Fundamentals of Nursing (Ain Shams University) 1st Year PDF

Ain Shams University Specialized Hospital Technical Institute of Nursing Fundamentals of Nursing 1st year First term )...

Ain Shams University Specialized Hospital Technical Institute of Nursing Fundamentals of Nursing 1st year First term )2022-2023) Prepared by:- Miss: Reham Samy Gerges Miss: Mayssa Sayed Ali Auditored by:- Miss: Amal Abdel Razek 1  Ain Shams University Specialized Hospital Technical Institute of Nursing Vision:- Vision of Technical Institute of Nursing Specialized Hospital Ain Shams University is to promote excellence in nursing education and scientific research; through focusing on community needs for high quality health care and scientifically educated professional nurses. Mission:- Technical Institute of Nursing is aiming to prepare a qualified nurse scientifically and skillfully to be capable of performing quality nursing care and total societal health awareness and improving her managerial and leadership abilities. 2  List of Content Topics Page No. I - Introduction to Nursing 1 - 6 - Introduction of nursing. II - Prevention of danger of microorganism; hygienic measures:- 7 - 13 - Infection control measures. 14 - 17 - Hand washing. 18 - 26 - Bed bath. 27 - 31 - Hair shampoo. III - Providing for patient safety:- - Bed making. 32 - 40 - Position & transferring. 41 - 56 IV - Assessing hemodynamic measures:- - Body temperature. 57 - 77 - Pulse. - Respiration. - Blood pressure. V- Implementing special nursing measures:- - Drug administration. 78 - 97 - Injection 98 - 102 - Intravenous infusion therapy. 103 -111 - Oxygen therapy. 112 - 119 - Nasogastric tube. 120 -127 - Hot and cold application. 128 -133 - Enema. 134 - 139 - Catheterization. 140 - 152 - Dressing. 153 - 160 - Bandages and binder 161 - 166 VI- References. 167 3 I- Introduction to Nursing:- Introduction of Nursing Objectives: At the end of this lecture, the student should be able to: 1. Define nursing 2. Define nurse 3. List characteristics of nurse 4. Discuss roles and functions of the nurse Out lines: 1. Definition of nursing 2. Definition of nurse 3. Characteristics of nurses 4. The professional Roles and Functions of the nurse 4  Definition of Nursing in Egypt: Nursing is an art and science based on knowledge, skills and attitudes aimed at assisting the individual, family, and Community in health and illness , to avoid complications and to fulfill reliance in meeting daily health needs. Definition of Nurse: The nurse is a person who has completed a program of basic, generalized nursing education and is authorized by the appropriate regulatory authority to practice nursing in her country. WHO definition of nurse: A nurse is a person who has satisfactory completed a program of basic nursing education and who is qualified in her country to practice nursing where in individual countries it is relevant. Nurses provide and coordinate Patient cares, educate patients and the public about various health conditions, and provide advice and emotional support to patients and their family members. Characteristics of Nurses : 1. Being Responsible: The job of nursing requires that to be able to think critically about each Patient while carrying out all physicians’ orders and handling unexpected admissions and emergencies that may arise. Nursing is a unique field in which to work because of the amount of responsibility involved. 2. Being Honest. 3. Being Caring. 4. Being Organized. 5. Professional in Nursing. 6. Professional Appearance and Behavior. 5 The professional roles and functions of the nurses: A provider of health care to individuals, families and groups of the 1. Community. 2. A manger and leader for nurses and auxiliary personnel both in service and education settings or institution. 3. A teacher and trainer for student nurses in nursing Science both theory and practice. 4. A researcher (Evidence Based Nursing) 0 5. A consultant in nursing for national and international bodies. 6 II- Prevention of danger of microorganism; hygienic measures:- Infection control measures Objectives: At the end of this lecture, the student should be able to :- 1- Define the following key terms:- a. Infection. b. Infection control. c. Disinfection. d. Nosocomial infection. 2- Explain the relationship of chain of infection to transmission of infection. 3- Give an example for preventing infection for each element of the infection chain. 4- Differentiate between types of infection. 5- Describe stage of infection; give an example of each stage. 6- Explain how I.C.U risks area for infection. 7- List sites and causes for nosocomial infection. 8- Write function of infection control doctor & nurse. 9- Apply infection control in intensive care units. Outlines: 1. Introduction. 2. Chain of infection and how to break. 3. Cause of infection by stage. 4. Nosocomial infection. 5. Infection control team. 6. Application of infection in Intensive care units. 7 Introduction: In order to explore the meaning of the infection control, a knowledge base is needed a bout:- 1- The body’s normal defenses against infection. 2- Asepsis. 3- Infection control precaution. 4- The chain of infection. Definitions: Infection control the set of methods used to control and prevent the spread of disease. Infections are caused by pathogens (germs). Communicable disease disease spread from one person to another. Infectious disease disease caused by a pathogen (germ or bacteria). Contaminated means something dirty, soiled and unclean. Disinfection cleaning so that germs are destroyed. Mode of transmission the way germs are passed from one person to another. Mucous membranes membranes that linen body cavities that open to the outside of the body. The body’s normal defenses against infection: Immune system. White blood cells. Skin. Asepsis: It means free from all living micro-organisms. It is the major process for controlling infection. Aseptic technique: It is an effort to keep the patient free from exposure to infectious pathogens as possible. 8  Forms of a sepsis: - Two forms of a sepsis are used to accomplish the goal of controlling infection:- 1- Medical asepsis. 2- Surgical asepsis. 1-Medical asepsis :-( clean technique) Are practices that reduce the number of micro-organisms, through interfering with the chain of infection in a variety of ways (Hand washing, routine environmental cleaning). ▪ Principles of medical a sepsis: 1- Micro-organisms exist everywhere except on sterilized equipment. 2- Frequent hand washing is the best method for reducing the transmission of micro-organisms. 3- Blood and body substances are considered major reservoirs of micro- organisms. 4- Using personal protective equipments such as gloves, gown, mask, overhead and overshoes. 5- A clean environment reduces the presence of micro-organisms. 6- Cleaning should be done from cleaner to dirty areas. ▪ Examples of medical a septic practices: Using antimicrobial agents. Performing hand washing. Wearing hospital garments. 2-Surgical a sepsis: Surgical a sepsis refers to measure that render supplies and equipment totally free of micro-organisms. 9 ▪ Principles of surgical a sepsis:- 1- If a sterile item touches unsterile item, it becomes unsterile. 2- If a sterile item becomes wet, it is considered unsterile. 3- If a sterile item exposed to air, it is considered unsterile. 4- If a sterile item is out of its expiration date, it is considered unsterile. 5- If there is an opening in sterile item, it is considered unsterile. 6- If there is any doubt about sterility of an item, it becomes unsterile. 7- If you across over a sterile item, it is considered unsterile. The process of sterilization: Sterilization is the physical and chemical techniques that destroy all micro-organisms, including spores. Types of sterilization: Physical sterilization Micro-organisms are destroyed physically by using:- (a) Radiation: - ultraviolet radiation can kill bacteria (especially T.B. Organism). (b) Boiling water: - it is a convenient way to sterilize items used in the home. (c) Dry heat: - hot air sterilization (like baking items in an oven).It is a good method for sterilizing sharp instruments because moist heat damages cutting edges. It prevents rusting of objects that are not made of stainless steel. (d) Steam under pressure: - the autoclave is the type of pressure steams sterilizer that most health care agencies use. Heat sensitive tape that changes color when exposed to high temperature is used on sterilized packages as visual indicators that the wrapped item is sterile. 10  Chain of infection Chain of causation in infectious disease: (a)Elimination infectious agent:- - The nurse must be alert to the physiological changes in the infectious patient such as:- Elevated white blood cells. Pus or exudates. Purulent discharge from a wound. Production of thick sputum or cloudy urine. Elevated body’s temperature (Exceeding 38°c). (b)Reservoir:- Healthy personnel in hospital. Environmental cleaning and sanitation. Eliminate sources of body’s fluids, drainage, or solutions that might harbor micro-organisms. (c) Portal of exit:- Hand washing. Proper waste disposal. Proper handling of the blood, secretions &mucus. (d)Mode of transmission:- It is the weakest link in the infection chain 11 Action:- Hand washing. Proper food handling. Proper sterilization and disinfection of equipment. (e) Portal of entry:- Proper catheters care. Proper wound care. Proper closed drainage system care. Proper waste disposal, e.g. needle disposal. (f) Susceptible host:- Recognition of the high risk patients. Treatment of any underlying diseases. ▪ Infection control precautions: There are two major categories of infection control precautions:- Standard precautions. 1- 2- Transmission based precautions. 1-Standard precautions: Are measures for reducing the risk of micro-organisms transmission from both recognized and unrecognized source of infection. 1-Wash hands after touching blood, body fluids, secretions,… etc. 2- Wash hands immediately after gloves are removed. 3- Wear clean non sterile gloves when touching blood, body’s fluids, and secretions…….etc. 4- Wear a mask and eye protection and gown during patient’s care activities. 5- Discard single use items properly. 6- Prevent injuries when using needles 7- Avoid removing, recapping, bending or breaking used needles, never point the needle toward a body’s part. 2-Transmission based precautions: -Are also called isolation precautions. 12 -Are measures for controlling the spread of infection from patient known to be or suspected of being infected with highly transmissible pathogens. e.g. (Air born, droplet, and contact precautions). ▪ If an infection occurs, the following measures are to be done:- 1- Locating a patient in an equipping a room so that the pathogens are confined to one area. 2- Using personal protective equipment such as cover gowns, face protection devices and gloves to prevent spreading micro-organisms through direct and indirect contact. 3- Disposing of contaminated linen, equipment, and supplies in such a way that pathogens are not transferred to others. 4- Using infection control measures to prevent pathogens from spreading when transporting laboratory specimens. ▪ Role of the infection control nurse: 1- Providing staff education on infection control. 2- Reviewing infection control policies and procedures. 3- Reviewing patient’s records and laboratory reports to recommend appropriate isolation procedures. 4- Consulting with occupational health department concerning recommendations to prevent and control the infection among personnel e.g. T.B testing. 5- Gathering statistics regarding the epidemiology of nosocomial infection. 6- Notify the public health department of incidence of communicable disease. 7- Educating patients and families. 8- Identify infection control problems with equipment. 9- Checking micro organisms sensitivity to antibiotics and prevent resistance. 10- Communicate with hospital and community health care personnel. 13  Hand Hygiene Definition: A measure carried out to remove dirt and minimize of micro- organisms present on the skin surface using soap or antimicrobial liquid soap and friction. Purpose of hand washing: - To maintain a safe, clean environment. - To provide safety for the nurse and prevent cross contamination of patient or spread of microorganisms. - To prevent infection. Clinical situations in which hand should be washed: 1- Before and after any contact with patients or supplies or equipment that have had contact with the patient. 2- Before and after performing any procedure. 3- Whenever gloves are worn. 4- When handling blood, body fluids, secretion or excretion “contaminated equipment’s”. 5- After urinary and bowel eliminations. 6- Before eating to prevent transferring or acquiring microorganisms from the patient. 14 Types of hand hygiene: - Routine hand wash Water and non-anti-microbial soap. - Antiseptic hand wash Water and antimicrobial soap. - Antiseptic hand rub Alcohol-based hand rubs. - Surgical antisepsis Water and anti-microbial soap for hands and forearm Equipment: - Warm running water - Paper towel - Liquid soap - Hand lotion - Trash can 15  Routine hand washing procedure Nursing action Rational 1- Prepare and assess your hands: - To less carring of microorganisms. Roll sleeves to elbow. Nail must be short. 2- Remove your jewelry except wedding - Jewelry contains groves usually ring. which contains microorganisms. 3- Stand in front of sink: - For good body mechanics to avoid contamination. Keeping hands and uniform away from sink. 4- Adjust the temperature of water and - To avoid carrying moderate stream. microorganisms. 5- Wet your hand and wrists under - The running water mechanically running water. wash organisms. 6- Apply soap to the hands use: firm - Continue the motion for 15 rubbing, friction, circular movements seconds. to wash the palms, back, and wrist of each hand and interlacing fingers and thumb. 7- Rinse the hands - To facilitate run dirt and organisms into the sink. Wiping from the fingertips to the wrist and above. 8- Dry them with disposable towels, - Dry to skin prevents chapping. wiping from the fingertips to the wrist and above. - Discard the towels in a trash can use - To prevent recontamination of your foot to open. hands. - Take a fresh paper towel and turn off - Opened at start with contaminated the water faucets. hand. 16 17  Bed Bath Objectives: At the end of this lecture the students should be able to:- 1-Define bed bath. 2-List Purposes of bed bath. 3-Differentiate Types of bath. Outlines: 1. Introduction. 2. Definition of bed bath. 3. Purposes of bed bath. 4. Types of bath. 18 Introduction: Bed bath is important part of personal hygiene, maintenance of personal hygiene is necessary for an individual’s comfort, safety and sense of wellbeing. To provide skin care the nurse should understand the structure and function of the skin. Definition of bed bath: Cleansing the skin which stimulates circulation and reduces body odor by removing secretions, perspiration and bacteria from the skin. Purposes of bed bath: 1- To maintain patient hygiene and cleanliness 2- To provide patient with comfort and safety 3- To observe patient's skin for bed sore, rash, skin disease as scabies. 4- To improve the blood circulation to prevent bed sore and DVT. 5- To raise patient's spirit. Types of bathes:- 1- Complete bed bath: Administered to patients, who are totally dependent, the nurse gives the bath with the client in bed. It includes all parts of the body. 2- Partial bed bath: Consists of bath only body parts as (hands, face, axillaries and perineal area). 3- Morning care: This care before the breakfast and includes (Mouth; Face; and hand) used to prepare the patient to the activities of the day. 4- Evening care: This care before sleeping, includes (face, hands, feet, back rubbing; offer bed ban and urinal, used to help the patient to relax and sleep well. 19 Patients who need bed bath: 1- Comatosed patient. 2- patient suffering from cardiac problems 3- Patient suffering from fractures. 4- Big surgery. Equipments: 1- Table for the equipment. 2- Two dishes full of water with comfortable temperature. 3- Bath thermometer. 4- Kidney basin. 5- Cup. 6- Teeth brush and tooth paste. 7- Big bath towel. 8- Small bath towel (wash cloth). 9- -soap. 10- Rubbing alcohol if the patient fatty. 11- Oil or other emollient if the skin dry. 12- Comb or hair brush. 13- Normal saline. 14- Tongue depressor and gauze 5×5. 15- Scissors for nails. 16- Abron; terbone 17- Clean patient's gown. 18- Clean bed linens. 19- Bed ban and urinal. 20- Laundry bag or hamper. 21- Rubber sheet (mackintosh). 20  Procedure of Complete Bed Bath Nursing action Rational 1-Wash hand. To prevent across of infection. 2-Prepare all equipment. Nurses will not have to leave the patient during the procedure. 3-Explain the procedure to To be cooperative if he is conscious. the patient. 4-Close windows and To prevent air drafts. doors. 5-Keep the patient's To promote comfort. privacy. 6-Use good body To reduce the effort. mechanics. 7-Offer the bed ban or the To avoid disruption of the procedure. urinal to the patient. 8-Pull side rails up. 21 9-Loosen the bed cover at foot bed and fold it carefully into three parts. 10-Cover the patient with To keep his privacy. top sheet. 11-Remove the pillow & To promote comfort. rest the head of 30-45 degree. 12- Place a towel under the patient’s chin and cleans the patient’s teeth with paste & brush; let the patient to rinse his mouth with water. N.B: If the patient has an artificial teeth, remove it To dissolve the oral secretions carefully and clean. If the patient unconscious, clean his teeth by tongue blade & gauze 5x5 and normal saline. 13-Move the patient to the nearest bed side for you and put the towel under his head. 22 14-Wash the patient’s eyes To prevent the obstruction of the eye with plain warm water ducts, and to prevent the irritation of from inner to outer side in the eyes by soap. one direction without soap. 15-Fold the wash cloth around the fingers of your hand. 16-Ask the patient if he Many people not prefer soap on the prefers to use soap on his face. face or not. 17-Wash, rinse and dry well, start from forehead, nose, cheeks, ears, chin and neck. 18-Start from the farthest To prevent the spread of infection. side to the nearest side. 23 19-uncover the farthest Use the circular motion to stimulate the arm, then place the towel circulation. under it, wash well with soap and water, rinse and dry well. 20-Wash the nearest arm in the same way. 21-Place the bath towel N.B: change the water if it is soapy or over the patient’s chest cool. and abdomen, wash, rinse and dry, if the patient is a woman check under the To detect any irritation. breast. 22-Place towel under the N.B: observe any abnormality. leg and thighs farthest from you, wash, rinse and dry. 23-Wash the nearest leg in the same way. 24 24-Turn the patient on his To keep the body mechanics. side with back nearest to you. 25-Place the towel on the bed, washes, rinses and dry by circular motion and take care of boney area. 26-Back rubbing massage To improve the circulation. by: Alcohol if the patient is fatty. Or by panthenol if the patient is thin. 27-Do chest percussion. To remove the chest secretions. 28-Turn the patient on his back. 29-Place the towel on the bed under the patient’s feet, place wash basin on the towel, place the patient’s feet One at time in basin & wash particular between toes. 25 30-Remove the basin & Dry carefully between the toes to dry the feet, rub the ankle. prevent irritation. 31-Change the water & place The way of cleaning perineal area: mackintosh; towel and bed Pubic area in one direction ban under the patient’s The farthest libia majora from upper to buttocks, wash the perineal down in one direction area if the patient unable to do The nearest libia majora from upper to by herself. down in one direction N.B: If the patient is male call The farthest libia minora from upper to a male nurse to do this. down in one direction The nearest libia minora from upper to down in one direction The midline to the anus in one direction from up to down Rinse carefully with cup of water and dry well N.B observes the perineal area for any hair; bad odor or inflammation. 32-Wearing the patient a clean gown. 33-Clean, cut fingers by curved way and toes nails by straight way. 34-Comb the patient's hair. 35-Make occupied bed. 36-Replace the bathing equipment & discard the used one. 37-Leave the patient comfortable & check his condition. 38- Wash your hands & record nursing notes. 26  Hair shampoo Objectives: At the end of this lecture the student should be able to: Define hair shampoo. List the purposes of hair shampoo. Know who patients need hair shampoo. Outlines: Introduction Definition of hair shampoo Purposes of hair shampoo Who patients need hair shampoo 27 Introduction: Shampooing, combing and brushing are basic hygienic measures. Hair care is very important to a person’s body image. Definition of hair shampoo: Hair shampoo is a procedure operating to immobilize patient to stimulate circulation and reduces bad odor by removing secretions and bacteria from the hair. Purposes of hair shampoo: To clean hair and scalp. To stimulate circulation of scalp. To observe and assess the scalp for abscess, lices, dandruff. To promote comfort and wellbeing. To prevent complications. Who patients need hair shampoo: Comatose patient. Hemiplegia. Quadriplegia. Fracture in upper limbs. Equipments of clean hair: Table with:- Dish with warm water. Bath towel. Soap or shampoo. Rubber sheet. Sponge cotton. One cup. Comb. Lotion. Disposable gloves. Overhead. Large pail. 28  Procedure of Clean Hair Nursing action Rational 1-Five principles. 2-put on gloves. 3-Move the patient to the near To reduce the effort. side of bed. 4-place the bath towel around the To facilitate rolling it around the patient’s neck as fan. hair. 5-Fold and place rubber sheet under the patient’s head & shoulders as water course. 6-place pieces of sponge cotton in To prevent entrance of water into the patient’s ears. the ears. 7-Ask the patient to close his/her eyes, and then pour the warm water over the hair slowly and carefully by cup. 8-Use soap or shampoo slowly on hair and scalp. 9-Do massage with circular To stimulate circulation. motion using finger's tips and pressure on the scalp. 10-Rinse the hair with clean warm water. 11-Repeat the washing and rinsing if the hair unclean. 12-Remove the towel which Wrap the towel carefully to dry the around the patient’s neck and hair. wrap it around the hair. 29 13-Remove rubber sheet and Discard rubber sheet and cotton in sponge cotton from the patient’s the red box. ears. 14-Comb and arrange the hair of the patient. 15-Place overhead. 16-Leave the towel until completely hair dry. 17-Remove the equipments, and return it to the proper place. 18-Document nursing note. 30  Procedure of unclean hair N.B: Take informed consent from the patient or her family to cut her hair. Equipments: As the clean hair in addition to:- Drug as licide. Vaseline or oilment. Nursing action Rational 1-Five principles. 2-Put on disposable gloves. 3-Move the patient to the nearest side of the bed. 4-Remove the pillow. 5-Place Vaseline around forehead with piece of cotton. 6-Place cotton in the patient’s ears. 7-Place the towel around the patient’s neck. 8-Place the rubber sheet under the patient’s shoulders. 9-Divide the hair to tresses and wet it with licide, starting from the scalp to the end of the tress. Comb the hair to ensure distribution of licide and 10- treatment as doctor order at least one hour. 11- Wash the hair by the same way of clean hair. 12- Document nursing note. 31 III- Providing for patient safety :- Bed Making Objectives: At the end of this lecture the student should be able to:- 1- Define bed making. 2- Defrientiate between various types of beds. 3. List the purposes of bed making. 4- Apply body mechanics principles during performing bed making procedure. Outlines: 1- Introduction. 2- Definition of bed making. 3- Purposes of bed making. 4- Types of bed making. 32 Introduction: Making a bed is an important responsibility of the nurse. When the patient is admitted to a hospital, he will spend more time in bed. Therefore, the way a patient’s bed is made is very important to his comfort and feeling of wellbeing. Definition of bed making: It is the technique of preparing types of bed with scientific procedure to make patient comfortable. Purposes of bed making: 1- To provide safety by good alignment. 2- To provide psychological and emotional support. 3- To promote comfort. 4- To give the unit neat appearance. 5- To prevent injuries & complications. Types of bed making:- (A) Closed bed: This bed is not being used before, the top linens are not folded back, and this bed is ready to receive a new patient. (B) Open bed: This bed is being used before; the top linens are folded back, so that the patient can get easily into the bed. N.B: Closed bed becomes open by top linens are folded back. (C) Surgical bed ( post operative or recovery bed): This bed is to be made for receiving the patient after operation, so that the patient moved from the stretcher (trolley) to the bed. (D) Occupied bed: This bed is made when the patient lying in it during the procedure. 33 Equipments of bed making: 1- Bed with suitable mattress. 2- Mattress sheet (cover). 3- Bed side chair. Or table to place the equipment over it. 4- Bottom (lower) sheet. 5- Protective draw sheet. 6- Linen draw sheet. 7- Top (upper) sheet. 8- Blanket or spread according to the season. 9- Pillow case. 10- Disposable gloves. 11- Laundry bag. (Portable hamper). Equipments of occupied bed: As mentioned before, in addition to the following: 1- Dish with soapy water. 2- Cotton. 3- Clean gown to the patient. 4- Overhead. 5- Apron. 34  Procedure of bed making (Closed; open; surgical) Nursing action Rational 1-Five principles before any procedure: -wash hands. To prevent the spread of infection. -prepare the equipments outside the door. To safe time & effort. To gain the PT. cooperation. -introduce yourself to the patient & explain the procedure to him. To save his/ her dignity. -keep the patient’s privacy. -Apply body mechanics. To reduce fatigue & increase efficiency of work. 2- Put on disposable gloves. To prevent cross infection. 3-Fix the brakes of the bed by your To prevent any accident. foot. 4-Loosen the unclean sheets around the bed, starting from the head of the bed at foot. 5-Roll and discard the unclean sheets in laundry bag outside the door. 6-Change the position of the mattress. To be good ventilated; to be firm & comfortable. N.B: Don’t shake the mattress. To prevent spread of microorganism. 7- Draw untrue line in the middle of the mattress. 35 8-Place the bottom sheet in the middle of the mattress. 9-Make the edge of the bottom sheet equal to the edge of the mattress at the foot of the bed. 10-Insert the end of the bottom sheet To fix the sheet under the under the mattress at the head of the mattress. bed. 11-During sheet insertion, keep the To prevent injury of the hands. back of your hands to up. 12-Make corner and insert the side of the bottom sheet under the mattress. The corner gives beautiful view to the bed. The insertion of the linen for fixation of linen under the mattress. 13-During bed making prevent any Make linens tightly and firmly to wrinkles by tight or firm the linens to prevent bed sores. be smooth 0 14-place the protective draw sheet. To protect the mattress and lower sheet from wetting. 15-place linen draw sheet over the To protect the skin of the PT. protective draw sheet. from inflammation which leads to bed sores. 16- Place the top linen, where it’s edge equal to the edge of the mattress at the head of the bed. 36 17- Place the spread over the top linen, To prevent the friction of PT. with leaving a distance approximately chin by edge of linen to prevent 20cm between the edge of the top linen its injury. and the edge of the spread. 18-Insert both top linen and spread at To fix them. the foot of bed and make the corner. 19- Do bed making from one side to To safe time and effort. another one. 20- Perform the opening of the pillow case in the opposite direction of the door. To give beautiful view. 21- After finishing the Closed bed, make it open one. 22- Then loose the top linen and spread from the head and the leg of the bed, to make a triangle and roll it to the direction of the door. To facilitate the entry of the PT. into the bed. 23- Remove the gloves & discard it in an appropriate place. 24- Perform hands washing. 37  Procedure of occupied bed Definition: Occupied bed is making the bed during the presence of the patient inside it. Objectives: As mentioned before in page (32). Who are the patients need occupied bed? Bed ridden patients as: -Patient has amputation in lower limbs. -Hemiplegia or quadriplegia. -Fracture of lower limbs, pelvis or vertebral column. -Comatose patient. Nursing action Rational 1-Five principles. 2-Lower the head of the bed. 3-Put on disposable gloves. To prevent cross of infection. 4-Lower the bed rail near you and For patient’s safety. leave the other one elevated. 5-Loosen all top linens at foot of bed and remove spread or blanket. 6-Leave unclean top sheet over the To keep patient’s privacy. patient. 7-Raise side rail that the patient To protect the patient of falling. turned towards. 38 8-Assisst the patient to turn on the Support his neck and joints to side away from the nurse and toward prevent cervical disc or raised side rail, by placing his arms dislocation. on his chest and flex one leg on the other one. 9-loosen bottom linens on side of bed near the nurse. 10-Fan fold dirty linens separated This way facilitates removal of toward the center of bed as close to linens. and under the patient as possible. 11-Wipe off and dry the mattress as For cleaning and disinfecting it. needed. 12-Place new bottom sheet on bed and vertically fan fold the half to be used on far side of the bed as close to patient as possible. 13-Place protective draw sheet at the site of secretions. 39 14-Place linen draw sheet over protective draw sheet as in closed bed. 15-Mobilize the patient on the clean linens, and make the other side. 16-Place the upper linen and spread with leaving approximately 20cm between them after removing unclean linen that the patient was covered with it. 17-The nurse moved to the leg of the to prevent foot drop bed and holds the top linen and spread over the window of the bed to make foot fold. 18-Insert top linen and spread under the mattress, and make corner in two sides of bed. 19-Change pillow case and patient’s clothes. 20-place the patient in comfortable position. 21-Perform hand washing. 22-Document date, time, any observation, any complications and signature. 40  Positioning and transferring Objectives:- At the end of this lecture the student should be able to:- 1- Define positioning. 2- List purposes of positioning. 3- Identify description and uses of different positions. 4- Define transferring. 5- Enumerate the objectives of transferring. 6- Know the cases need for transferring. 7- Know the methods of transferring. Outlines:- 1- Definition of positioning. 2- Purposes of positioning. 3- Description and purposes of different positions. 4- Definition of transferring. 5- Objectives of transferring. 6- Cases need for transferring. 7- Methods of transferring. 41 Definition of positioning: Is a procedure performed daily by the nurse to protect the patient from any complications or prepare the patient for any procedure. Purposes of positioning: 1- To maintain body alignment. 2- To provide comfort for patients who are bed ridden. 3- To prepare the patient for any procedure. Description and uses of different positions: Positions:- 1- Supine position Description: Patient lies flat on back. Support the patient’s head and shoulders on a pillow. Placing the arms and hands at the patient’s side. The patient’s arms maybe supported with regular size pillows. The hands maybe supported on small pillows with the palms. Uses: For physical examination, resting in bed. 2- Dorsal recumbent position: Description: The patient lying on his back with the legs separated and the knee bent. The soles of the feet rest, flat on the bed. Uses: - Cleaning the female genital organs. - Catheterization in female. - Vaginal examination 42  3- Prone position: Description: Patient lies on abdomen with the head turned to one side. Placing small pillow under the patient’s head, one under the abdomen and other under the legs. The arms are flexed at the elbows and the hands are near the head. Placing a pillow under the legs is to position the patient, so that his feet hangover the end of the mattress. Uses: - Back examination. - Back massage. - To relieve pressure on the back, coccyx and hips. 4- Lateral position: Description: Patient lies on the side of the body with the top leg over the bottom leg. Placing a pillow under the patient’s head and shoulders. Supporting the top leg and thigh with a pillow. Placing a small pillow under the top hand and the arm. Positioning a pillow against the patient’s back. Uses: - Back examination. - To relieve pressure on bony prominence of the coccyx and sacrum. 43  5- Fowler’s position: Description: Elevating the head of the bed so that the patient is in a semi setting position. The head of the bed is elevated between 45 : 60 degree. Keeping the back straight. Supporting the head with a small pillow, and supporting the arms with pillows. Uses: - Oxygen therapy. - Ryle feeding. - After abdominal surgeries to relieve tension on incision. 6- Sims position: Description: Patient lies between lateral and prone with legs flexed in front of the patient. The lower arm is behind the patient. Place a pillow under the patient’s head and shoulders. Support the top leg with a pillow. Place a pillow under the top arm and hand. 44 Uses: - I.M injection. - Rectal and vaginal examination. - In recovery room after mouth operation. Uses on left side: - Enema. - Rectal suppository. - Measuring rectal temperature. 7- Knee- chest position: Description: The patient is turning on abdomen. The patient rest on his knees and chest, with the body flexed approximately 90°c at the hip. The head turned to one side rests on small pillow, the arms are flexed at elbow and rest bedside the patient’s head. Uses: Rectal examination. 8- Lithotomy position: Description: The patient lies on his back with his buttocks are brought to the edge of the table. The knees are flexed and the feet are supported in stirrups. 45  Uses: - Vaginal examination. - Delivery of neonate. - Pelvic and gynecological surgery and procedures. 9- Trendelenburg position: Description: Lying on back with arms at sides, bed positioned so that foot is higher than the head. Place the head of the bed lower than the feet. Uses:- -During some abdominal surgeries to shift abdominal contents upward. - Used in situations such as hypotension and medical emergencies. -It promotes venous return to major organs such as the head and heart. 46  10- Reverse Trendelenburg: Description: Lying on back with arms at sides, bed positioned so that head is higher than foot but with no flexion at waist. Uses:- - After certain angiography procedure, allows head of bed to be elevated without causing pressure on the femoral artery. - During certain abdominal surgeries to shift abdominal contents downward. 47 Definition of transferring: Moving a patient from place to another, such as from bed to a chair or stretcher or wheelchair with maximum comfort and safety for patient and nurse. Purposes of transferring: 1- To know the right method of patient’s transferring. 2- To prevent complications during patient’s transferring. 3- To provide safe transferring to patient or nurse. 4- To provide a change in body position of patient. 5- To transfer the patient to another place without injury. Cases which need for transferring: 1- Heart disease. 2- Unconscious patient. 3- After operation. 4- Paralysis in lower limbs. 5- Amputation in lower limbs. 6- Fracture. 7- Spinal cord surgery or injury. 8- From ICU to medicine unit. 9- Worsens of patient’s condition to ICU. 48 Methods of transferring: 1- By wheelchair. 2- By stretcher. 3- By a movable bed. 49 Types of patient’s transferring:- (1) Transferring the patient between bed and chair or wheelchair (a) One person’s technique for anterior transferring Equipments:- - Linen sheet, slippers, belt, pillow and robe. Procedure Nursing action Rational 1-Five principles. 2-Place the bed in low position. 3-Place the back of chair at the head of bed. 4-Lock the wheel of the chair and -for patient’s safety. bed, or use a wheel block. 5-Tell the patient what you are going -to be cooperative. to do. 6-Bring him to assisting position with his legs over the edge of the bed following the steps as shown in the illustration Bellow. 7-Let him rest a moment if he feels -to prevent fainting. dizzy. 50 8-Put his slippers on. 9-Put your arms around his chest and hold your hands together behind his back. 10-Support the leg that is farther from the wheelchair between your legs. 11-Lean back, shift your leg and lift. 12-Pivot your body towards the chair. 13-Ensure client safety. 14-Documentation. 51 (b) Two persons technique for posterior transferring Equipments:- - linen sheet, slippers, belt, pillow and robe. Procedure Nursing action Rational 1-Five principles. 2-One nurse stand behind the bed and put her hands under the patient’s axillary. 3-The other nurse stand in front of the chair and place her hands under the patient’s knees. 4-When ready (1,2,3,) elevate the patient together on the same time to move him and place him gently into the wheelchair. 5-cover the patient’s leg with linen and sure that he is comfortable. 52 (2) Transferring the patient from stretcher to bed (a)By using draw sheet and six persons after operation Nursing action Rational 1-Put the stretcher attached to the bed and three persons on bed, three persons in front of the stretcher. 2-With draw sheet six persons when ready (1,2,3,) elevate the patient on the same time to the bed and check all tubes. (b)By using three carriers lift:- Nursing action Rational 1-Put the stretcher on right angle (90°c) at the leg of bed. 2-put the arms of the patient on his chest. 3-One nurse put her arms under the patient’s neck and shoulders. 4-Another nurse, put her arms under the waist. 5-Another one, put her arms under the patient’s knees. 6- When three nurses are ready (1, 2, 3) hold the patient to their chest. 7-The moving start from the tallest nurse. 8-Place the patient gently on the bed. 53 (3) Moving the patient in the bed: Equipments:- - Pillows, Side rail, Draw sheet. Procedure Nursing action Rational (a) To up in the bed:- One person's technique:- 1-Ask the patient to flex his knees and catch with window of bed or side rails. 2-The nurse put one arm under patient’s knees and other arm under patient’s shoulders. 3-Ask the patient to grasp the head of the bed with both hands and pull during the move. Two persons technique with draw sheet:- 1-Place the patient’s arms on his chest. 2-Release bed side rails. 3-Each nurse in each side of bed. 4-With draw sheet elevate the patient to up. 5-Elevate the head of bed and raise bed side rails. 6-Provide appropriate support devices for the patient’s new position. 7-Decument all relevant information. 54  Nursing action Rational (b) Turning patient to the lateral side in bed:- 1-Place the patient’s arms on his chest. 2-The nurse place one arm under patient’s neck and shoulders and other arm under the patient’s knees. 3-Pull or roll the patient toward you to the lateral position. 4-Document all relevant information. 55  (4) Turning the patient in the bed:- Nursing action Rational (a) Toward the nurse:- 1-Place the patient’s arms on his chest. 2-The nurse put one hand around patient’s shoulders and other one around patient’s buttocks and maintain her body mechanics. 3-Roll the patient on his side toward her. 4-Support the patient’s back with pillow, and one between his legs and another one under his arm and one under his head. 5-Raise bed side rails. 6-Documents. (b) Away from the nurse:- 1-Place the patient’s arms on his chest. 2-The nurse support shoulders and buttocks then turn the patient to the opposite side of her. 3-Place pillow between legs, under head, and under patient’s arm. 4- Raise bed side rails. 5-Document. (5) Logrolling the patient:- 1-Place the patient’s arms on his chest. 2-Place supportive devices as pillow between his legs when turned. 3-Two nurses, one support patient’s shoulders, and other one support his buttocks and knees, then turn the patient on his side without flex his back in spinal cord injury or knee joints change. 56 IV- Assessing hemodynamic measures:- Measurement of vital signs (1) Body temperature Objectives: At the end of this lecture the student should be able to: 1- Define body temperature. 2- List kinds of body’s temperature. 3- State the normal body temperature range. 4- List factors affecting body temperature. 5- Identify the sites for taking body temperature. 6- Describe the types of thermometer. 7- Assess of body temperature Outlines: 1- Introduction 2- Definition 3- Kinds of body’s temperature 4- Normal range of body’s temperature 5- Purposes of measuring body’s temperature 6- Alterations in body’s temperature 7- The sites for taking body’s temperature 8- The types of thermometer 9- Factors affecting body’s temperature 10- Assessment of body’s temperature 57 Introduction: Body’s temperature is one of the vital signs which are: Temperature. Pulse. Respiration. Blood pressure. Definition of body temperature: Body temperature is the balance between the heat produced by the body and the heat lost from the body. Kinds of body temperature: ▪ Core temperature: Is the temperature of the deep tissues such as thorax and abdominal cavity, it remains relatively constant about 37°c. ▪ Surface temperature: Is the temperature of the skin and the subcutaneous tissues and fats; it rises and falls in response to the environment. Normal range of body temperature is: 36.5°c : 37.4°c Purposes of measuring body’s temperature: 1- To determine the health status. 2- To assess the patient’s condition. 3- To provide medical & nursing therapy. 4- To solve the patient’s problems. 58 Factors affecting body temperature: 1- Age. 2- Emotional states. 3- Exercises. 4- Hormonal influence. 5- Environment. 6- Drinking hot or cold liquids. 7- Smoking. Alterations in body’s temperature: Hyperthermia ( hyperpyrexia, pyrexia or fever): Definition: A body temperature above the normal range is called hyperthermia, pyrexia or fever. Hypothermia: Decrease body temperature below the normal range, this condition occurs when the body exposed to cold, which usually develop gradually. The sites of taking body temperature: The sites used for taking temperature should be: Closed to prevent air currents. Have abundant blood supply. 1- Oral temperature: There is a rich blood supply under the tongue. 2- Rectal temperature: The rectum is highly vascular, so it is the most accurate measurement of body temperature. 3- Axillary temperature 4- Aural ( ear ) temperature: The aural (ear) site is used with the recently developed tympanic membrane thermometer. 5- Rectal temperature 59 Types of thermometers:- 1-Electronic thermometer. 2-Mercury glass thermometer. 3-Tympanic membrane thermometer. 60 4-Chemical thermometer Contraindications of use the sites of temperature measurement: Oral site:- - children under 6 years. - confused or convulsive patient. - drinking or eating very hot or cold fluid or food for 15minutes. - patients with oral or nasal surgery. Rectal site:- Rectal surgery or inflammation. Constipation or diarrhea. Axillary site:- Surgery or inflammation in the axilla. Injury or fracture to the chest or the arm. Tympanic membrane ( aural site ):- Ear and tympanic membrane inflammation or surgery. Equipments of measuring oral temperature: Tray Equipments of hand washing Mercury glass thermometer Cup of sponge cotton Kidney basin Watch with second hand Red pen Vital signs sheet record Disposable gloves 61  Procedure of measuring oral temperature Nursing action Rational 1-five principles. 2-wash the thermometer with soap and running water. 3-wipe the thermometer with a clean sponge -from the least contaminated area cotton in circular motion from the bulb to the to more contaminated one stem end. 4-shake down thermometer until the mercury -Shake it gently to prevent column descends below 35°c. broking 5-ask the patient to open his mouth, then place the -not by teeth, to avoid braking of thermometer in one side of the mouth under the thermometer, to avoid poisoning tongue then close his lips. or inflammation of mucus membrane 6-leave the thermometer under the tongue for 3 minutes. 7-remove the thermometer and wipe it from the -oral secretions make it difficult to stem to the bulb end using a firm circular motion read in one direction. -wiping it in this way prevent spread of micro-organism 8-hold the thermometer at the eye level, rotation it to see the column of mercury. 9-read the thermometer and record the temperature as it is in follow up sheet. 10-wash the thermometer with soap and running water. 11-shake it down the mercury below 35°c and put it in it’s container. 12-wash your hands. 62  Procedure of measuring axillary temperature Equipments: Tray Mercury glass thermometer Cup of sponge cotton Cup with two big pi pieces of cotton Cup of water Disposable gloves Kidney basin Watch with second hand Red pen Vital signs sheet record Nursing action Rational 1-five principles. 2-put on disposable gloves. 3-expose the patient’s axilla. 4-clean the axilla site with wetting cotton in one direction. 5-dry with dry cotton in the same way. 6-prepare the thermometer. 7-place the bulb end of the thermometer in the center of axilla. 8-help the patient to put his arm tightly close to the chest. 9-leave the thermometer in this place for 5 minutes. 10-remove the thermometer and wipe it from stem to bulb. 11-record it after adding 0.5°c. 12-clean the thermometer and shake it down 35°c. 13-replace it in it’s container. 14-gather the equipment & wash your hands. 63  Procedure of measuring rectal temperature Equipments: Tray Rectal glass thermometer Disposable gloves Rubber sheet and towel Cup of water Cup of sponge cotton Kidney basin Watch with second hand Red pen Vital signs sheet record KY jell & gauze 5×5 Nursing action Rational 1-five principles. 2-put on disposable gloves. 3-prepare the thermometer. 4-help the patient for lying on a lateral position in the left side with upper leg flexed. 5-place rubber sheet & towel under the patient. 6-raise the upper buttock to expose the anus. 7-clean the anus with wet cotton and dry it in circular motion. 8-lubricate the thermometer with KY jell on gauze 5×5. 9-ask the patient to take deep breath & insert the bulb of thermometer approximately 1inch (2cm). 10-hold the thermometer by tips of your fingers and leave it for 1 minute. 11-remove the thermometer from the site & wipe it. 12-record the temperature after minus 0.5°c in vital signs sheet. 13-gather the equipment & wash your hands. 64 (2) Pulse Objectives: At the end of this lecture the student should be able to: Define pulse Mention characteristics of pulse List factors affecting pulse rate Locate pulse sites Measuring the pulse rate Outlines: 1- Introduction 2- Definition of pulse 3- Characteristics of pulse 4- Factors affecting pulse rate 5- Pulse sites 6- Abnormalities of pulse 65 Introduction: The stimulus for conduction of the heart normally starts as an electrical impulse in the senatorial (S A) node of the right atrium. In adults the SA node initiates the impulse 60: 100 beats per minute. The electrical impulse then spreads quickly through the conduction system to the remainder of the heart, so that the heart muscle fibers contract in a synchronous fashion. Irregularities of heart rhythm usually indicate a failure in the conduction system or origination of an impulse in a site other than the SA node. Definition of pulse: It is waves of blood forced through arteries by contraction of the left ventricle. Characteristics of pulse: a. Rate:- Is the number of pulsations felt over artery per minute. b. Rhythm:- Pulse rhythm refers to the time intervals between each pulse beat. c. Volume:- The strength of a pulse reflects the volume of blood ejected against the arterial wall with each heart contraction and the condition of the arterial vascular system leading to the pulse site. 66 Factors affecting pulse rate: (1) Age:- Pulse rate decreases with increase in age. Age Heart rate ( beats / min) Infant(1m:1yr) 120:160 b/m Toddler ( 1yr: 3yrs) 90:140 b/ m Preschoolers( 3yrs: 6yrs) 80:110 b/m School age( 6yrs: 12yrs) 74:100 b/ m Adolescent: adults 60:100 b/ m (2) Sex (3) Exercise (4) Temperature (5) Stress & emotions (6) Medication (7) Hemorrhage (8) Position changes (9) Pulmonary condition (10) Disease condition. Pulse sites: *Temporal *Carotid *Apical *Brachia *Radial *Ulnar *Femoral *Popliteal *Posterior tibia *Dorsalis pedis 67 Abnormalities of pulse: Tachycardia: Is an abnormally elevated pulse rate, above 100b/m in adults. Bradycardia: Is an abnormally slow pulse rate, below 60b/m in adults. Ventricular tachycardia: In which the pulse is weak ( heart rate 150- 250 b/m), discharging of impulses from hyperexcitable focus in the ventricles not from SA node.it is characterized by palpitation. Atrial fibrillation: In which the pulse is irregular, very weak to be felt at wrist, there is pulse deficit and palpitation. Measuring the radial pulse Equipments: Tray Watch with second hand Green pen Vital signs sheet Nursing action Rational 1-Five principles. 2-Place the patient in comfortable position, sitting or lying. 3-Place the forearm across region of lower abdomen or chest. 4-Put three fingers on the inside of the wrist in line with patient’s thumb, and observe the character, rest your thumb on the back of the patient’s wrist, press gently. 5-Count pulse for full one minute. 6-Record the pulse in the sheet, rate, strength and rhythm of the pulse. 7-Assist the patient in returning to comfortable position. 8-Report if there is any abnormality. 9-Gather the equipment & wash your hands. Respiration 68  Objectives: At the end of this lecture the student should be able to:- 1- Define the respiration. 2- List components of respiration. 3- Describe the respiratory cycle. 4- Describe the normal respiration. 5- List the factors affecting respiration. 6- Identify some respiratory patterns. Outlines: 1-Definition of respiration. 2-Components of respiration. 3-Respiratory cycle. 4-Normal respiration. 5-Factors affecting respiratory rate. 6-Some respiratory patterns. Definition of respiration:- Respiration is the exchange of gases between an organism and it’s environment. i.e. intake of oxygen and out put of carbon dioxide. 69 Components of respiration: External respiration:- this is the exchange of gases between blood in the pulmonary capillaries and the air in the lungs. Internal respiration:- this is the exchange between the blood and the tissue cells. The respiratory cycles: At rest a normal adult about 16T/m. Each respiration cycle consists of inspiration and expiration. Inspiration: a- The tips of the ribs are pulled upward and downward by contracting of the intercostal muscles. b-The dome shaped diaphragm is flattened by contraction of it’s muscles, the chest cavity is enlarged, the air pressure outside forces air into the lungs through the glottis. Expiration: a- The tips of the ribs move backwards. b-The muscles of the diaphragm relax and its bulges into the thorax, also the pressure of the abdominal organs. The chest cavity is reduced, the pressure inside is increase, and the air is driven out of the lungs, which being elastic, decrease in size. Normal respiration: Age R.R T/m At birth 30:40 t/m During 1st 26:30 t/m year of life During 2nd 20:26 t/m year of life Adolescence 18:20 t/m Middle age 16:18 t/m Old age 12:16 t/m 70 Factors causing variation in respiration: 1- Age 2- Sex 3- Rate 4- Exercise and muscular activity 5- During digestion 6- Diseased conditions 7- Drugs 8- Application of cold 9- Application of heat 10- Pain 11- Toxins 12- Fever 13- Hemorrhage 14- Change in atmospheric pressure. Identifying respiratory patterns ( on monitor screen: 71  Measuring of respiration Equipments: Tray Watch with second hand Black pen Vital signs sheet Nursing action Rational 1-wash your hands 2-Keep patient’s privacy 3-Put your hand against the patient’s Don’t explain the procedure chest as if continue taking the pulse, to the patient. or place the patient’s arm across his chest. 4-Observe each chest movement “rising& falling”. 5-Count each inspiration and expiration for one minute. 6-Observe the rate, depth and rhythm. 7-Record the rate in the sheet. 8-Report for any abnormality. Blood pressure 72  Objectives: At the end of this lecture the student should be able to:- 1- Define blood pressure. 2- Know normal range of blood pressure. 3- Recognize the homodynamic effects on blood pressure. 4- Mention the factors that influencing blood pressure. 5- Know equipments used for measuring blood pressure. 6- Apply the procedure of measuring blood pressure. Outlines: 1-Definition of blood pressure. 2-Normal range of blood pressure. 3-Homodynamic effects on blood pressure. 4-Factors that influencing blood pressure. 5-Equipments used for measuring blood pressure. 6-Procedure of measuring blood pressure. Definition of blood pressure: Blood pressure: It is the force exerted by blood against the walls of arteries. Systolic blood pressure:- It is the peak maximum pressure in the large arteries when the left ventricle pumps the blood into the aorta. Diastolic blood pressure:- It is the peak minimal pressure exerted on the wall of large arteries when the heart is relaxed. The standard unit of measuring blood pressure: It is millimeter of mercury ( mmhg ). 73 Normal range of blood pressure: 120/80 +/- 20/15 mmhg. Pulse pressure: It is the difference between systolic and diastolic pressure = 40mmhg. Hypertension: It is the persistent blood pressure measurements above the normal 140/90 mmhg. Hypotension: It is a condition in which blood pressure measurements below the normal 100/65 mmhg. Homodynamic effects on blood pressure: Increased blood pressure due to: Increased cardiac output. Increased blood volume. Increased viscosity. Decreased arterial elasticity. Decreased blood pressure due to: Decreased cardiac output. Decreased blood volume. Decreased blood viscosity. Increased arterial elasticity. Factors influencing blood pressure: 1- Age. 2- Stress. 3- Gender. 4-Race. 5-Medications. 74 Equipments used for measuring blood pressure: (A)A sphygmomanometer: Pressure manometer. An occlusive cloth cuff. A pressure bulb with a release Valve to inflate the cuff. The two types of manometer: Android and mercury: The Android manometer: It has a glass enclosed circular gauge containing a needle that registers millimeter calibrations. Mercury manometers: The mercury manometers are on upright tube containing mercury. 75 ( B ) A stethoscope: It is instrument used to listen to the sounds produced by the heart, lungs and other body’s organs. 76  Procedure of measuring blood pressure Nursing action Rational 1-Five principles. 2-Place the patient in comfortable position, -using the left arm makes B/P expose left arm, keep it at the level of the heart reading consistent over time. and the palm is up. 3-Place the cuff neither tight nor soft around -cuff should be applied over bare the patient’s bare arm above the antecubital arm, not over clothing; a mercury space. Put the sphygmomanometer gauge so column should be read at eye level that it is easily read. to obtain accurate reading. 4-Place ear tips of stethoscope in your ears Brachial pulse is located on the pointing forward, feel the brachial pulse with medial aspect of the antecubital your fingertips. Place the stethoscope over the space. artery where you felt the beat. 5-Close the valve of sphygmomanometer bulb. -inflating the cuff in this way helps Pump the bulb until the mercury column rises you to hear systolic B/P clearly. to 40mmhg over anticipated systolic pressure. 6-Release air from the cuff at a rate of about 2 -this point presents the systolic mmhg per minute and listen for korotk off's pressure. sounds. I.e. appearance of a faint clear Note the number on the scale at which you first tapping sound. hear sound. 7-Continue to release air in the cuff until you -this point represents the diastolic note the point at which the sound muffles. pressure. I.e. the loudness of the sound suddenly drops. 8-Allow the remaining air to escape, remove the cuff, and assist the patient in comfortable position. Recording findings according to agency policy. Clean the earpieces and diaphragm of the stethoscope with alcohol wipes. 9-Return equipments to proper place. 10-Wash your hands. 77 V- Implementing special nursing measures:- Medication Administration Definitions: - Medication: Is a substance administered for the diagnosis, treatment, relief of a symptom or for prevention of disease. - Drug: The term drug legally obtained “substance such as: Heroin, cocaine, or amphetamines”. - Antibody: A protein substance developed in response to presence of antigen in the body. - Antigen: A substance that causes formation of antibodies. 78  Effect of Drug Systemic effect Local effect The drug is absorbed into The drug is applied drug the circulation and carried administered. to the cell such as: - To skin mucous membrane Injection antiseptic such as: Alcohol Lotion - To mucous membrane: Drug applied to mouth, nose, throat Suppositories for rectum or vagina. Purpose: 1- For diagnosis of diseases (e.g., barium X-rays). 2- For disease management. 3- Drugs used for temporary relief of symptoms. 4- Drugs used to restore normal functions as digitals for “heart failure”. 5- Drugs used to cure disease as “quinine” to cure malaria. 6- Drugs used to prevent disease as “vaccines”. 7- To support body functions as “vitamins”. 79 Drugs forms: Solid, semisolid as: (Capsules – pills, tablets). Solutions on such as: (Sterile parental, syrup). Suspension such as: (Divided drug particles). Lotion: (Applied externally to protect the skin). Ointment semisolid: (Applied externally). Routes of Administration: Route Explanation 1. Oral - Swallowed by mouth as tablet, capsule or syrup. 2. Inhalation - Breathed in through a tube or mask. 3. Parenteral - Given by injection; I.M – S.C – I.V – I.D 4. Topical - Applied to the skin or mucous membrane. Vaginal: inserted into vagina. Rectal: inserted into the rectum. Sublingual: held under the tongue. Buccal: held inside the cheek. NB: Drugs may also be injected into heart tissues, spinal card by physician. 80 Factors that affect the drug administration 1. Size (weight). 2. Sex. 3. Age. 4. Patient condition. The essential component of drug orders: All orders should be written clearly and legibly contain 7 parts: 1- The name of the client. 2- The date and time when the order is written. 3- The name of the drug. 4- The dose. 5- The route by which it is to be administered. 6- The time administration and frequency. 7- The signature of the physician. (This makes the order a legal request) The five rights of drug administration: The nurse uses five guidelines to ensure safe drug administration: 1- The right patient. 2- The right drug. 3- The right dose. 4- The right route. 5- The right time. 81  The right patient: The nurse asks the patient to state his full name to avoid making the patient fell uneasy that the question is routine for giving a drug or identity card. The right drug: When administering drug, the nurse compares label of the drug container with the medicine ticket. a. Before removing the container from the shelf. b. As the amount of drug ordered is removed from container. c. Before returning the container to the shelf. e.g., tablet → tab Ampule → A Capsule → Cap Syrup → Syr The right dose: After calculating dosages, the nurse prepares the drug using standard measuring devices; such as spoons ➔ All of them refer to amount: Teaspoons = 5 cc Cup = 150 cc Tablespoons = 15 cc Can = 300 cc Sweet spoons = 10 cc 1 liter = 1000mlilliter =cc=ml ½ liter = 500mlilliliter =cc=ml ¼ liter = 250 milliliter =cc=ml 82 ➔ Refere to the dose of the drug: (Kg) =1000 gram kilogram Gram = 1000 Milligram Milligram. =100 micro. Gram 1 gram. =1000 Milligram ½ gram. = 500 Milligram ¼ gram. = 250 Milligram 1/8 gram. = 125 Milligram N.B: International unit (IU)=1cm AS: Insulin-clexan-heparine Tablet tab. Capsule cap. Ampule A Syrup syr. N.B: The day = 24 h. Times of the work = A : 8am. : 3pm B : 3pm : 8pm C : 8pm : 8am 83 ➔ The child dose: adult dose × the weight of the child in kilogram Dose of child = 68 kilogram of the medium wright of adult 𝑎𝑑𝑢𝑙𝑡 𝑑𝑜𝑠𝑒 ×𝑐ℎ𝑖𝑙𝑑′ 𝑠 𝑎𝑔𝑒 Dose of child 𝑐ℎ𝑖𝑙𝑑 𝑎𝑔𝑒 + 12 The right route: If the physician’s order doesn’t designate a route of administration, the nurse consults the physician. as: oral – inhalation – parenteral – topical. The right time: The nurse must know whether why drug is ordered for a certain time of the day and whether the time schedule can be altered. Ex: two drugs are ordered one every 8 hr and the other three time daily both medications are three times within 24 hr period, but given in different times. 84  Distribution Date Medications time / / / / / / 10:00 am Drug Dr. Concentration Drug forms name Signature 500 mg tab Pyral Time Route Duration Dose 1×3 Oral Date 1000 mg 2 tab Date / / 4:00 pm Time 10:00 pm Pharmacy→ Medications Dr. Drug Drug Signature Concentration name forms ½ gm Meronym Vail Duration Dose Time Route Date ½ gm 12/ h I.V Date 5 days / / Instructions of giving Time Pharmacy → 85 Frequency of Administration of Drugs: 1-Treatment of hours 2- Treatment of Times 3- Special orders Treatment of hours: it starts at 6 am in the morning. /2h. 24÷2h. =12 /4h. 24÷4h.= 6 Time time 6 am 6 am 8 am 10 am 10 am 2 pm 12 MD 6 pm 2 pm 10 pm 4 pm 2 am. 6 pm 8 pm 10 pm 12 MN 2 am 4 am 86  /6h. 6am /8h 6am 12 MD 2pm 6 pm 10pm 12 MN 6 am /12h. /24h 6am 6pm 10 am 10am Or: Or: 10pm Treatment of Times: it starts at 10 am. 1×1 1×2 10am 10 am =twice 10pm =once =at the morning 1×3 1×4 10am 10am =four times 2pm =three times 6pm 4pm 10pm =after meal 10pm 1×5 10am =five times 1pm 4pm 7pm 10pm 87  special order: Early morning At morning 610am am At night=*before sleep* 10 pm After lunch. 4 pm After meals =1x3 10 am 4 pm 10 pm Before meals. 9.30am 3.30pm 9.30pm Emergency: according to the case at the time doctor ordered Telephone orders: Saturday ‫السبت‬ Sunday ‫األحد‬ Monday ‫اإلثنين‬ Tuesday ‫الثالثاء‬ Wednesday ‫األربعاء‬ Thursday ‫الخميس‬ Friday ‫الجمعة‬ 88 Responsibilities of the nurse and rules for giving medication 1. Be sure you follow the five rights. 2. Ask the doctor if a written order is not clear as to the meaning or it can't be read well. 3. Don't give any medication for which there is no written order except in an emergency. 4. Wash your hands before preparing any medication. 5. Make certain all equipment is dry and clean. 6. Don't touch pills tablets or capsules with your hands pour them into the proper container directly from the bottle. 7. Don't put any medication back into the original container if it is not used. 8. Don't use any drug that has changed in odor, color, or consistency. 9. Don t pour a medicine from any bottle into another. 10. Know the maximum and minimum dosages for each medicine you give. 11. Don't permit one PT to take medicine to another PT. 12. If you make a mistake in giving a medication report it immediately to the doctor. 13. Always give the PT fresh water with the medicine unless contraindicated. 14. The nurse who pours a medicine must also give it and chart it. 15. Don't give medicine another nurse has prepared. 16. If a medicine card becomes soiled or wet make a new one immediately. 89 17. Measuring medicine: Measure the right dose. Don't allow interruptions when you are measuring. Hold the medicine glass at eye level and place your thumbnail of the hand holding the glass at the mark on the glass. 18. Labels of medication: Don't give any medicine that is not clearly labeled. For each medicine, you prepare to read the labeled 3time. Before taking the medicine from the shelf. Before/pouring the amount of medicine. Before putting the medicine bottle back on the shelf. 19. Pour liquid medicines from the bottle on the side opposite the label. 20. Ifa drug has two names that are often used, both should be on the label. 21. Giving medicines: Give the medicine at right time or before and after l/2hrtime. Be sure you give the medicine to the RT.PT. If the PT refuses to take the medicine or can't take it notify the doctor immediately. Stay with the PT until he takes the medicine. Never leave any medicine at the PT's bedside. Give only medicine which you have prepared. If the PT is to receive nothing by mouth no medicine are given unless ordered in writing by the doctor. If present many routes of admin started tab, syrup, and injection. 90 22. Charting medicine: Chart each medication as soon as it’s given. Chart if APT. refuses or can’t take the medicine. Chart only the medicine you gave. Chart: Time. Name of medicine. Sign your name. Chart effect the drug any unusual occurs and any complication about the medicine. Chert any mistakes you make in giving medicine. Never chart a medicine before you give it. 91  Administration of Oral Medication Equipment: Cup of medication. Medication. Gloves. Kidney basin. Cup of water. Tissue paper. Tray. Procedure Rational 1. Read patient’s medication - Be sure you have the 5 rights. record to determine medication 2. Wash your hands and prepare - To prevent the spread of equipment’s. microorganisms, save time and error free. 3. More medication from - Organization facilitates error free and container according to 3 steps save time. into the medication cup. 4. Prepare medication for one - This prevents errors in medication patient at a time. administration. 5. Multi-dose containers: when - removing tablets or capsules from a multi-dose bottle, pour the necessary number into the bottle cap and then place tablets in the medication cup. Don’t touch tab with hands. 92 6. At the level of the eye pour all - To prevent medication from staining the liquid medications; hold the tablet. bottle; so the table is against the palm of your right hand. Place your thumb nail of your left hand at the marking of medication glass. 7. Transport medications to the - patient’s bedside carefully. 8. Identify the patient using two - Encourage the patient’s participation in methods: taking the medications. a. Ask patient his or her name. b. Identity card (bracelet) 9. Assist the patient to an upright or sitting position. - 10.Remain with the patient until - To be sure that the patient takes each medication is swallowed. medication. Never leave medication of the patient’s bedside. 11.Perform hand hygiene leave - Prevent spread of microorganisms. the patient in confortable position within 30 minutes. 12.Recording - Documentation and additional assessment of effectiveness of pain relief and adverse. If the drug refused → record and report of doctor. 93  Administration of Eye Drops and ointments Equipment: Cup of medication. Eye drop. Sponge cotton with water. Sponge dry cotton. Kidney basin. Gloves. Tray. o Position of patient:- Supine or a sitting position Procedure Rational 1- The same steps from 1:4 2- Clean eye lids and eyelashes. 3- Using moistened cotton balls. 4- Wipe the eye from inner to outer - To protect tear duct from infection and dry. and obstruction. 5- Tell patient to look toward the ceiling. 6- Gently draw the lower eye lid. - To expose the conjunctival sac. 7- The dropper should be held 1 drop. 8- Apply ointment 1 cm in the sac. 9- Tell patient close eye and circular - For distribution. motion. 10- Give patient paper. - To protect face from any drop (tears) 11- The same steps from 10 : 12. 94  Administration of ear medication: Equipment: Gloves. Cup with warm water. Small sponge cotton. Kidney basin. Bath towel. Cup for medication. Small colon with water. Tray. o Position of the patient One side 10 minutes. Adult: Pull the auricle up and back. Children: younger than 3 years old pull the auricle down and back. This technique straightens the ear canal for proper channeling of medication. 95  Administration of medication via rectal suppository Equipment: Bath towel. Plastic draw sheet. Lubricant for anus suppository. Kidney basin. Cotton swap with water. Cotton dry swap. Gloves. Cup for medication. Tray. o Position of the patient: Lateral position left side because it anatomical position. Procedure Rational 1- The same steps from 1:4 2- Remove the suppository from the fail wrapper, apply lubricant to tip of suppository. 3- Put the patient in the left side. 4- Spread the buttocks and clean - To be sure it is clean. the opening with a wet sponge. 5- Ask the patient to take a deep - To help insertion of a suppository. breath. 6- Ask the patient to remain for about 10 minutes. 7- The same steps 10 : 12. 96  Administration of inhaler medication Equipment: Cup of water. Cotton sponge. Paper tissue. Gloves. Tray. Mouthpiece o Position of the patient: Sit up straight or standup Procedure Rational 1- The same steps for preparing. 2- Ask patient to sit up straight. 3- Remove the cap from the mouthpiece of inhaler and shake the inhaler vigorously to effectively. 4- Close lips around the spacer device and mouthpiece and breathe normally. 5- Inhale slowly and completely This makes the droplets into the for about 5 seconds; hold spacer mist stick together. breath for a count of 5 : 10 seconds. Then breathe out. 6- Don’t spray more than one puff. 7- Rinse the mouth following delivery of medication. 97  Injection Sterile procedure under clean technique Parental Method: Definition: It is a method of introducing liquid drugs into the tissue through a needle. Parts of syringe Syringe size 1 cc – 2 cc – 3 cc – 5 cc 10 cc – 20 cc – 50 cc Injection Degree & Angels 98 1- Administering Intradermal Injection: Are administered into the dermis Site: Anterior surface of the forearm. Purpose: For drug allergic test. For diagnosis. Local anesthesia Angle: 15o Equipment: Sterile syringe. Tray Alcohol. Medication as order. Cotton sponge. (Computer & rails) 99 2- Administering a subcutaneous Injection (S.C) Are administered into the adipose tissue layer just below the epidermis and dermis. Site: Upper are from front to back. Front of the thigh. Upper back. Abdominal (around the umbilical). Purpose: Easily to reach to it. A wide space for infection. There is not present a large nerve. Patient infects himself as (insulin). Absorption is faster. Angle: 45o 100 Administering an intramuscular Injection Intramuscular injections deliver medication through the skin and subcutaneous tissues into certain muscles. Site: Deltoid muscle. Gluteal muscle, upper outer quadrant. Vastus muscle. Purpose: Gluteal muscle, upper outer quadrant. There is not present nerves or blood vessel. Skin thin. Bone signs which guide to this place are known easily. → Vastus muscle: safety to children. Empty from nerve of blood vessels. Large size of muscle helps in taking large amount of medication. Ability to repeat injection in it for large size. → Deltoid muscle: Easily reach to it, do not need to take off clos. Inject small amount 1 ml only. 101 Complications of the injection: Injection of large dose of medication in I.M leads to: Pain. Necrosis of tissue. Strain to muscle tissue. Delay in medicine absorption. Injection in the same place leads to: Pain. Tissues become fibrosis. Tissues become inelastic. Wrong I.M injection leads to: Abscess. Sematic nerve injury leads to paralysis in leg. Injury tissue and inflammation. Infection. 102  Administration of Intravenous Infusion Objectives: At the end of this lecture the student should be able to:- 1- Define Intravenous therapy. 2- List the purposes of Intravenous Infusion. 3- Enumerate indications of Intravenous Infusion. 4- Know types of Intravenous fluids. 5- Know drop factor. 6- Use formula for flow rate calculation. 7- List complications of Intravenous therapy. Outlines: 1- Definition of Intravenous therapy. 2- Purposes of Intravenous Infusion. 3- Indications of Intravenous Infusion. 4- Types of Intravenous fluids. 5- Drop factors. 6- Formula for flow rate calculation. 7- Procedure of Intravenous therapy. 8- Complications of Intravenous therapy. 103 Definition of Intravenous therapy: Is therapy that delivers fluids directly into a vein as drips, supplied by gravity. Purposes of Intravenous Infusion: 1- Provide fluid and electrolyte maintenance. 2- Restoration of acid base balance. 3- Administer medication and nutritional feeding. 4- Administer blood and blood products. 5- Administer chemotherapy to cancer patients. Indications of Intravenous Infusion: 1. In case of fluid disturbances as in hemorrhage. 2. If the patient unable to eat or drink. 3. In case of electrolytes imbalance. 4. Post operative especially if the patient taken general anesthesia. 5. In emergency cases as cardiac arrest. 104  Types of Intravenous fluids Solutions Example 1. Isotonic:- 0.9% normal saline. Solutions that have the same 5% dextrose in water osmotic pressure of the blood ( D5W). plasma. Lactated ringer’s. 2. Hypotonic:- 0.45% normal saline. Solutions that have less osmotic pressure than blood plasma. 3. Hypertonic:- 3% normal saline. Has higher osmotic pressure 5% normal saline. than blood plasma. The cell has 10% Dextrose in water an excessive amount of solute (D10W). extracellular and osmosis is 5% Dextrose in 0.9% causing water to rush out of the normal saline. cell intracellular to the 5% Dextrose in 0.45% extracellular area which will normal saline. cause the cell to shrink. 5% Dextrose in lactated ringer’s. Manitol & Dextrose 25%. 4. Colloids:- Albumin 5%. Solutions which contain large Albumin 25%. molecules that don’t pass through semipermeable membrane and remain in the blood vessels. 105 5.Blood:- 45% blood cells+ 55% (a) whole blood:- plasma. Used to treat blood loss. (b) Packed cells:- Red blood cells. Used to treat anemia. (c ) Plasma substitute:- Used to improve circulating blood volume. (d) Fresh frozen plasma:- Water, lipids, vitamins Used to treat coagulation and proteins. disorders to correct hypoproteinemia, to restore blood volume. (e) Platelets:- Used for prothrombin time. Drop factors: One cm. of I.V. set = 15 drops / min. One cm. of blood set = 10 drops/ min. One cm. of micro drip set = 60 drops/min. 106 Formula for flow rate calculation: Amount of solution ( in / ml) × No. drops/ml. ____________________________________= drops/min. No. of hours × 60 min. EX. When the doctor’s order reads 500ml of G. 5% over 6hours. Use a regular drip set 500ml.× 15 drop/ ml _________________= 20 drop/ m. 6 hours × 60 min. Procedure of Intravenous therapy Equipments: Tray with: Prescribed bottle of solution. I.V. set. Cup of dry sponge cotton and another one of sponge cotton with alcohol. Cannula with suitable size. Tourniquet. Adhesive tape. Saline flush. Drip stand. Sterile gloves. Kidney basin. 107  Procedure of vein puncture Nursing action Rational 1-Five principles. 2-Select the site for vein puncture according to:- Availability of site. Size of cannula. Type, volume, rate and length of infusion. Age & condition of the patient. 3-Place the extremity well supported exposed to To facilitate light. choose of suitable vein. 4-Place tourniquet around the extremity, one hand above site of puncture. 5-Ask the patient to open & close his hand and keeping it closed until needle is in vein. 6-Allowing the extremity to hang down off the bed for a short time. 7-Palpate vein, when felt clean the site by cotton To prevent cross with alcohol. of infection. 8-Hold the needle at 45°c angle along side the wall of the vein and decrease angle until parallel with the skin and slightly to one side to puncture & enter the vein. 9-Enter slowly if there is a flow back of blood This is sign that through the needle the vein has been entered. the cannula is in correct site. 10-Fix the cannula with adhesive tape. 11-Write the date of cannula insertion on the adhesive tape. 108  Procedure of Intravenous therapy Nursing Rational 1-Wash your hands. -to reduce transmission of micro-organisms. 2-Gather the equipments. 3-Introduce yourself and explain the -this builds trust with patient purpose of the assessment. and allows time for the patient to ask questions. 4-Put on sterile gloves. 5-Checking bottle of fluid:- Checks it is the same fluid and quantity as prescribed on drug chart. Checks it is being given for the right patient and right reason. Checks if any additives required. Checks bottle in date. Checks bottle has not been tampered with no leaks. 6-Connecting fluid to I.V. set : Remove bottle from its outer casing. Remove cap from bottle. 109 7-Remove I.V. set from bag. -should be maintain aseptic technique. 8-close valve. 9-Insert giving set spike. 10-Squeeze giving set chamber until filled halfway. 11-Slowly opening valve to allow fluid to fill the line and drip into kidney basin. 12-Check no air bubbles in line. 13-Put on the prepared label over the solution bottle. 14-Prepare the cannula port:- Place apiece of dry cotton under cannula. Wipes port with alcohol wipe. Flush port with normal saline. 15-Hold the bottle on I. V. stand. 110 16-Connect the solution with cannula. 17-Regulates the solution flow according -this range if there is no to:- doctor’s order. Type of solution. Patient’s condition. Normal range 40:60 drop / min. 18-Dispose gloves and equipments into an appropriate clinical waste bin. 19-Wash hands. 20-Document including:- Date & time. Start of infusion and ending time Batch number on drug chart and fluids chart. Comments in patient’s notes. Your signature 111  Administration of oxygen therapy Objectives: At the end of this lecture the student should be able to: 1- Define the oxygen gas. 2- Define the oxygen therapy. 3- Know the sources of oxygen therapy. 4- List the purposes of oxygen therapy. 5- Recognize the indication of oxygen therapy. 6- Know the methods of oxygen therapy. Outlines: 1- Introduction. 2- Definition of oxygen. 3- Definition of oxygen therapy. 4- Sources of oxygen. 5- Purposes of oxygen therapy. 6- The commonest causes of oxygen lacking. 7- Methods of oxygen therapy. 8- Safety rules during oxygen therapy. 9- Procedure. 112 Introduction: Oxygen administration is a common supportive treatment for patients with acute respiratory failure and for those with chronic lung diseases and hypoxemia. The goal of this therapy is maintaining normal hemoglobin saturation, so as to facilitate normal oxygen delivery to peripheral tissues. Definition of oxygen: Oxygen is a colorless, odorless gas that is essential for the body to function properl