Foundations of Nursing III 2022 UNMEB Answers

(a) Outline ten (10) important points a nurse should remember while caring for a patient with tracheostomy (10 marks):

• Keep a spare tracheostomy tube (same size) at the bedside for emergencies.
• Always maintain a patent airway by suctioning only when clinically indicated.
• Ensure inspired oxygen is appropriately humidified to prevent mucus crusting.
• Hyperoxygenate the patient strictly before and after each suctioning pass.
• Never apply negative pressure (suction) while inserting the catheter.
• Limit each suctioning attempt to a maximum of 10-15 seconds to prevent severe hypoxia.
• Clean the inner cannula routinely using normal saline to prevent blockages.
• Provide alternative communication methods (whiteboards/pen) as the patient cannot speak.
• Perform rigorous oral hygiene every 2-4 hours to prevent ventilator-associated pneumonia.
• Monitor the stoma site daily for signs of bleeding, purulent drainage, or subcutaneous emphysema.

(b) Describe ten (10) nursing responsibilities to a patient undergoing abdominal paracentesis (10 marks):

• Obtain Informed Consent: Ensure the physician has fully explained the risks and the patient has signed the consent form before proceeding.
• Empty the Bladder: Strictly instruct or assist the patient to void immediately before the procedure to prevent catastrophic trocar puncture of a distended bladder.
• Record Baseline Vitals: Take a complete set of vital signs and measure the patient’s abdominal girth and weight to establish a baseline for post-procedure comparison.
• Optimal Positioning: Position the patient sitting upright (High Fowler’s) on the edge of the bed or in a chair, supporting their back and feet, to allow ascites fluid to pool in the lower abdomen.
• Provide Psychological Support: Stay with the patient throughout, explaining what is happening to reduce severe anxiety and ensure they remain perfectly still during trocar insertion.
• Monitor During Drainage: Observe the patient constantly for signs of vascular collapse, pallor, or hypovolemic shock if large volumes of fluid are drained rapidly.
• Assist the Physician: Maintain the sterile field, hand over sterile syringes, local anesthetics, and precisely handle the specimen collection tubes for laboratory analysis.
• Apply Sterile Dressing: Once the trocar is removed, apply firm pressure to the puncture site and secure a sterile, absorbent dressing to prevent fluid leakage and infection.
• Post-Procedure Vitals: Re-assess vital signs every 15 minutes for the first hour, checking for severe hypotension or tachycardia indicating internal bleeding.
• Document: Accurately record the total volume, color, and consistency of the drained fluid, the patient’s tolerance of the procedure, and post-procedure abdominal girth.

(a) Outline the ten (10) general principles for bandaging (10 marks):

1. Use a tightly rolled bandage of suitable width and maintain one.
2. Face the patient when bandaging an arm or leg except when bandaging the head.
3. Hold the head of the bandage uppermost.
4. Hold the bandage in the right hand when bandaging the left limb and vice versa.
5. Bandage the limb from inside outwards and from below upwards, keeping the pressure even throughout.
6. Begin the bandage with a secure turn and allow each turn to cover 2/3 of the preceding one.
7. Ensure that the bandage is neither too tight nor too loose.
8. Finish off the bandage with a straight turn, fold in the end and secure avoiding joints and the site of injury.
9. Fasten with safety pins or with the fasteners provided with some bandages.
10. A tape is always used in mentally handicapped or pediatric patients instead of pins or other sharp appliances.

(b) Explain the procedure for carrying out gastric lavage (10 marks):

Requirements (Trolley Setup):

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Procedure for Gastric Lavage:

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(a) Outline five (5) specific nursing observations that should be made for a patient on skeletal traction (5 marks):

• Pin Site Assessment: Observe the insertion sites where the metal pins enter the bone for extreme redness, swelling, purulent drainage, or foul odor indicating osteomyelitis.
• Neurovascular Checks (CMS): Continuously assess the color, motion, and sensation of the toes distal to the fracture to detect life-threatening compartment syndrome early.
• Traction Alignment: Ensure the ropes remain exactly within the pulley grooves and that the traction pull is in a completely straight, uninterrupted line with the fractured bone.
• Weight Status: Observe that the prescribed weights are hanging completely free and are not resting on the floor or the bed frame, which would negate the pulling force.
• Skin Integrity: Frequently inspect the skin over high-pressure bony prominences (sacrum, heels, elbows) for signs of redness or skin breakdown due to forced immobility.

(b) State five (5) nursing concerns for a patient on skeletal traction (5 marks):

• High Risk for Severe Infection: The metal pins penetrating the skin directly to the bone create a direct pathway for bacteria, risking fatal osteomyelitis.
• Deep Vein Thrombosis (DVT) / Embolism: Severe, prolonged immobility leads to blood pooling in the legs, massively increasing the risk of fatal pulmonary embolisms.
• Impaired Skin Integrity: Inability to turn freely places the patient at immense risk for developing deep, necrotic decubitus (pressure) ulcers.
• Respiratory Complications: Immobility prevents full lung expansion, leading to atelectasis or hypostatic pneumonia due to retained respiratory secretions.
• Psychosocial Distress: The prolonged confinement to a hospital bed, combined with severe pain and loss of independence, frequently causes acute anxiety and depression.

(c) Describe the procedure for bladder irrigation (10 marks):