DNE 111: Foundations of Nursing III - Dec 2022

🍽️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. 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.

💧🧑‍⚕️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.

💧🚽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):

II. Procedure Phase:

A. For Intermittent (Manual) Bladder Irrigation:

B. For Continuous Bladder Irrigation (CBI):

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