose, potential benefits, risks, and alternatives. Answer any questions the patient may have. Rationale: Upholds patient autonomy and legal requirements. Ensures the patient is fully aware of what to expect and has agreed to the procedure, which can reduce anxiety.
2. Assess Baseline Vital Signs and Abdominal Girth:🩺📏Responsibility: Obtain and record baseline vital signs (temperature, pulse, respirations, blood pressure, SpO2) and measure the patient's abdominal girth at the level of the umbilicus (mark the site for consistency). Also, assess baseline weight if indicated. Rationale: Provides a baseline for comparison during and after the procedure to detect any adverse changes (e.g., hypotension if a large volume of fluid is removed). Abdominal girth and weight help quantify the amount of ascites and monitor the effectiveness of therapeutic paracentesis.
3. Instruct and Assist the Patient to Empty Their Bladder:🚽Responsibility: Instruct the patient to void (empty their bladder) completely just before the procedure. If the patient is unable to void, notify the physician as catheterization may be considered. Rationale: An empty bladder reduces its size and moves it away from the typical needle insertion site in the lower abdomen, significantly minimizing the risk of accidental bladder perforation during the paracentesis.
4. Gather and Prepare Necessary Equipment and Supplies:🛠️Responsibility: Assemble all required sterile equipment, including the paracentesis tray (containing items like local anesthetic, needles, syringes, drapes, antiseptic solution, trocar/catheter), sterile gloves, collection containers/bottles (may need to be vacuum-sealed), laboratory specimen tubes (if diagnostic samples are needed), and a dressing for the puncture site. Rationale: Ensures all necessary items are readily available, promoting efficiency and maintaining sterility during the procedure, thereby reducing the risk of delays or infection.

During the Procedure:

5. Position the Patient Appropriately and Provide Comfort:🛌🧘Responsibility: Assist the patient into the correct position, typically sitting upright in bed (High Fowler's) or on the side of the bed leaning over an overbed table, with feet supported. Ensure patient comfort and provide reassurance. Rationale: An upright position allows ascitic fluid to pool in the lower abdomen by gravity, facilitating easier needle insertion and fluid drainage. It also allows the bowel to float posteriorly, away from the anterior puncture site. Comfort measures help reduce patient anxiety.
6. Assist the Physician and Maintain Aseptic Technique:🧑‍⚕️🧤Responsibility: Assist the physician as needed during the procedure (e.g., by providing sterile supplies, labeling specimen containers). Strictly maintain aseptic technique throughout to prevent introducing infection into the peritoneal cavity. Rationale: Asepsis is crucial to prevent peritonitis, a serious complication. Teamwork between nurse and physician ensures the procedure is performed smoothly and safely.
7. Monitor Patient's Vital Signs and Tolerance of the Procedure:💓⚠️Responsibility: Continuously monitor the patient's vital signs (especially blood pressure and heart rate), level of consciousness, skin color, and any complaints of pain, dizziness, shortness of breath, or nausea during fluid removal. Rationale: Rapid removal of large volumes of ascitic fluid can lead to significant fluid shifts and complications such as hypotension, vasovagal reaction, or electrolyte imbalances. Close monitoring allows for early detection and intervention if adverse reactions occur.

After the Procedure:

8. Apply a Sterile Dressing and Monitor the Puncture Site:🩹Responsibility: After the needle/catheter is removed, apply firm pressure to the puncture site briefly (if needed) and then apply a sterile dressing. Regularly inspect the site for any leakage of ascitic fluid, bleeding, or signs of infection. Rationale: The dressing protects the site from infection. Monitoring for leakage is important as persistent leakage can occur and may require further management (e.g., a pressure dressing, or rarely, a suture).
9. Monitor Post-Procedure Vital Signs, Abdominal Girth, and Weight:📉⚖️Responsibility: Continue to monitor vital signs at specified intervals (e.g., every 15 mins for an hour, then less frequently if stable). Re-measure abdominal girth and weight (if done pre-procedure) to assess the amount of fluid removed and the patient's response. Rationale: Post-procedure monitoring helps detect delayed complications like hypotension, hypovolemia (if large volumes removed without albumin replacement in some cases), or re-accumulation of ascites.
10. Document the Procedure and Patient's Response:✍️Responsibility: Accurately document all aspects of the procedure, including pre-procedure preparations, patient tolerance, amount and characteristics (color, clarity) of fluid drained, any specimens sent to the lab, vital signs, post-procedure assessments, and any interventions performed or complications noted. Rationale: Comprehensive documentation is essential for legal purposes, communication among the healthcare team, continuity of care, and for evaluating the patient's progress and response to the therapeutic intervention.
11. Educate the Patient on Post-Procedure Care and Signs to Report:🗣️🆘Responsibility: Instruct the patient on care of the puncture site, activity restrictions (if any), and signs and symptoms of potential complications to report to the healthcare provider after discharge (e.g., fever, increasing abdominal pain or tenderness, redness or drainage from the site, dizziness, rapid re-accumulation of fluid). Rationale: Patient education empowers them to participate in their own care, recognize early warning signs of complications, and seek timely medical attention if needed.

🩹Bandaging is a common nursing procedure at Nurses Revision Uganda used for various purposes such as supporting an injured part, immobilizing a joint, securing a dressing, applying pressure to control bleeding, or promoting venous return. Adherence to general principles is crucial for effectiveness and patient safety.

1. Ensure Proper Patient Positioning and Comfort:🧘 Position the patient comfortably and ensure the body part to be bandaged is well-supported and in the desired anatomical alignment (e.g., a joint in a functional position or position of rest) before starting. Rationale: Proper positioning makes the bandaging process easier for the nurse, more comfortable for the patient, and ensures the bandage is applied to maintain the desired alignment or function once completed.
2. Select the Appropriate Type and Size of Bandage:📏 Choose a bandage material (e.g., gauze, elastic, crepe, adhesive) and width that is appropriate for the size of the body part being bandaged and the purpose of the bandage. Rationale: Using the correct type and size ensures the bandage can effectively achieve its purpose (e.g., a wider bandage for a larger limb, an elastic bandage for compression). An inappropriately sized bandage can be ineffective or cause constriction.
3. Maintain Cleanliness/Asepsis as Appropriate:🧼 Wash hands before starting. If bandaging an open wound, use aseptic technique and sterile materials where indicated. Ensure the patient's skin is clean and dry before application. Rationale: Prevents the introduction or spread of infection, especially if the bandage is being applied over a wound or broken skin.
4. Bandage from Distal to Proximal (Usually):⬆️ When bandaging a limb, generally start at the distal end (furthest from the body, e.g., fingers or toes) and work towards the proximal end (closer to the body, e.g., shoulder or hip). Rationale: Bandaging in this direction helps to promote venous return, prevent fluid congestion or edema distal to the bandage, and provides more even support.
5. Apply Even, Consistent Pressure and Tension:⚖️ Apply the bandage with smooth, even, and firm (but not too tight) pressure. Each turn should overlap the previous one by about one-half to two-thirds of its width. Rationale: Even pressure ensures the bandage is effective for its purpose (e.g., support, compression) without causing constriction of blood flow or nerve compression. Uneven pressure can lead to discomfort or impaired circulation. Overlapping ensures secure coverage.
6. Avoid Excessive Tightness and Check Circulation:🖐️🩸 Ensure the bandage is not too tight, as this can impair circulation, cause pain, numbness, tingling, or swelling distal to the bandage. After application, and regularly thereafter, assess neurovascular status distal to the bandage (check color, temperature, capillary refill, sensation, and movement of fingers/toes). Rationale: Impaired circulation due to a tight bandage is a serious complication that can lead to tissue damage or ischemia. Regular neurovascular checks are essential for early detection.
7. Cover the Entire Area Adequately but Leave Tips Exposed (If Applicable):✅ Ensure the bandage covers the intended area completely and securely. However, when bandaging extremities (fingers or toes), it's often advisable to leave the very tips exposed if possible. Rationale: Adequate coverage ensures the bandage serves its purpose (e.g., securing a dressing, providing support). Leaving the tips of digits exposed allows for easy monitoring of circulation, color, and sensation.
8. Secure the End of the Bandage Safely:🔒 Secure the end of the bandage firmly but safely using adhesive tape, clips, or by tucking the end in, depending on the type of bandage. Avoid using pins if possible, especially in confused or pediatric patients, as they can cause injury. Rationale: Proper securing prevents the bandage from unraveling and becoming ineffective or causing a hazard. Safe securing methods prevent accidental injury.
9. Keep the Bandage Clean and Dry:🚫💧 Instruct the patient to keep the bandage clean and dry. If it becomes wet or soiled, it should be changed promptly. Rationale: A wet or soiled bandage can harbor microorganisms, leading to skin maceration, irritation, or infection. It can also lose its effectiveness (e.g., a wet P.O.P. backslab).
10. Provide Patient Education:🗣️ Instruct the patient (and/or caregiver) on the purpose of the bandage, how to care for it, signs of complications to report (e.g., increased pain, numbness, tingling, swelling, color changes in digits, foul odor, slippage), and when to seek re-bandaging or follow-up. Rationale: Patient education promotes adherence to care instructions, empowers them to identify potential problems early, and ensures they understand when to seek further medical attention.
11. Use Appropriate Bandaging Technique for the Body Part:🔄 Utilize specific bandaging techniques (e.g., spiral, reverse spiral, figure-of-eight, recurrent) that are appropriate for the contour and function of the body part being bandaged. Rationale: Different techniques are designed to provide optimal fit, support, and immobilization for specific areas (e.g., a figure-of-eight for a joint like an ankle or elbow, a spiral for a cylindrical part like an arm or leg).
12. Avoid Bandaging Over Bony Prominences Without Adequate Padding (If Applying Pressure):🦴 If the bandage is intended to apply pressure, ensure bony prominences are adequately padded to prevent pressure sores or skin breakdown. Rationale: Bony prominences are susceptible to pressure injury. Padding distributes pressure more evenly and protects the underlying skin.

💧⚕️Gastric lavage, also known as stomach washout or stomach pumping, is a procedure to empty the contents of the stomach, typically performed in cases of poisoning or drug overdose to remove unabsorbed toxic substances. It is an invasive procedure that must be carried out by trained healthcare professionals at facilities like Nurses Revision Uganda with careful attention to patient safety and specific indications/contraindications. The procedure involves several key steps:

I. Preparation Phase:

1. Verify Indication and Contraindications:✅🚫 Confirm that gastric lavage is appropriate for the specific substance ingested, the time since ingestion (usually most effective within 1-2 hours), and the patient's clinical condition. Identify contraindications such as ingestion of corrosive substances (acids, alkalis), petroleum distillates (risk of aspiration pneumonitis), unprotected airway in an obtunded patient, or risk of gastrointestinal hemorrhage or perforation. Rationale: Ensures the procedure is beneficial and safe. Lavage can be harmful if contraindicated, e.g., causing further damage with corrosives or severe aspiration with hydrocarbons.
2. Obtain Informed Consent (if possible):🗣️ If the patient is conscious and competent, explain the procedure, its purpose, potential benefits, risks, and alternatives, and obtain informed consent. If the patient is unconscious or incompetent, proceed based on emergency medical necessity (implied consent) and institutional policy, often with consent from next of kin if available. Rationale: Respects patient autonomy. Even in emergencies, providing information to the extent possible is important.
3. Gather and Prepare Equipment:🛠️ Assemble all necessary sterile or clean equipment:
   • Large-bore orogastric or nasogastric tube (e.g., 36-40 French for adults, appropriate size for children). Orogastric is preferred for lavage due to larger bore for particulate matter.
   • Water-soluble lubricant.
   • Large syringe (e.g., 50-60 mL catheter tip).
   • Lavage fluid (e.g., normal saline or tap water at body temperature, typically 100-300 mL aliquots for adults, 10-15 mL/kg for children). Activated charcoal may be instilled after lavage if indicated.
   • Collection bucket or container for returned lavage fluid.
   • Suction equipment (for airway protection and potentially for aspirating lavage tube).
   • Personal Protective Equipment (PPE) for staff: gloves, gown, mask, eye protection.
   • Airway protection equipment if needed (e.g., endotracheal tube if patient has altered mental status or absent gag reflex).
   • Stethoscope, pH paper.
   Rationale: Ensures all necessary items are readily available, promoting efficiency and safety, and preventing delays during an urgent procedure. PPE protects staff from exposure to gastric contents or toxic substances.
4. Prepare the Patient:🛌 Position the patient in the left lateral decubitus (side-lying) position with the head slightly lower than the feet (Trendelenburg position, about 15 degrees) if possible. This helps to pool gastric contents away from the pylorus and reduces the risk of aspiration if vomiting occurs. If the patient is unconscious or has an impaired gag reflex, protect the airway with a cuffed endotracheal tube *before* initiating lavage. Establish IV access if not already present. Rationale: Proper positioning minimizes aspiration risk, which is a major complication. Airway protection is paramount in at-risk patients. IV access is for supportive care or emergency medications.

II. Procedure Phase:

5. Measure and Insert the Gastric Tube:📏➡️ Measure the orogastric tube from the bridge of the nose to the earlobe and then to the xiphoid process to estimate the insertion length. Lubricate the tip of the tube. Gently insert the tube through the mouth (or nose if nasogastric) into the stomach. Rationale: Correct measurement helps ensure the tube reaches the stomach without coiling or entering the trachea. Lubrication facilitates easier and less traumatic insertion.
6. Confirm Tube Placement:✔️ Aspirate gastric contents with the syringe to confirm placement in the stomach. The aspirate can be tested with pH paper (gastric pH is typically <5.5). Auscultation of an air bolus over the epigastrium while insufflating air is a less reliable method but sometimes used. Radiographic confirmation is definitive but not usually done emergently for lavage unless there's doubt. Rationale: Ensuring correct tube placement is critical to prevent instilling lavage fluid into the lungs (which would cause severe aspiration pneumonitis) or other incorrect locations.
7. Perform Lavage (Instillation and Aspiration):💧🔄
   • Once placement is confirmed, instill an aliquot of the lavage fluid (e.g., 100-300 mL for adults, 10-15 mL/kg for children, up to a maximum of 250 mL per aliquot in children) into the stomach through the tube using the syringe or a funnel.
   • Immediately lower the tube below the level of the stomach (or gently aspirate with the syringe) to allow the gastric contents and instilled fluid to drain out by gravity or suction into the collection container.
   • Repeat this cycle of instillation and drainage multiple times until the return fluid is relatively clear of particulate matter or until a prescribed total volume of lavage fluid has been used (or as clinically indicated). Keep a careful record of the volume instilled and returned.
   Rationale: The repeated washing action helps to remove stomach contents. Using aliquots prevents overdistension of the stomach (which could induce vomiting or push contents into the duodenum). Clear return fluid suggests most particulate matter has been removed. Monitoring fluid balance is important.
8. Instill Activated Charcoal (if indicated):⚫ After the lavage is complete and if prescribed, a dose of activated charcoal (sometimes with a cathartic like sorbitol) may be instilled through the tube before its removal. The tube is then clamped. Rationale: Activated charcoal adsorbs (binds to) many drugs and toxins remaining in the GI tract, preventing their systemic absorption. A cathartic speeds transit through the intestines.

III. Post-Procedure Phase:

9. Remove the Gastric Tube (or leave in place if further suction needed):⬅️ If the tube is to be removed, pinch it off securely during withdrawal to prevent aspiration of any fluid remaining in the tube. Withdraw it smoothly and quickly. Rationale: Pinching prevents trailing contents from entering the pharynx and potentially the airway during removal.
10. Monitor the Patient Closely:💓🩺 Continuously monitor vital signs, level of consciousness, respiratory status (for signs of aspiration), and for any complications such as vomiting, abdominal discomfort, electrolyte imbalance, or signs of esophageal/gastric injury. Rationale: Gastric lavage can have complications. Close monitoring allows for early detection and management of adverse events. Aspiration pneumonia is a significant risk.
11. Provide Comfort and Supportive Care:🤗 Provide oral hygiene. Ensure the patient is comfortable. Continue supportive care as indicated by their condition (e.g., IV fluids, oxygen, specific antidotes if available for the ingested substance). Rationale: The procedure can be uncomfortable and distressing. Supportive measures improve patient comfort and aid recovery.
12. Document the Procedure Thoroughly:✍️ Document the time of procedure, type and size of tube used, confirmation of placement method, type and total volume of lavage fluid instilled and returned, characteristics of the return fluid (e.g., presence of pill fragments), any substances instilled after lavage (e.g., charcoal), patient's tolerance of the procedure, vital signs before, during, and after, and any complications encountered and interventions taken. Rationale: Accurate and comprehensive documentation is essential for legal records, communication with the healthcare team, and monitoring the patient's progress and response to treatment.

🦴👀Skeletal traction involves applying a pulling force directly to a bone using pins, wires, or tongs inserted surgically. Nurses at Nurses Revision Uganda must make specific and regular observations to ensure its effectiveness and to detect potential complications early.

1. Pin Site Integrity and Signs of Infection:📍🦠Observation: Regularly inspect each pin insertion site for signs of infection, such as redness, swelling, warmth, increased pain or tenderness, purulent (pus-like) or foul-smelling discharge, and loosening of the pins. Note the character and amount of any drainage. Rationale: Pin site infection is a common and serious complication of skeletal traction that can lead to osteomyelitis (bone infection) if not detected and treated promptly. Meticulous observation is key to early identification.
2. Neurovascular Status of the Affected Extremity:🖐️🩸Observation: Frequently assess the neurovascular status of the limb distal to the traction pins and any associated bandages or splints. This includes checking:
   • Color: Observe skin color (e.g., pink, pale, cyanotic, mottled).
   • Temperature: Feel the skin temperature (e.g., warm, cool, cold).
   • Capillary Refill: Press on a nail bed or skin and note the time it takes for color to return (should be <2-3 seconds).
   • Pulses: Palpate distal pulses (e.g., pedal, radial) and compare with the unaffected limb.
   • Sensation: Assess for numbness, tingling (paresthesia), or decreased sensation by light touch. Ask about pain character and location.
   • Movement: Assess ability to move fingers or toes.
   Rationale: Skeletal traction, associated swelling, or tight bandages can compromise blood flow or nerve function in the affected limb. Early detection of neurovascular impairment (e.g., compartment syndrome, nerve palsy) is critical to prevent permanent damage.
3. Alignment and Functioning of the Traction Apparatus:⚙️⚖️Observation: Verify that:
   • The prescribed weights are hanging freely and not resting on the bed, floor, or other objects.
   • The ropes are in the grooves of the pulleys and are not frayed or knotted.
   • The pulleys are functioning smoothly.
   • The line of pull is correct as per the orthopedic plan (maintaining desired bone alignment).
   • The patient's body is in correct alignment with the traction (e.g., not slumped down in bed, maintaining countertraction).
   Rationale: For skeletal traction to be effective in reducing a fracture or immobilizing a limb, the mechanical setup must be functioning correctly and consistently applying the prescribed force in the intended direction. Any disruption can compromise treatment.
4. Patient's Body Alignment and Position:🛌Observation: Ensure the patient is positioned correctly in bed as prescribed to maintain the effectiveness of the traction and countertraction, and to prevent complications. For example, the patient should not be allowed to slip down in bed, which would negate the effect of traction using body weight as countertraction. Rationale: Correct body alignment is essential for the traction to achieve its therapeutic goal (e.g., bone alignment) and to prevent undue pressure or strain on other body parts. It also ensures countertraction is effectively maintained.
5. Skin Integrity (General and Around Traction Components):🧴Observation: Besides pin sites, inspect the skin over bony prominences (e.g., sacrum, heels, elbows) for signs of pressure injury, especially if the patient's mobility is limited. Also, check skin under any splints, bandages, or components of the traction apparatus (like the ring of a Thomas splint) for redness, irritation, or breakdown. Rationale: Prolonged immobility and pressure from the traction device or bed rest can lead to skin breakdown. Regular skin assessment and preventive care are crucial.
6. Patient's Comfort Level and Pain:😖Observation: Assess the patient's level of pain regularly, differentiating between incisional pain (at pin sites), fracture pain, and pain due to muscle spasm or pressure from the traction. Note the effectiveness of analgesia. Rationale: While some discomfort is expected, severe or increasing pain can indicate complications like infection, pressure, nerve impingement, or compartment syndrome. Effective pain management is crucial for patient comfort and cooperation.
7. Signs and Symptoms of Systemic Complications:⚠️🩺Observation: Monitor for signs of systemic complications associated with immobility or trauma, such as:
   • Respiratory complications: e.g., shallow breathing, cough, adventitious breath sounds (suggesting atelectasis or pneumonia).
   • Thromboembolic events: e.g., calf pain, swelling, redness (suggesting DVT), or sudden shortness of breath, chest pain (suggesting PE).
   • Urinary complications: e.g., urinary retention, signs of UTI.
   • Constipation.
   Rationale: Patients in skeletal traction are often immobilized for extended periods, increasing their risk for various systemic complications. Early detection allows for timely intervention.

😟🦴Caring for a patient on skeletal traction at Nurses Revision Uganda involves addressing several critical nursing concerns to ensure patient safety, promote healing, and prevent complications. These concerns guide the nursing care plan.

1. Risk for Infection (Pin Site and Systemic):🦠Concern: The insertion of pins or wires directly into the bone creates a portal of entry for microorganisms, posing a significant risk of localized pin site infection, which can progress to osteomyelitis (bone infection) or even systemic sepsis if not managed properly. Rationale: Infection can delay healing, cause severe pain, necessitate removal of the traction, and lead to long-term disability. Meticulous pin site care and vigilant monitoring are essential.
2. Risk for Impaired Neurovascular Function:🖐️🩸Concern: The traction itself, associated swelling, or pressure from bandages or positioning can compress nerves or blood vessels in the affected limb, leading to impaired circulation, nerve damage, or compartment syndrome. Rationale: Neurovascular compromise is an emergency that can result in permanent muscle and nerve damage or even loss of the limb if not detected and treated promptly. Frequent neurovascular assessments are critical.
3. Risk for Impaired Skin Integrity and Pressure Ulcers:🧴🤕Concern: Prolonged immobility due to traction, pressure from the traction apparatus (e.g., splints, rings, bandages), and shearing forces can lead to skin breakdown, friction injuries, and pressure ulcers, especially over bony prominences. Rationale: Pressure ulcers cause pain, increase the risk of infection, prolong hospital stays, and impact the patient's quality of life. Regular skin assessment, repositioning (within the limits of traction), and pressure-relieving measures are vital.
4. Pain Management (Acute and Chronic):😖💊Concern: Patients in skeletal traction often experience significant pain from the underlying injury (e.g., fracture), the traction pins, muscle spasms, or prolonged immobility. Inadequate pain control can hinder recovery, affect mood, and reduce cooperation with care. Rationale: Effective and consistent pain assessment and management using both pharmacological (analgesics) and non-pharmacological interventions are essential for patient comfort, promoting rest, facilitating mobility (where possible), and preventing chronic pain development.
5. Psychosocial Issues and Coping:😔🤝Concern: Being in skeletal traction can be a distressing and lengthy experience, leading to anxiety, fear, depression, boredom, feelings of helplessness or dependence, altered body image, social isolation, and difficulties coping with prolonged immobility and hospitalization. Rationale: Addressing the patient's psychosocial needs is as important as managing their physical condition. Providing emotional support, encouraging diversional activities, facilitating communication with family, and involving them in care planning can help improve coping and overall well-being.
6. Complications of Immobility:🚶‍♂️➡️🚫Concern: Prolonged bed rest and immobility associated with skeletal traction put the patient at risk for numerous systemic complications, including:
   • Respiratory issues (e.g., atelectasis, pneumonia).
   • Thromboembolic events (e.g., deep vein thrombosis (DVT), pulmonary embolism (PE)).
   • Muscle atrophy and joint contractures.
   • Constipation and urinary stasis/infection.
   • Loss of bone density (disuse osteoporosis).
   Rationale: Proactive nursing interventions are needed to prevent these common complications, such as encouraging deep breathing and coughing exercises, promoting hydration, ensuring adequate nutrition, performing range-of-motion exercises for unaffected limbs, and applying anti-embolism stockings or prophylactic anticoagulants if prescribed.
7. Ineffective Traction or Malalignment:⚙️❌Concern: Ensuring the traction system is set up and maintained correctly to achieve and maintain the desired bone alignment and therapeutic effect. Problems like weights resting on the floor, ropes off pulleys, or incorrect patient positioning can render the traction ineffective. Rationale: If traction is not functioning properly, it can delay bone healing, lead to malunion or nonunion of fractures, or fail to alleviate muscle spasms, prolonging recovery and potentially requiring further interventions.

💧🚽Bladder irrigation is the process of flushing the bladder with a sterile solution. It is performed for various reasons, such as to remove blood clots, sediment, or mucus from the bladder; to instill medication; or to maintain patency of an indwelling urinary catheter. At Nurses Revision Uganda, this procedure must be done using strict aseptic technique to prevent urinary tract infections (UTIs).

There are two main types: Continuous Bladder Irrigation (CBI) and Intermittent (Manual) Bladder Irrigation. The general principles apply to both, but the setup differs.

I. Preparation Phase (Common to both types, with specifics noted):

1. Verify Physician's Order and Purpose:✅ Confirm the order for bladder irrigation, the type of irrigation (continuous or intermittent), the specific irrigating solution to be used (e.g., sterile normal saline 0.9%, sterile water, or medicated solution), the amount of solution for intermittent irrigation, and the desired flow rate or frequency for CBI. Understand the reason for the irrigation. Rationale: Ensures the correct procedure is performed as intended and is appropriate for the patient's condition. Prevents errors.
2. Explain the Procedure to the Patient and Obtain Consent (if applicable):🗣️ Explain what will be done, why it's needed, and what the patient might feel (e.g., a sensation of fullness or coolness). Answer any questions and obtain verbal consent if not an emergency or ongoing treatment. Provide privacy. Rationale: Reduces patient anxiety, promotes cooperation, and respects patient autonomy.
3. Gather and Prepare Equipment (using aseptic technique):🛠️
   • For Intermittent Irrigation: Sterile irrigation tray (often pre-packaged) containing a sterile container for irrigant, a sterile large-volume syringe (e.g., 50-60 mL catheter-tip or Toomey syringe), sterile protective cap for catheter, sterile drape, antiseptic swabs, clean gloves, PPE (gown, eye protection if splashing likely), bed protector, and collection basin for returned fluid.
   • For Continuous Bladder Irrigation (CBI): Sterile prescribed irrigating solution (large volume bags, e.g., 1-3 Liters), sterile CBI tubing set (usually a Y-type tubing with a drip chamber and clamps for inflow and outflow, connecting to a triple-lumen catheter or via a Y-connector to a double-lumen catheter), IV pole, clean gloves, PPE, and a large urinary drainage bag with volume markings.
   • Warm the irrigating solution to body temperature if indicated (check policy, as cold solution can cause bladder spasms).
   Rationale: Ensures all necessary sterile items are available to perform the procedure safely and efficiently, minimizing the risk of introducing infection. Warming solution can improve patient comfort.
4. Wash Hands and Don PPE:🧼🧤 Perform thorough hand hygiene and don appropriate PPE (gloves are essential; gown and eye protection if risk of splashing). Rationale: Prevents transmission of microorganisms and protects the healthcare provider.
5. Position the Patient:🛌 Position the patient comfortably in a supine position with knees slightly flexed, or as tolerated. Place a bed protector under the patient's buttocks/catheter area. Rationale: Provides easy access to the urinary catheter and protects bed linens from spillage.

II. Procedure Phase:

A. For Intermittent (Manual) Bladder Irrigation:

6. Prepare the Sterile Field and Irrigant:✨ Open the sterile irrigation tray using aseptic technique. Pour the prescribed amount of sterile irrigating solution into the sterile container. Rationale: Maintains sterility and prevents contamination of the solution and equipment.
7. Disconnect Catheter from Drainage System (if closed system):🔗 If the patient has an indwelling catheter connected to a closed drainage system, cleanse the catheter-drainage tube junction with an antiseptic swab. Carefully disconnect the catheter from the drainage tubing, ensuring the end of the drainage tubing remains sterile (e.g., by covering with a sterile cap or placing on a sterile field). Cover the end of the catheter with a sterile protective cap if there will be a delay. Rationale: Prevents contamination of the closed drainage system. Protecting sterile ends is crucial.
8. Instill the Irrigating Solution:➡️💧 Draw the prescribed amount of irrigating solution (e.g., 30-50 mL for adults, or as ordered) into the sterile syringe. Gently insert the tip of the syringe into the catheter lumen. Slowly and gently instill the solution into the bladder. Do NOT force the fluid if resistance is met. Rationale: Gentle instillation prevents trauma to the bladder mucosa and avoids causing excessive bladder pressure or spasm. Forcing fluid against resistance could indicate an obstruction or cause injury.
9. Allow Solution to Drain or Gently Aspirate:⬅️💧
   • For passive drainage: Remove the syringe and allow the fluid to drain out by gravity from the catheter into the collection basin.
   • For gentle aspiration (if ordered or indicated to remove clots): Gently pull back on the syringe plunger to aspirate the fluid and any debris/clots. Avoid forceful aspiration, which can traumatize the bladder lining.
   Rationale: Allows removal of the instilled fluid along with any sediment, clots, or mucus. Gentle handling minimizes bladder trauma.
10. Repeat as Necessary:🔄 Repeat the instillation and drainage cycle with fresh solution as prescribed or until the return flow is clear or the desired outcome is achieved (e.g., clots removed). Rationale: Ensures adequate flushing and cleansing of the bladder.
11. Reconnect to Drainage System:🔗 Once irrigation is complete, cleanse the catheter end and the drainage tube end with antiseptic swabs and securely reconnect the catheter to the sterile closed drainage system. Ensure there are no kinks in the tubing. Rationale: Re-establishes the closed urinary drainage system to prevent infection and allow continuous urine drainage.

B. For Continuous Bladder Irrigation (CBI):

6. Set up the CBI System:⚙️ Spike the bag(s) of sterile irrigating solution with the sterile CBI tubing, prime the tubing to remove air, and hang the bags on an IV pole. Rationale: Priming prevents air from entering the bladder. Correct setup ensures continuous flow.
7. Connect Tubing to Catheter:🔗 Using aseptic technique, connect the inflow lumen of the CBI tubing to the irrigation port of the triple-lumen catheter (or the appropriate port if using a Y-connector with a double-lumen catheter). Ensure the outflow lumen of the catheter is securely connected to a large-capacity urinary drainage bag. Rationale: Establishes the closed system for continuous inflow of irrigant and outflow of urine and irrigant.
8. Regulate Inflow Rate:💧⏱️ Open the roller clamp on the inflow tubing and adjust the drip rate as prescribed by the physician, or to maintain a clear or light pink urine outflow (e.g., in post-TURP patients to prevent clot formation). Rationale: The flow rate is critical. Too slow may not prevent clot formation; too fast can cause bladder distension or fluid overload if outflow is obstructed. The goal is often to keep urine clear.
9. Monitor Outflow and Drainage Bag:📊 Continuously monitor the character (color, clarity, presence of clots) and volume of the outflow. Ensure the drainage tubing is patent (not kinked) and the drainage bag is positioned below the level of the bladder to facilitate gravity drainage. Empty the drainage bag frequently, especially if inflow rates are high, to prevent backflow and accurately measure output. Rationale: Outflow should approximate inflow plus urine output. Decreased outflow despite continued inflow can indicate catheter obstruction (e.g., by clots), requiring immediate attention (e.g., manual irrigation if ordered, checking for kinks).

III. Post-Procedure Phase (Common to both, with specifics):

10. Assess Patient Comfort and Tolerance:😊 Assess the patient for any pain, bladder spasms, or discomfort during and after the procedure. Administer analgesics or antispasmodics as prescribed if needed. Rationale: Bladder irrigation can sometimes cause discomfort or spasms. Addressing these improves patient tolerance.
11. Monitor Intake and Output Accurately:📉📈 For intermittent irrigation, record the amount of irrigant instilled and the amount returned, noting the difference as true urine output or retained irrigant. For CBI, meticulously calculate true urine output by subtracting the total volume of irrigant instilled from the total volume of fluid drained from the bag over a specific period. Rationale: Accurate I&O is crucial for assessing fluid balance, renal function, and detecting potential problems like catheter obstruction or fluid retention.
12. Observe for Complications:⚠️ Monitor for signs of UTI (e.g., fever, chills, cloudy/foul-smelling urine, suprapubic pain), bladder perforation (rare, severe pain, abdominal rigidity), hemorrhage (increased frank blood in outflow), or electrolyte imbalance (especially with prolonged irrigation using hypotonic solutions, though less common with saline). Rationale: Early detection of complications allows for prompt intervention and management.
13. Dispose of Waste and Clean Equipment:🗑️ Dispose of used supplies according to biohazard waste protocols. Clean any reusable equipment. Rationale: Maintains infection control and a safe environment.
14. Document the Procedure:✍️ Record the date, time, type and amount of irrigant used, characteristics of the return fluid, true urine output (for CBI), patient's tolerance, any complications, and nursing interventions. Rationale: Provides a legal record of care, ensures communication among the healthcare team, and tracks patient progress.