🏥 Nurses Revision Uganda
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FOUNDATIONS UHPAB 2025 June Revision Guide
SECTION A: Objective Questions (20 marks)
💡 Exam Focus: These questions test practical nursing knowledge prioritization. Remember ABCs (Airway, Breathing, Circulation) always come first in emergency situations!
1
Which of the following Nursing diagnoses denotes a patient's failure to cope with having a catheter in situ?
(b) Ineffective coping
Ineffective coping is the NANDA-I approved diagnosis for inability to manage internal/external stressors effectively. It describes the failure to adapt to a health situation like having an indwelling catheter. This diagnosis includes manifestations like anxiety, refusal to look at catheter, verbalized inability to cope, and maladaptive behaviors.
NANDA COPING DIAGNOSES: "Ineffective coping" = inability, "Readiness for enhanced coping" = willing to improve, "Compromised family coping" = support system issue
2
Which of the following is NOT a key component of wound assessment?
(b) Medication history
While medication history is important for overall patient assessment, it is not a direct component of wound assessment. The TIME framework (Tissue, Infection/Inflammation, Moisture, Edge) and wound characteristics like size, depth, tissue type, exudate, and pain are the core components. Medication history is part of the broader patient history, not wound-specific assessment.
📏 Wound Assessment Framework: TIME - Tissue, Infection/Inflammation, Moisture, Edge. Photograph with ruler for documentation!
3
Which of the following is the nurse's responsibility in preparing a patient for Barium Enema? To tell the patient
(c) to prepare for the procedure
The nurse's primary responsibility is holistic preparation - explaining the procedure steps, bowel prep requirements, what to expect, and post-procedure care. This includes informed consent, psychological preparation, and ensuring compliance with bowel prep. Simply stating "it's uncomfortable" or "painful" is insufficient and may increase anxiety. Starvation is only part of the prep, not the complete responsibility.
PRE-PROCEDURE PREP: "P-E-D-I-C" - Purpose, Explanation, Diet prep, Informed consent, Comfort measures
4
A patient who spends most of the time in bed is likely to have more of the following diagnosis;
(d) risk for constipation related to immobility
"Risk for" diagnoses are appropriate when risk factors are present but the problem hasn't manifested yet. In a bedridden patient, immobility is a major risk factor for constipation, but until the patient actually fails to pass stool for 3+ days, the appropriate diagnosis is "Risk for constipation". This allows for preventive interventions rather than reactive treatment.
⚠️ Diagnosis Timing: Use "Risk for" BEFORE problem occurs. Use actual problem diagnosis only with defining characteristics present. Prevent > Treat!
5
For which of the following reasons will nurses insert a nasogastric tube?
(b) Decompression of the stomach
Nasogastric (NG) tubes are primarily inserted for gastric decompression - removing gas, fluid, and food from the stomach. Indications include bowel obstruction, ileus, post-operative gastric stasis, and prevention of aspiration. The tube drains stomach contents by gravity or suction, relieving distension and preventing vomiting.
NG TUBE INDICATIONS: "D-F-E-E-D" - Decompression, Feeding, Emptying stomach, Evacuation of toxins, Drug administration (rare)
6
The nurses' priority assessment for a comatose patient is on
(a) breathing
Airway and breathing are always the first priority in any unconscious patient. Comatose patients have impaired protective reflexes and cannot maintain their airway. The tongue can fall back, secretions can pool, and aspiration risk is high. First assessment is looking, listening, and feeling for breathing while simultaneously protecting the cervical spine. Without adequate breathing, circulation and neurological status are irrelevant.
🚨 ABCDE Approach: Airway, Breathing, Circulation, Disability (neuro), Exposure. Never deviate from this sequence in emergencies!
7
The highest score on the Glasgow Coma scale for eye opening is
(c) 4
Glasgow Coma Scale Eye Opening component has 4 points maximum: 4 = spontaneous opening, 3 = opens to voice, 2 = opens to pain, 1 = no eye opening. The total GCS maximum is 15 (E4 V5 M6). Eye opening is the first component assessed and provides insight into brainstem function (reticular activating system).
GCS SCORING: "E-V-M 456" - Eyes 1-4, Verbal 1-5, Motor 1-6. Total: 3-15. ≤8 = severe brain injury/coma
8
Which of the following is indicative of increased intracranial pressure?
(a) Vomiting
Vomiting is a classic sign of increased intracranial pressure (ICP), especially when projectile and not preceded by nausea. It results from pressure on the medulla oblongata's vomiting center. Unlike GI-related vomiting, ICP-induced vomiting is often sudden and forceful. Other signs include severe headache, altered consciousness, papilledema, and Cushing's triad (hypertension, bradycardia, irregular respirations).
🧠 Emergency: Projectile vomiting + headache + altered consciousness = ICP until proven otherwise. Elevate head 30°, maintain airway, call neurosurgeon STAT!
9
Which of the following is an invasive procedure done to establish renal disease?
(c) Renal biopsy
Renal biopsy is an invasive procedure where a needle is inserted through the back into the kidney to obtain tissue samples for histopathological examination. It is the gold standard for diagnosing glomerulonephritis, nephrotic syndrome, unexplained renal failure, and transplant rejection. Performed under ultrasound guidance with local anesthesia. Risks include bleeding, hematuria, and perinephric hematoma.
RENAL DIAGNOSTICS: "B-U-C-P" - Biopsy (invasive), Ultrasound (non-invasive), CT/MRI, Pyelogram
10
The nursing diagnosis for fluid loss as a result of furosemide drug with little replacement is
(c) fluid volume deficit
"Fluid volume deficit" is the standardized NANDA-I diagnosis for decreased intravascular, interstitial, and/or intracellular fluid. It specifically addresses isotonic dehydration from diuretic use. The diagnosis includes defining characteristics like decreased urine output, dry mucous membranes, hypotension, tachycardia, and poor skin turgor. It guides interventions like fluid replacement and monitoring electrolytes.
🏷️ Use NANDA Language: Always use standardized diagnoses. "Fluid volume deficit" is correct, "dehydration" is medical. Exam markers look for precise terminology!
11
The most appropriate amount of feeds administered for a patient with a gastrostomy tube is …………………….. mls.
(a) 240 – 300 mls
Gastrostomy feeds are typically administered in boluses of 240-300 mls (approximately 1 cup) over 20-30 minutes, 3-6 times daily. This volume mimics a normal meal size and is well-tolerated by the stomach without causing distension, regurgitation, or dumping syndrome. Larger volumes increase risk of aspiration and discomfort. Continuous feeds are run at slower rates (50-125 ml/hr) but the question asks about bolus amounts.
G-TUBE FEEDS: "MOM" - 240-300 mls (Meal size), Over 20-30 min, Monitor residual before next feed
12
The surgical procedure performed on a patient with a foreign body in the throat is
(d) tracheostomy
Tracheostomy is performed for upper airway obstruction from foreign bodies that cannot be removed via Heimlich maneuver or laryngoscopy. It creates a surgical airway below the obstruction (between cricoid cartilage and suprasternal notch). This is an emergency, life-saving procedure when complete obstruction threatens asphyxiation. Contrasts with cricothyroidotomy which is easier and faster in true emergencies.
🆘 Emergency Algorithm: Choking → Heimlich → Laryngoscopy → Can't remove? → Cricothyroidotomy (fast) or Tracheostomy (definitive)
13
How does a nurse confirm that her unconscious patient is in pain?
(d) Tachycardia
In unconscious patients, pain is assessed through physiological and behavioral indicators since self-report is impossible. Tachycardia (HR >100 bpm) is a reliable autonomic response to pain mediated by sympathetic nervous system activation. Other indicators include hypertension, diaphoresis, muscle tension, guarding, grimacing, and increased respiratory rate. The Critical-Care Pain Observation Tool (CPOT) uses these objective measures.
PAIN INDICATORS in UNCONSCIOUS: "THRASH" - Tachycardia, Hypertension, Restlessness, Autonomic signs, Sweating, Grimacing
14
In which of the following positions does the nurse place an unconscious patient?
(d) Semi fowlers
Semi-Fowler's position (30-45° head elevation) is standard for unconscious patients. This position promotes lung expansion, prevents aspiration, facilitates drainage of secretions, and reduces ICP. It also prevents pressure injuries by allowing position changes. The slight elevation helps gastric contents stay down and makes oral care easier. Upright is too vertical and unsafe for unconscious patients.
🛏️ Position Matters: Semi-Fowler's prevents aspiration pneumonia (leading cause of death in unconscious patients). Reassess position every 2 hours!
15
The nurse takes a 24 hour collection of urine to
(c) measure calcium loss
24-hour urine collection is the gold standard for measuring calcium excretion and diagnosing hypercalciuria or hypocalciuria. It's also used for protein (nephrotic syndrome), creatinine clearance (renal function), catecholamines (pheochromocytoma), and 5-HIAA. For calcium, the patient collects all urine over 24 hours to account for circadian variation. Normal calcium excretion is <200 mg/day for women, <250 mg/day for men.
24-HR URINE TESTS: "C-3-P" - Calcium, Creatinine clearance, Catecholamines, Protein, 5-HIAA
16
The nurse performs Babinski's and Hoffman's tests to assess for
(b) reflexes
Babinski (plantar reflex) and Hoffman (finger flexor reflex) are upper motor neuron reflex tests. Babinski involves stroking the sole to assess for abnormal toe extension (UMN lesion). Hoffman involves flicking the middle finger to test for abnormal thumb flexion (hyperreflexia). Together they identify pyramidal tract lesions from stroke, spinal cord injury, or neurological disease. These are primitive reflexes that should be absent in adults.
🧠 UMN vs LMN: UMN lesion = hyperreflexia, positive Babinski. LMN lesion = hyporeflexia, muscle atrophy, fasciculations. Location matters!
17
Which of the following is an invasive surgical procedure?
(b) Cystoscopy
Cystoscopy is an invasive surgical procedure where a rigid or flexible endoscope is inserted through the urethra into the bladder. It requires sterile technique, anesthesia (local/spinal/general), and is performed in operating theatre or procedure room. Used for diagnostic (visualize bladder lesions, hematuria) and therapeutic purposes (remove stones, biopsy tumors, resect prostate). Carries risks of infection, bleeding, and urethral injury.
INVASIVE PROCEDURES: "C-SPI" - Cystoscopy, Surgical incision, Puncture (LP), Insertion (lines, tubes)
18
The first line of nursing care for a patient with chemical injury to an eye includes
(a) neutralising by irrigation
Chemical eye injury is a TRUE EMERGENCY requiring immediate copious irrigation. Time is critical - every minute of chemical contact increases corneal damage. Use 1000-2000 mL of normal saline or Ringer's lactate continuously for 15-30 minutes before anything else. Do NOT attempt to neutralize with opposite pH solution. Irrigation removes chemical, dilutes residue, and restores normal pH. Delay for examination or other treatments risks permanent blindness.
⏱️ Golden Rule: Irrigate FIRST, ask questions later. Use Morgan lens if available. Don't wait for pH testing before starting. Continuous irrigation is vision-saving!
19
Which of the following preventive strategies will decrease the likelihood of persistent leakage of ascitis fluid?
(c) Using the Z-tract method when inserting the needle
The Z-tract technique creates a non-linear path through tissue layers. When needle is removed, the tissues realign in a zigzag pattern, sealing the tract and preventing persistent fluid leakage. This is especially crucial in ascites where intra-abdominal pressure is high. Method: pull skin laterally 1-2 cm before inserting needle, then release after removal. Reduces leakage from 30% to <5%.
PARACENTESIS TIPS: "Z-SAFE" - Z-tract technique, Small needle gauge, Assess dressing frequently, Fluid pressure reduction, Elevate head of bed
20
Which of the following statements is incorrect concerning pre-operative care?
(c) Pre-operative care is given only on an inpatient surgical ward
This statement is FALSE. Pre-operative care is provided in multiple settings: outpatient pre-op clinics, day surgery units, emergency departments (for urgent cases), and even at home (preparation instructions). Modern surgery is increasingly ambulatory; patients arrive from home on day of surgery after completing pre-op preparation at home.
🏥 Settings for Pre-op Care: Inpatient ward, Day surgery unit, Pre-op clinic, Emergency dept, Home (via phone/leaflets). Modern nursing is mobile!
SECTION B: Fill in the Blank Spaces (10 marks)
21
Lack of awareness of one's surrounding and failure to respond to stimuli is referred to as ……………………………………………..
Unconsciousness (or Coma)
Unconsciousness is a state of impaired arousal and awareness where the patient cannot be aroused by external stimuli. Ranges from lethargy to deep coma (GCS <8). Causes include brain injury, hypoxia, metabolic disturbances, drug overdose, and seizures. Requires immediate assessment of airway protection and vital signs.
22
The nurse records noisy breathing which occurs in the patient who is unconscious as ……………………………………….
Stertorous respirations (or Obstructed airway sounds)
Stertor is a heavy snoring or rattling sound caused by partial airway obstruction from tongue falling back, secretions, or soft tissue collapse. Indicates partially protected airway and risk of complete obstruction. Requires immediate positioning (jaw thrust), suctioning, and possible airway adjuncts. Contrast with stridor (upper airway obstruction) and gurgling (fluid in airway).
23
The medical procedure where a tube is inserted into the stomach to remove its contents is called …………………………………..
Gastric lavage (or Gastric suctioning)
Gastric lavage involves inserting a large-bore orogastric tube and washing out stomach contents with repeated instillations of saline and removal. Used for poison ingestion (within 1 hour), gastric bleeding diagnosis, and pre-endoscopy preparation. Risks include aspiration, esophageal perforation, and electrolyte imbalance. Largely replaced by activated charcoal for poisoning.
24
A surgical procedure in which a stoma is opened in the wind pipe to provide a direct airway is called ………………………………………
Tracheostomy
Tracheostomy is a surgical opening into the trachea through the neck, creating a stoma for direct airway access. Indicated for long-term ventilation ( >2 weeks), upper airway obstruction, difficult intubation, and secretion management. Performed in theatre or ICU. Requires meticulous post-op care: humidification, suctioning, stoma care, tube changes every 7-30 days.
25
Alignment of a patients fractured bones to ease pain and accelerate the healing process is known as………………………………………….
Reduction (or Fracture reduction)
Reduction is the process of restoring fractured bone fragments to their normal anatomical position. Can be closed reduction (manipulation without surgery) or open reduction (surgical with internal fixation). Proper alignment is essential for: pain relief, normal healing, restoration of function, and prevention of deformity. Performed under anesthesia (local, regional, or general).
26
Which gadget is used to add warmth to a patient suffering from hyperthermia ……………………………………
Blanket (warming blanket) or Warm air convection device (e.g., Bair Hugger)
Actually, the question contains an error! Hyperthermia means elevated body temperature (fever/heat stroke). The treatment is COOLING, not warming. The gadget would be cooling blankets, ice packs, or evaporative cooling. If the question meant hypothermia (low temperature), then warming blankets and forced-air warmers like Bair Hugger are used. This is a critical temperature management concept.
🔥 Temperature Clarification: HYPERthermia = too HOT → COOL. HYPOthermia = too COLD → WARM. Mixing these up in practice can be fatal! Always double-check terminology.
27
The length in cm that an enema tube inserted into the patients is ……………. cm.
7-10 cm for adults (3-4 inches)
Standard enema tube insertion length is 7-10 cm (3-4 inches) for adults. Insert gently to the level of the rectosigmoid junction. Inserting too far ( >10 cm) can cause the tube to coil in the rectum or enter the sigmoid colon, causing cramping and ineffective administration. Too short (<5 cm) leads to leakage. In children: 5-7.5 cm (2-3 inches). Always lubricate generously!
28
The instrument used to examine the patients ears is called …………………………………………….
Otoscope (or Auriscope)
An otoscope is a handheld device with a light source and magnifying lens used to visualize the external auditory canal and tympanic membrane. Different sized specula are used for adults and children. Assesses for otitis media (bulging, red TM), otitis externa, foreign bodies, and perforations. Pneumatic attachment can test TM mobility. Essential primary care tool.
29
The recommended minimum average flow rate of an infusion of intravenous fluids is……………………
20-30 drops per minute (for standard macrodrop set: 20 drops = 1 ml) OR 50-100 mL/hr for maintenance fluids
The "minimum average flow rate" depends on purpose: For maintenance hydration: 50-100 mL/hr (1.2-2.4 L/day). Using standard macrodrop (20 drops/mL): 20-30 drops/min = 60-90 mL/hr. For pediatric patients: 4-2-1 rule (4 mL/kg for first 10kg, 2 mL/kg for next 10kg, 1 mL/kg for remaining weight). Always calculate based on patient weight and fluid needs.
30
Patients lie horizontally on the back with the face and torso facing upwards in ……………………………………. position.
Supine (or Dorsal recumbent)
Supine position is the standard anatomical position - patient flat on back, face up, arms at sides or on abdomen. Used for most examinations, procedures, and post-op care. Variations include dorsal recumbent (knees flexed) for pelvic exams. Contraindicated in late pregnancy (aortocaval compression) and some respiratory conditions. Requires pressure injury prevention measures.
SECTION B: Short Essay Questions (10 marks)
31
State five (5) points nurses consider when preparing a victim of road traffic accident for CT scan of the head. (5 marks)
Preparation must ensure patient safety, image quality, and hemodynamic stability during transfer:
1. Airway and cervical spine protection: Ensure patency with endotracheal tube if GCS <8, maintain manual in-line cervical stabilization during transfer; CT table is hard and movement can worsen spinal injury.
2. Hemodynamic stability: Secure two large-bore IV lines, ensure blood pressure >90 systolic, control active bleeding with pressure dressings; CT scanner is remote from resuscitation area.
3. Remove all metal objects: Remove jewelry, piercings, ECG leads, spinal boards (metal components) to prevent imaging artifacts that obscure pathology; replace with CT-compatible equipment.
4. Monitor vital signs continuously: Transfer with portable monitor showing ECG, BP, SpO2; CT environment is isolated; detect deterioration during scan; have emergency drugs ready.
5. Communication with radiology team: Provide mechanism of injury, GCS, vital signs, anticoagulation status; alert them to potential agitation needing sedation; ensures appropriate protocol (contrast vs non-contrast).
🚨 Trauma CT Protocol: Always include cervical spine CT with head CT for RTA victims. Time is brain - but safety first during transfer!
32
Outline five (5) indications of lumbar puncture. (5 marks)
Lumbar puncture obtains CSF from subarachnoid space for diagnostic or therapeutic purposes:
1. Diagnose meningitis/encephalitis: Collect CSF for cell count, glucose, protein, Gram stain, culture to differentiate bacterial (low glucose, high neutrophils) from viral (normal glucose, lymphocytes) meningitis.
2. Diagnose subarachnoid hemorrhage: When CT is negative but clinical suspicion remains; detects xanthochromia (yellow CSF) and RBCs from blood breakdown products.
3. Measure opening pressure: Diagnose idiopathic intracranial hypertension (pseudotumor cerebri) with pressures >250 mm H₂O; also assesses normal pressure hydrocephalus.
4. Diagnose demyelinating diseases: CSF protein electrophoresis shows oligoclonal bands in multiple sclerosis; also evaluates Guillain-Barré syndrome (high protein, normal cells).
5. Therapeutic drug administration: Intrathecal chemotherapy for leukemia/lymphoma prophylaxis; intrathecal antibiotics for ventriculitis; contrast for myelography.
LP INDICATIONS: "MINDS" - Meningitis, Intracranial pressure, Neoplasms/cancer drugs, Demyelinating disease, SAH diagnosis
⚠️ Contraindications: Increased ICP (risk of herniation), local infection, coagulopathy, severe spinal deformity. Always check fundi for papilledema first!
SECTION C: Long Essay Questions (60 marks)
33
(a) Describe with rationale six (6) nursing interventions implemented for a client undergoing abdominal paracentesis. (12 marks)
(b) Outline eight (8) nursing interventions implemented for a client post abdominal paracentesis. (8 marks)
(b) Outline eight (8) nursing interventions implemented for a client post abdominal paracentesis. (8 marks)
(a) Pre-Paracentesis Nursing Interventions:
1. Obtain informed consent and explain procedure: Ensures legal/ethical compliance and reduces anxiety. Explain sensation of pressure, need to lie still, and post-procedure expectations. Improves cooperation and reduces vasovagal reactions.
2. Ensure bladder is emptied (void immediately before): Prevents accidental puncture of an over-distended bladder during needle insertion. Ask patient to void or insert urinary catheter if unable. Critical safety measure.
3. Position patient semi-recumbent (45°) with back supported: Allows fluid to pool in lower abdomen for easier access; prevents orthostatic hypotension; patient can maintain position comfortably for 20-30 minutes.
4. Monitor baseline vital signs (BP, HR, RR, SpO2, Temp): Provides comparison to detect complications (hypotension from fluid shift, vasovagal syncope, infection). Record pre-procedure values in chart.
5. Assess coagulation profile (INR, platelets) and administer FFP/platelets if indicated: Prevents hemorrhage from puncture of dilated abdominal wall vessels. Therapeutic paracentesis typically requires INR <2.0 and platelets>50,000.
6. Prepare sterile field and equipment (paracentesis kit, collecting bag, local anesthetic): Prevents infection and ensures smooth procedure flow. Check expiration dates, ensure all components available, maintain sterility throughout.
(b) Post-Paracentesis Nursing Interventions:
1. Monitor vital signs every 15 minutes for first hour: Detects circulatory collapse from rapid fluid removal causing hypovolemia and hypotension. Large volume paracentesis (>5L) can cause profound fluid shifts.
2. Inspect puncture site for leakage/bleeding and apply pressure dressing: Prevents persistent ascitic fluid leak and hemorrhage. Use Z-tract technique during removal and apply firm pressure for 5 minutes. Use ostomy bag if heavy leakage.
3. Measure and record amount, color, and character of fluid removed: Documents procedure effectiveness and provides diagnostic information (clear yellow = portal HTN; bloody = malignancy; milky = chylous; cloudy = infection).
4. Weigh patient and measure abdominal girth post-procedure: Quantifies fluid loss and monitors reaccumulation. Expect 1-2 kg weight loss per liter removed and 2-4 cm girth reduction.
5. Administer albumin if large volume removed (>5L) as prescribed: Prevents post-paracentesis circulatory dysfunction and hypotension. Albumin maintains intravascular oncotic pressure. Give 6-8g per liter removed.
6. Assess for complications: peritonitis (fever, abdominal pain), hypotension, hyponatremia, hepatic encephalopathy: Early detection enables prompt treatment. Monitor mental status, temperature, blood pressure, serum sodium.
7. Position patient on side of puncture or supine: Reduces pressure on puncture site and prevents leakage. Maintain position for 2 hours post-procedure to allow tract sealing.
8. Provide comfort measures and post-procedure teaching: Explain mild shoulder pain (referred from diaphragm irritation) is normal. Advise to report dizziness, bleeding, fever, or severe abdominal pain. Provide written instructions.
PARACENTESIS CARE: "PRE-POST" - Prepare, Rest, Empty bladder, Site prep, Observations, Support, Teach / Post - Pressure, Observe fluids, Site care, Signs of complications, Teach
💧 Large Volume Paracentesis: Removing >5L without albumin replacement causes circulatory collapse 6-12 hours later. Always give albumin prophylactically!
34
(a) Outline five (5) indications of tracheotomy. (5 marks)
(b) Outline five (5) observations nurses take note of while caring for a patient on tracheotomy. (5 marks)
(c) Describe the procedure of suctioning a tracheostomy tube. (10 marks)
(b) Outline five (5) observations nurses take note of while caring for a patient on tracheotomy. (5 marks)
(c) Describe the procedure of suctioning a tracheostomy tube. (10 marks)
(a) Indications of Tracheotomy:
1. Upper airway obstruction: Relief of obstruction from trauma, foreign bodies, tumors, angioedema, laryngeal stenosis, or severe obstructive sleep apnea when other measures fail.
2. Prolonged mechanical ventilation (>2 weeks): Facilitates secure airway, improves patient comfort, allows oral intake, and enables mobilization while on ventilator. Reduces laryngeal damage from long-term intubation.
3. Ineffective cough and secretion retention: Conditions like spinal cord injury, neuromuscular diseases (ALS, Guillain-Barré), severe COPD where patient cannot clear secretions, leading to recurrent atelectasis and infections.
4. Head and neck surgery: Provides intra-operative airway control during procedures involving larynx, pharynx, or maxillofacial region; allows post-op swelling to resolve without airway compromise.
5. Congenital anomalies: Severe laryngomalacia, tracheomalacia, or craniofacial abnormalities (Pierre Robin sequence) causing airway compromise in infants and children.
(b) Observations for Tracheostomy Care:
1. Respiratory status and oxygen saturation: Monitor for signs of obstruction or displacement - increased work of breathing, stridor, decreased SpO2, cyanosis. Tube can become dislodged or blocked by secretions - life-threatening emergency.
2. Amount, color, and consistency of secretions: Assess quantity (scant, moderate, copious), color (clear, yellow, green, bloody), and viscosity (thin, thick, tenacious). Changes indicate infection, bleeding, or dehydration.
3. Stoma site condition: Inspect for redness, swelling, purulent discharge, skin breakdown, bleeding, or tube displacement. Early signs of infection or pressure injury require immediate intervention.
4. Air entry through tracheostomy tube: Auscultate bilateral lung fields to ensure tube is in correct position and not obstructed. Assess for equal air entry; diminished sounds may indicate blockage or dislodgement into pretracheal space.
5. Patient's ability to communicate and comfort level: Assess anxiety, frustration with communication difficulties, pain at insertion site, need for suctioning, and effectiveness of communication methods (writing boards, yes/no signals, speaking valves).
TRACHEOSTOMY INDICATIONS: "A-PRO-C" - Airway obstruction, Prolonged ventilation, Retained secretions, Oral surgery, Congenital anomalies
TRACHEOSTOMY OBSERVATIONS: "S-SCAR" - Secretions, Stoma condition, Air entry, Respiratory status, Comfort/Communication
TRACHEOSTOMY OBSERVATIONS: "S-SCAR" - Secretions, Stoma condition, Air entry, Respiratory status, Comfort/Communication
⚠️ EMERGENCY: If tracheostomy tube dislodges in first 7 days post-op, DO NOT replace blindly - call ENT immediately! Tract is not mature and blind insertion creates false passage.
(c) Procedure for Suctioning a Tracheostomy Tube:
Suctioning is a sterile procedure to clear airway secretions and maintain patency. Follow these steps systematically:
1. Preparation and hand hygiene: Perform thorough hand hygiene and don sterile gloves. Maintain sterile technique throughout to prevent hospital-acquired pneumonia. Prepare equipment: sterile suction catheter (size = half of tube diameter), sterile saline, connecting tube, and functional suction source set to 80-120 mmHg for adults (60-80 mmHg for children).
2. Pre-oxygenate the patient: Hyperoxygenate with 100% O₂ for 30-60 seconds using trach collar or manual resuscitation bag. RATIONALE: Suctioning causes hypoxemia by removing oxygen along with secretions; pre-oxygenation prevents desaturation and cardiac arrhythmias.
3. Insert catheter without applying suction: Gently insert sterile catheter into tracheostomy tube until resistance is met (carina) or patient coughs, then pull back 1 cm. RATIONALE: Applying suction during insertion increases risk of mucosal trauma and induces hypoxia. Catheter should only be in airway for <10-15 seconds total.
4. Apply intermittent suction while withdrawing: Apply intermittent suction (depress button for 5-10 seconds) while rotating and smoothly withdrawing catheter in a circular motion. RATIONALE: Intermittent suction prevents mucosal damage and airway collapse; rotation ensures 360° secretion removal.
5. Assess effectiveness and patient response: Observe amount, color, consistency of secretions (purulent = infection, bloody = trauma). Monitor SpO₂, HR, color. RATIONALE: Evaluates need for repeat suctioning; detects complications (hypoxia, bradycardia from vagal stimulation, bleeding).
6. Re-oxygenate and repeat if necessary: Re-oxygenate between passes. Limit to maximum of 3 passes per session to prevent mucosal injury and hypoxia. RATIONALE: Multiple passes increase complication risk; allow recovery time between suctioning attempts.
7. Discard equipment and provide comfort: Wrap catheter in sterile glove and discard. Provide mouth care (even with trach, oral secretions colonize airway). RATIONALE: Prevents cross-contamination; improves patient comfort and reduces infection risk.
8. Document procedure and outcomes: Record pre/post-suction vitals, amount/color/consistency of secretions, patient tolerance, and any complications. RATIONALE: Provides legal record, communicates to team, and guides future suctioning frequency.
TRACH SUCTION STEPS: "P-PASS-O":
- Prepare equipment
- Pre-oxygenate
- Advance catheter without suction
- Suction while withdrawing
- Stop (time limit)
- Observe/oxygenate/Document
⏱️ Critical Safety: Never suction longer than 10-15 seconds! Multiple short sessions are safer than one long session. Monitor for bradycardia (vagal response) - stop immediately if heart rate drops >20 bpm!
35
(a) Outline four (4) signs and symptoms of wound infection. (4 marks)
(b) With rationale for each, describe eight (8) nursing interventions performed for a patient on traction. (16 marks)
Copy
(b) With rationale for each, describe eight (8) nursing interventions performed for a patient on traction. (16 marks)
(a) Signs and Symptoms of Wound Infection:
1. Purulent drainage with foul odor: Presence of thick, yellow-green, or brown discharge with offensive smell indicates bacterial colonization and neutrophil breakdown products.
2. Erythema and warmth around wound edges: Localized redness and increased temperature extending >2 cm from wound margins indicates inflammatory response to pathogens.
3. Increased pain and tenderness: Pain that worsens after initial improvement or is disproportionate to wound size suggests invasive infection and nerve stimulation by inflammatory mediators.
4. Systemic signs: fever, chills, elevated WBC count: Temperature >38°C, leukocytosis >10,000 indicate systemic spread of infection and sepsis risk.
INFECTION SIGNS: "SHARP" - Swelling, Heat, Advancement of redness, Redness, Pain, Purulent drainage
(b) Nursing Interventions for Patient on Traction:
1. Ensure proper alignment and countertraction: Align body in straight line with pulleys; ensure weights hang freely without touching floor or bed. RATIONALE: Maintains correct pull force, prevents pressure injuries, ensures effective bone alignment and pain relief.
2. Perform neurovascular checks every 2 hours: Assess distal pulses, capillary refill, sensation, movement, color, temperature. RATIONALE: Traction can compromise circulation and nerve function; early detection prevents permanent damage.
3. Pin site care for skeletal traction: Clean with sterile saline/chlorhexidine daily; assess for infection (redness, drainage, pain). RATIONALE: Prevents pin tract infection which can lead to osteomyelitis; sterile technique is critical.
4. Prevent complications of immobility: Turn every 2 hours, deep breathing exercises, leg exercises, heel protection. RATIONALE: Prevents pressure injuries (especially on occiput, sacrum, heels), atelectasis, pneumonia, DVT, and muscle atrophy.
5. Maintain skin integrity: Inspect pressure points, keep skin clean/dry, use specialized mattresses, document skin condition. RATIONALE: Friction from traction devices and prolonged immobility increase pressure injury risk dramatically.
6. Monitor bowel and bladder function: Assess for constipation (opioids, immobility), provide fluids/fiber, bowel regimen; monitor urine output. RATIONALE: Immobility and analgesics slow gut motility; constipation increases pain and discomfort.
7. Manage pain effectively: Assess pain using numeric scale, administer analgesics before painful procedures, use adjunctive measures (positioning, relaxation). RATIONALE: Uncontrolled pain causes vasoconstriction, delayed healing, muscle spasm, and patient distress.
8. Provide psychological support and education: Explain purpose of traction, expected duration, encourage family involvement, address anxiety/depression. RATIONALE: Prolonged immobilization causes psychological distress; informed cooperative patients have better outcomes.
🦴 Traction Types: Skin traction (Bucks, Russell) - short-term, less force. Skeletal traction (crutches, pins) - long-term, more force. Both require meticulous care!
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