قناة تمريضيانو - كتاب أساسيات التمريض العملي PDF

‫قناة أولى تمريضيانو على التليجرام‬  FIRST YEAR FUNDAMENTAL OF NURSIN PRATICAL BOOK 0  Prepared By Dr. Mai El-Sayed Mohsen Medical- Surgical Nursing Dr. Mayada Soliman Rashed MSc. Abdullah Shokrey...

‫قناة أولى تمريضيانو على التليجرام‬  FIRST YEAR FUNDAMENTAL OF NURSIN PRATICAL BOOK 0  Prepared By Dr. Mai El-Sayed Mohsen Medical- Surgical Nursing Dr. Mayada Soliman Rashed MSc. Abdullah Shokrey Ismail Obstetrics and Gynecology Nursing Critical Care &Emergency Nursing MSc. Muhammad Said Seif Dr. Hanaa El-sayed Mohame Medical- Surgical Nursing Pediatric Nursing 1  List of content Procedure Page 1 Hand hygiene and Handwashing 1 2 Personal Protective Equipment (PPE) 12 3 Vital signs 27 4 Oxygen therapy 80 5 Body mechanics 88 Moving a patient up in bed procedure. 93 Assisting a patient to a sitting position procedure. 98 Moving a patient from bed to stretcher procedure. 103 Bed to wheelchair transfer procedure. 111 6 Bed bath 116 7 Bed making. 127 8 Medication administration 142 9 Urine spacemen 173 2  Hand hygiene and Handwashing Objectives: Students will be able to: Define of Hand Hygiene and Handwashing Differentiate between types of Hand Hygiene Determine equipment's needed during the procedure Demonstrate hand washing Procedures: o Antiseptic Hand rub o Antiseptic Handwash o Surgical Antisepsis Terms Hand Hygiene. It is a general term that applies to handwashing, antiseptic handwash, antiseptic hand rub, or surgical hand antisepsis Hand Washing. It is defined as the washing of hands with plain (i.e., non- antimicrobial) soap and water. Antiseptic Handwash. A term that applies to handwashing with an antimicrobial soap and water. Surgical Hand Antisepsis. Commonly called as a surgical hand scrub. This is to remove as many microorganisms from the hands as possible before the sterile procedure. Purposes The purposes of hand hygiene are: Hand washing can prevent infection Avoid pathogenic microorganisms and to avoid transmitting them 1 Types of Hand Hygiene The following are the types of hand hygiene: ▪ Routine handwash. Use of water and non-antimicrobial soap for the purpose of removing soil and transient microorganisms. ▪ Antiseptic handwash. Use of water and antimicrobial soap (e.g., chlorhexidine, iodine and iodophors, chloroxylenol, triclosan) for the purpose of removing or destroying transient microorganisms and reduce resident flora. ▪ Antiseptic hand rub. Use of alcohol-based hand rub. ▪ Surgical antisepsis. Use of water and antimicrobial soap (e.g., chlorhexidine, iodine and iodophors, chloroxylenol, triclosan) for the purpose of removing or destroying transient microorganisms and reduce resident flora. Recommended duration is 2-6 minutes. Indicators of Hand Hygiene According to the World Health Organization (WHO), there are Five Moments for Hand Hygiene: 1. Before Patient Contact. 2. Before and Antiseptic Task. 3. After Body Fluid Exposure Risk. 4. After Patient Contact. 5. After Contact with Patient Surroundings. Hand Hygiene Moments. Image via: WHO.int 2 Supplies Needed The following equipment are needed to perform hand washing: Soap or detergent Warm running water Paper towels Alcohol Optional: Antiseptic cleaner, fingernail brush, plastic cuticle stick Procedures Below is the step-by-step guide for different hand hygiene methods: Antiseptic Hand rub: The use of alcohol-based hand rub. Steps Rational 1. Ensure jewelers have been removed To avoid microorganisms to accumulate inside accessory 2. Apply quantity of alcohol-based hand To ensure cover all surfaces of hygiene product as per manufacturer’s your hands and fingers recommendations into cupped hand. 3. Rub hands palm to palm. Right palm over To clean all surfaces left dorsum with interlaced fingers and vice versa. 3 4. Backs of fingers to opposing palms with To be cleaned well fingers interlaced. 5. Rotational rubbing of left thumb clasped in To clean all fingers right palm and vice versa. Rotational rubbing, backwards and forwards with To clean under nails clasped fingers of right hand in left palm and vice versa. 6. Rubbing hands together until hands are dry before continuing with patient care, or put on gloves. 4 Antiseptic Hand wash Also known as clean technique, includes procedures used to reduce the number of organisms on hands. 5  Steps Rational 1.Prepare the necessary equipment (liquid or bar To save time and effort soap, paper towels, orange wood stick, lotion) 2. Stand in front of sink. Don't allow your uniform to To prevent cross infection touch the sink during the washing. 3. Remove jewelry & secure it in safe place. To avoid microorganisms to accumulate inside accessory 4. Turn on water & adjust force & regulate the To adjust water temperature temperature until the water is warm. 5. Wet the hands & wrist area. Keep hands lower than To avoid cross infection elbows to allow water to flow toward fingertips. 6. Use enough amount of liquid soap (3-5ml) from To cover all areas in hands dispenser or rinse bar of soap & leather thoroughly. 7.With firm rubbing and circular motions, wash the palms and backs of the hands, each finger, the To ensure cover all surfaces knuckles, wrists, and forearms. Continue this friction motion for 30 seconds. 8. Use fingernail of other hand or clean orangewood To clean under nails sticks to clean under fingernail. 9.Rinse thoroughly with water flowing towards the fingertips 10. Dry hands, beginning with fingers & moving upward toward forearm, with a paper towel & discard it immediately without touching other clean hands. 6 Surgical hand scrub Also known as sterile technique, prevents contamination of an open wound, serves to isolate the operative area from the unsterile environment, and maintains a sterile field for surgery Steps Rational 1. Remove all pieces of jewelry. To avoid microorganisms to accumulate inside accessory 2. Wet hands using sterile water with water To adjust water temperature closest to your body temperature. 3. Wash hands to elbow using antimicrobial soap To remove microorganisms and/or povidone-iodine. 4. Clean subungual areas with a nail file To remove microorganisms 7 5.Scrub each side of each finger, between the fingers, and the backs and fronts of the hands for at least 4 minutes. 6. Proceed to scrub the hands, keeping the hand to prevent bacteria-laden soap higher than the arm at all times. and water from contaminating the hands. 7. Rinse hands and arms by passing them through the flowing water in one direction only, from fingertips to elbow. To be cleaned 8. Proceed to the operating room holding hands above elbows. 9. Dry hands and arms using sterile towel observing aseptic technique. 8  Checklist for different types of hand hygiene Checklist for hand rub Steps Mark Trail 1 Trail 2 Trail 3 Comment 1.Ensure jewelers removed 2.Apply alcohol-based hand hygiene product. 3.Rub hands palm to palm. 4.Backs of fingers to opposing palms with fingers interlaced. 5.Rotational rubbing of the thumb clasped in palm. Rotational rubbing backwards and forwards with clasped fingers of the hand in palm. 6.Rubbing hands together until hands are dry before put on gloves. 9  Checklist for hand wash Steps Mark Trail 1 Trail 2 Trail 3 Comment 1. Prepare the necessary equipment. 2. Remove jewelry. 3.Stand in front of sink. 4.Turn on water & adjust temperature. 5.Wet the hands & wrist area. 6.Use enough amount of liquid soap & leather thoroughly. 7.With firm rubbing and circular motions, wash the palms, hands back, each finger, wrists, and forearms. Continue this friction motion for 30 seconds. 8.Use fingernail of other hand 9.Rinse thoroughly with water. 10.Dry hands & discard it immediately. 10  Checklist surgical hand scrub Steps Mark Trail 1 Trail 2 Trail 3 Comment 1. Remove all pieces of jewelry. 2. Wet hands using sterile water. 3. Wash hands to elbow using antimicrobial soap. 4. Clean subungual areas with a nail file. 5. Scrub each side of each finger, between the fingers, and the backs and fronts of the hands for at least 4 minutes. 6. Rinse hands and arms by passing them through the flowing water in one direction only, from fingertips to elbow. 7. Proceed to the operating room holding hands above elbows. 8. Dry hands and arms using sterile towel. 11  Personal Protective Equipment (PPE) Objectives: Students will be able to: Define of Personal protective equipment Describe the types of Personal protective equipment. Determine equipment's needed during the procedure Apply Personal protective equipment. Definition: Personal protective equipment (PPE) is a specialized clothing or equipment worn by healthcare providers for protection against health effects & safety hazards. It is designed to protect many parts ie. Eyes, head, face, hand, feet, ear. Purposes: To enhance easy handling of sterile equipment's. To reduce the risk of transmission of microorganism to patient. To reduce the risk of transmission of infectious agent to oneself. To prevent cross infections. To prevent wound infection post operatively. To prevent contamination of sterile field. Types of PPE: Foot protection (overshoes). Head protection (cap or overhead). Gowns/aprons – protect skin and/or clothing. Masks and respirators– protect mouth/nose & protect respiratory tract from airborne infectious agents. 12  Goggles – protect eyes. Face shields – protect face, mouth, nose, and eyes. Gloves – protect hands. The following is a demonstration of the full order of donning PPE: 13  Donning and doffing cap & mask Steps Rational 1. Wash hands Reduces transmission of microorganisms. 2. Apply cap to head, being sure to tuck hair prevent the transmission of under cap. Males with facial hair should use a organisms from the nurse to the hood to cover all hair on head and face. client. The cap also protects the nurse from infectious pathogens 3. Secure mask around mouth and nose For masks with strings: a. Hold mask by top and pinch metal strip over bridge of nose. b. Pull two top strings over ears and tie at upper back of head. c. Tie two lower ties around back of neck so that bottom of mask fits snugly under chin. 14 4. Enter the client’s room and explain the Minimizes anxiety and feelings of rationale for wearing a cap and mask. isolation Doffing of Cap & Mask 1. After performing necessary tasks, remove cap Reduces transmission of organisms. and mask before leaving room. 2. Untie bottom strings of mask first, then top Prevents contaminated surface of strings, and lift off of face. Hold mask by mask from contacting uniform. strings and discard. 3. Grasp top surface of cap and lift from head Minimizes contact of hands to hair 4. Wash hands after removing mask Reduces transmission of microorganisms. 5. Document the type of protective barriers used 15  Checklist Donning & Doffing of Gown Steps Mark Trail 1 Trail 2 Trail 3 Comment Wash hands Apply cap to head. 3.Secure mask around mouth and nose For masks with strings: a. Hold mask by top and pinch metal strip over bridge of nose. b. Pull two top strings over ears and tie. c. Tie two lower ties around back of neck so that bottom of mask fits snugly under chin. Doffing of Cap & Mask Remove cap and mask before leaving room. Untie strings of mask, and lift off of face. Hold mask by strings and discard. Grasp top surface of cap and lift from head Wash hands. Document the type of protective barriers used 16  Donning & Doffing gown Gowns or aprons Providing an effective barrier should be worn during invasive procedures likely to result in the splashing of blood or other body fluids. Purpose: 1- To prevents spread of microorganisms from the nurse to the patient 2- To prevents contamination of the nurse clothing from the patient. 3- To prevent spread of air borne microorganisms from the patient to the nurse Steps Rationale 1- Wash your hands. To prevent cross infection 2- Opens wrapped gown package. To be ready 4- Pick up the gown. 4-Unfolds the gown while holding the inner To keep sterile neck area. 5-Insert each arm in the gown. 17 6-Mack sure the gown completely covers the Gown should protect entire uniform. front of your uniform. 7-Tie the strings at the back of the neck. 8-Remove gown: A-Gown that is not visibly soiled requires no particular technique for removal. For gown that is visibly soiled: -- b-Untie neck strings of gown. - Neck strings are considered clean. Remove gown without touching outside of Outside of gown is contaminated. gown by keeping one hand up and under the 18 gown cuff and using this protected hand to pull the opposite sleeve down and off. C-Use ungowned arm and hand to grasp the To prevent cross infection. gown from the inside and remove from the remaining arm. Remove gown and turn inside out and drop in appropriate container. 9-Wash hands thoroughly. 19  Checklist Donning & Doffing gown Steps Mark Trail 1 Trail 2 Trail 3 Comment 1- Wash your hands. 2- Opens wrapped gown package. 5- Pick up the gown. 4-Unfolds the gown while holding the inner neck area. 5-Insert each arm in the gown. 6-Mack sure the gown completely covers the front of your uniform. 7-Tie the strings at the back of the neck. 8-Remove gown: A-Gown that is not visibly soiled requires no particular technique for removal. For gown that is visibly soiled: -- b-Untie neck strings of gown. Remove gown without touching outside of gown then pull the opposite sleeve down and off. C-. Remove gown and turn inside out and drop in appropriate container. 9- Wash hands thoroughly. 20  Donning & doffing gloving Gloves Must be worn for all in invasive procedures. Donning sterile gloves Steps Rationale 1-Wash and dry hands carefully. Hand washing deters the spread of microorganisms. Gloves are easier to don when hands are dry. 2- Choose the correct size glove. Glove must be fit 3- Place sterile glove package on clean, dry Moisture could contaminate the sterile surface above your waist. gloves. Any sterile object held below the waist is considered contaminated 4-Open the outside wrapper by carefully This maintains sterility of gloves in inner peeling the top layer back. Remove inner packet. package, handing only the outside of it. 21 5- Carefully open the inner package and -The inner surface of the package is expose the sterile gloves with the cuff considered sterile. end closest to you. 6- With the thumb and forefinger of -Unsterile hand only touches sterile of non-dominant hand, grasp the top glove. Outside remains sterile. edge of the folded cuff of the sterile glove for dominant hand. 7- Life and hold glove with fingers -Glove is contaminated if it touches un down. Be careful it does not touch any sterile objects. unsterile object. 8- Carefully insert the dominant hand -Attempts to turn upward with unsterile hand glove and pull glove on. Leave cuff folded may result in contamination of sterile glove down until other hand is gloved. 22 9- Holding thumb outward, slide fingers of -Thumb is less likely to become gloved hand under cuff of remaining glove contaminated if held outward and lift glove upward. 10- Carefully insert non-dominant hand -Sterile surface touching sterile surface into glove. Adjust gloves on both prevents contamination. hands touching only sterile areas. 23  Doffing sterile gloves Steps Rationale 1-Using dominant gloved hand, grasp other - Contaminated area does not come in glove near cuff end and remove by inverting contact with hands or wrists. it, keeping the contaminated area on the inside. Continue to hold on to glove. 2- Slide fingers of ungloved hand inside the - Contaminated area does not come in remaining glove. Grasp glove on inside and contact with hands or wrists. remove by turning inside out over hand and other glove. 1- Discard gloves in appropriate container - Hand washing reduces the spread of and wash hands. microorganisms. 24  Checklist Donning sterile gloves Steps Mark Trail 1 Trail 2 Trail 3 Comment 2- 1-Wash and dry hands carefully. 3- 4- 5- 6- 7- 2- Choose the correct size glove. 3- Place sterile glove package above your waist. 4-Open the outside wrapper. Remove inner package, handing only the outside of it. 5- Carefully open the inner package and expose the sterile gloves. 6- With the thumb and forefinger of non-dominant hand, grasp the top edge of the folded cuff of the sterile glove for dominant hand. 7- Life and hold glove with fingers down. 8- Carefully insert the dominant hand glove and pull glove on. 9- Holding thumb outward, slide fingers of gloved hand under cuff of remaining glove and lift glove upward. 10- Carefully insert non-dominant hand into glove. Adjust gloves on both hands. 25  Checklist Doffing sterile gloves Steps Mark Trail 1 Trail 2 Trail 3 Comment 1-Using dominant gloved hand, grasp the other glove near cuff end and remove by inverting it. 2- Slide fingers of ungloved hand inside the remaining glove. Grasp glove on inside and remove. 3-Discard gloves in appropriate container and wash hands. 26  Vital signs Objectives: Students will be able to: Define vital signs. List the purpose of vital signs. Identify times to assess vital signs. Definition: Taking vital signs are defined as the procedure that takes the sign of basic physiology that includes temperature, pulse, respiration and blood pressure. If any abnormality occurs in the body, vital signs change immediately. Purpose: 1. To assess the patient’s condition 2. To determine the baseline values for future comparisons 3. To detect changes and abnormalities in the condition of the patient. Times to assess vital signs: 1. Upon admission to any healthcare agency. 2. Based on agency institutional policy and procedures. 3. Any time there is a change in the patient’s condition. 4. Before and after surgical or invasive diagnostic procedures. 5. Before and after activity that may increase risk. 6.Before and after administering medications that affect cardiovascular or respiratory functioning. 7.Before and after any nursing intervention that could affect the vital signs (e.g., ambulating a client who has been on bed rest). 27  1-Body temperature Objectives: Students will be able to: Define body temperature. Discuss the physiology of Body Temperature. Identify times to assess vital signs. Describe how to select the proper method to measure body temperature. Identify factors that affect body temperature. Explain alterations in Body Temperature. Differentiate between types of thermometers. Demonstrate measuring body temperature procedure. Definition: Body temperature is the balance between heat produced in the tissues and heat lost to the environment. The normal range of the body temperature is between 36.5-37.5c. Physiology of Body Temperature: Body temperature is the balance between the heat production due to chemical activities by the body and heat lost from the body through radiation, conduction, convection, and vaporization (evaporation). 28 Method for Measuring Body Temperature: Method Advisable Inadvisable Oral (“O”) Most adults and children who Patients who have had oral are able to follow instructions surgery, mouth sores, dyspnea; for properly holding the uncooperative patients; patients thermometer. on oxygen; infants and small children Rectal (“R”) Infants and small children; Active children; those with patients who have had oral recent rectal surgery or surgery; mouth-breathing complaints of diarrhea. Patients; unconscious patients. Axillary Small children Patients who have underarm (“AX”) rash, excessive perspiration. Tympanic Small children Patient with in-the-ear hearing (Aural) aids, impacted cerumen, (“T”) earaches, or ear infections. Temporal Most adults, infants, and small No restrictions—possibly Artery children; patients who have had difficult with combative (“TA”) oral surgery; mouth-breathing children or newborns. patients; unconscious patients. 29 Factors Affecting Body Temperature Time of Day Body temperature is lower in the morning upon waking, when metabolism is still slow, and the body’s highest temperature usually occurs in the evening. Age Infants and children normally have a higher body temperature than adults. Gender Women may experience a slight increase in body temperature at the time of ovulation. Physical exercise Body temperature will rise during exercise. Emotions Emotions such as crying and anger can cause an increase in body temperature. Pregnancy An increase in metabolism during pregnancy may cause the body temperature to rise. Environmental Exposure to excessively hot/cold temperatures will Changes increase/decrease body temperature. Infection An elevated temperature may be one of the first signs of an infection. Drugs Drugs may increase muscular activity or metabolism, which in turn increases temperature. Antipyretic lower the above- normal temperature. Food The process of eating and digestion may cause a rise in the body temperature. Alterations in Body Temperature: Fever or pyrexia: is a body temperature above 38°C. The four most common types of fevers are: 30 1. Intermittent Fever: during this type of fever, the body temperature alternates at regular intervals between periods of fever and periods of normal temperatures. 2. Remittent Fever: during this type of fever, a wide range of temperature fluctuations occurs over the 2-hour period, all of which are above normal. 3. Relapsing Fever: In a relapsing fever, short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature. 4. Constant Fever: during a constant fever, the body temperature fluctuates minimally but always remains elevated. Hyperpyrexia or hyperthermia: is a very high fever (41.5 °C) resulting from a regulated rise in core body temperature, usually a response to a physiological threat, such as an infection. Hypothermia: defined as a body temperature below (35°C) and is the result of the body losing more heat than it is producing. Sites for Assessing Temperature: 1. Orally (common way). (3 – 5 min). 2. Axillary (safe way). + 0.5 °C (10 min). 3. Rectal (accurate reading). – 0.5 °C (2 – 3 min). 4. Tympanic membrane. 31 Types of thermometers: Measuring body temperature Equipment: Appropriate thermometer Soft tissue or Alcohol wipe Pen, vital sign flow sheet or record, or patient’s electronic medical record Clean gloves, plastic thermometer sleeve, disposable probe or sensor cover Towel. N STEPS RATIONALE 1. Identify the patient. To give care to the correct patient. 2. Assess the site for temperature. Help in identifying the most appropriate site for reading temperature. 3. Wash hands. Reduces risk of cross infection. 4. Collect equipment. Saves time and energy. 32 5. Assist client into a comfortable position, Relieves patient’s fears and anxiety explain procedure, and gain consent moreover it gains cooperation. A. Oral method 6. Ensure patient has not taken hot / cold Ensures correct reading. fluids and not smoked for at least 10 – 15 minutes. 7. Hold mercury thermometer at eye level, For accuracy of measurement. rotating slightly to ensure mercury line is visible. Check mercury is low enough to record the temperature. If not, shake it down in a downward direction (35°C) 8. Place thermometer under the client’s To ensure correct reading. tongue beside the frenulum. 9. Instruct the patient to: Close his / her To ensures accurate results and prevents mouth carefully with lips held firmly thermometer from falling out and together. Avoid biting down the breaking down. thermometer. Refrain from speaking. 10. Leave the thermometer in place for 3 – 5 To ensure correct reading. minutes. 11. Grasp the stem of the thermometer, ask Less likely to chip on the patients’ teeth the patient to open his /her mouth, or break the thermometer. remove the thermometer. 12. Wipe off any secretion from Wiping allows clear reading of thermometer with cotton swab / tissue. thermometer. Wiping is done from area Wipe in rotating fashion from finger to of least contamination to area of greater bulb end. contamination. 33 13. Read the thermometer at eye level (by Ensure accurate reading. slowly rotating). 14. Clean thermometer by alcohol swab To minimize cross-infection from clean to unclean part/ or according to local policy. 15. Record result noting any significant To ensure continuity of care and prompt change and report accordingly. attention if necessary B. Axillary method 6 Put the curtains around patient’s bed or Provides privacy and comfort. close door (as required) 7 Moisture conducts heat, and may give Ensure that axilla is dry. an inaccurate reading. 8 Move clothing or gown away from Provides optimal exposure of axilla. patient’s shoulder and arm. 9 Place the thermometer in center of axilla, Maintains proper position of lower the patient’s arm over the thermometer against blood vessels. thermometer, and place the forearm across the chest. 10 Gently hold the arm in place (if required). Movement can displace thermometer can give false reading and thermometer can fall and break. 11 Leave the thermometer in place for a Ensure accurate reading. minimum of 5 – 10 minutes. 12 Remove the thermometer, raise it to eye Ensure accurate reading. level, and note the reading. 13 Wash thermometer with soap and warm Avoid contact of microorganisms with water using firm twisted motion. Rinse nurse’s hand. with cold water/ or according to local policy. 34  Dry it with cotton swab / tissue using firm twisted motion. 15 Inform client of temperature reading. Promotes participation in care and understanding of health status. 16. Replace thermometer in the provided Storage container prevents breakage. case / antiseptic solution. 17. Wash hands. Reduce transmission of microorganisms 18. Document accurately on flow sheet. To ensure continuity of care and prompt attention if necessary 35  Checklist oral/ axillary body temperature Steps Mark Trail 1 Trail 2 Trail 3 Comment 1. Identify the patient. 2. Assess the site for temperature. 3. Wash hands. 4. Collect equipment. 5.Assist client into a comfortable position, explain procedure, and gain consent A. Oral method 6. Ensure patient has not taken hot / cold fluids and not smoked for at least 10 – 15 minutes. 7. Check mercury is low enough to record the temperature (35°C). 8. Place thermometer under the client’s tongue beside the frenulum. 9. Instruct the patient to: Close his / her mouth. Avoid biting down the thermometer. 10. Leave the thermometer in place for 3 – 5 minutes. 11. Grasp the stem of the thermometer, asks the patient to open his /her mouth, remove the thermometer. 12. Wipe off any secretion from thermometer with cotton swab / tissue. Wipe in rotating fashion from finger to bulb end. 36 13. Read the thermometer at eye level (by slowly rotating). 14. Clean thermometer by alcohol swab from clean to unclean part/ or according to local policy. 15. Record result noting any significant change and report accordingly. B. Axillary method 6. Close door. 7. Ensure that axilla is dry. 8. Move clothing or gown away from patient’s shoulder and arm. 9. Place the thermometer in center of axilla, lower the patient’s arm over the thermometer, and place the forearm across the chest. 10. Gently hold the arm in place. 11. Leave the thermometer in place for a minimum of 5 – 10 minutes. 12. Remove the thermometer, raise it to eye level, and note the reading. 13. Wash thermometer with soap and warm water. Rinse with cold water/ or according to local policy. 14. Dry it with cotton swab / tissue using firm twisted motion. 15. Replace thermometer in the case. 16. Wash hands. 17. Document accurately on flow sheet. 37  C. Tympanic membrane temperature with electronic infrared thermometer Equipment: Tympanic membrane thermometer. Disposable protective probe cover. Paper and pen; patient’s medical record. Waste container. Clean gloves. Disposable probe or sensor cover. Alcohol swab. Steps Rational 1. Identify the patient. To give care to correct patient. 2. Wash hands. Reduces risk of cross infection. 3. Collect equipment. Saves time and energy. 4.Help patient assume comfortable position Ensures comfort and exposes auditory with head turned toward side away from you. If canal for accurate temperature patient has been lying on side, use upper ear. measurement. 5. Note if there is obvious earwax in patient’s Earwax on lens cover blocks a clear optical ear canal. pathway. 6. Remove the thermometer from its base. The Prepares it to measure temperature display should read “Ready.” 7. Attach a disposable probe cover to the Soft plastic probe cover prevents earpiece. transmission of microorganisms between patients. 38 8. With one hand, gently pull upward and out Straightens the external auditory canal; on the patient’s outer ear if an adult. Pull back allows maximum exposure of the tympanic and downward if the patient is an infant or membrane. child. 9.Gently insert the plastic-covered tip of the probe into the ear canal. 10. Activate the thermometer by pressing the Pressing scan button causes detection of scan button. Observe the temperature reading in infrared energy. the display window. 11. Gently withdraw the thermometer from the Prevents rubbing of sensitive outer ear ear canal. lining. 12. Dispose of the used probe cover into a waste Reduces transmission of microorganisms. container by pressing the eject button. 13. If temperature is abnormal a second reading To accurate measure is necessary. Repeat in another ear. 14. Help patient get into a comfortable position. Restores comfort and sense of well-being. 15. Return the tympanic membrane Automatically causes digital reading to thermometer to its base. disappear and prevents damage to Sensor. 16. Perform hand hygiene. Reduces transmission of microorganisms 17. Record the temperature in the patient’s To ensure continuity of care and prompt medical record, and which ear was used. attention if necessary -Report any abnormality finding. 39  Checklist tympanic membrane temperature with electronic infrared thermometer Steps Mark Trail 1 Trail 2 Trail 3 Comment 1. Identify the patient. 2. Wash hands. 3. Collect equipment. 4. Help the patient to head turned toward side away from you. 5. Note if there is obvious earwax in patient’s ear canal. 6. Remove the thermometer from its base. The display should read “Ready.” 7. Attach a disposable probe cover to the earpiece. 8. With one hand, gently pull upward and out on the patient’s outer ear if an adult. Pull back and downward if the patient is an infant or child. 9.Gently insert the plastic-covered tip of the probe into the ear canal. 10. Activate the thermometer by pressing the scan button. 11. Gently withdraw the thermometer from the ear canal. 12. Dispose of the used probe cover into a waste container. 13. If temperature is abnormal. Repeat in another ear. 14. Help patient get into a comfortable position. 15. Return the tympanic membrane thermometer to its base. 16. Perform hand hygiene. 17. Document, and report any abnormality. - Documentation provides coordination of care 40  D. Rectal temperature measurement with electronic thermometer Equipment: Gloves. Disposable bag. Lubricant. Appropriate chart. Appropriate thermometer. Modesty sheet/towel to protect patient’s dignity. Steps Rationale 1. Identify the patient. To give care to correct patient. 2. Wash hands. Reduces risk of cross infection. 3. Collect equipment. Saves time and energy. 4. Screen the bed/close door. Promotes comfort and dignity; minimizes embarrassment. 5. Assist client into lateral position with upper For patient comfort and dignity. leg flexed; keep majority of client covered; expose anal area only. 6. Apply lubricant to a tissue and dip end of Minimizes trauma to rectal mucosa during thermometer into lubricant. insertion. Using tissue avoids contamination of tube/container. 7. Ask client to relax and take deep breaths Relaxes anal sphincter for ease of With non-dominant hand separate client’s insertion. buttocks to expose anus. 41 8. Insert the thermometer no more than 5 cm into To prevent trauma. the rectum and hold the thermometer in place. To allow adequate time for the Allow the thermometer time to register thermometer to register. (minimum two minutes). Note the Reading 9. Wipe client’s anal area with a soft tissue; To promote comfort and prevent cross- remove gloves and dispose in waste bag. infection. 10. Assist the client into a comfortable position To promote client comfort and adhere to and record on measurement chart. legislation surrounding record keeping. 11. Clean thermometer, adhering to local policy. To minimize the risk of cross-infection. 12. Perform hand hygiene. Reduces transmission of microorganisms. 13. Document, Report any significant change or To ensure prompt attention. abnormality 42  Checklist Rectal temperature measurement with electronic thermometer Steps Mark Trail 1 Trail 2 Trail 3 Comment 1. Identify the patient. 2. Wash hands. 3. Collect equipment. 4. Screen the bed/close door. 5. Assist client into lateral position with upper leg flexed; expose anal area only. 6. Apply lubricant to a tissue and dip end of thermometer into lubricant. 7. Ask client to relax and take deep breaths. With non-dominant hand separate client’s buttocks to expose anus. 8. Insert the thermometer no more than 5 cm into the rectum and hold the thermometer in place. Allow the thermometer time to register (minimum two minutes). Note the reading. 9. Wipe client’s anal area with a soft tissue; remove gloves and dispose in waste bag. 10. Assist the client into a comfortable position. 11. Clean thermometer, adhering to local policy. 12. Perform hand hygiene. 13. Document, Report any significant change or abnormality 43  E. Temporal artery temperature measurement with electronic infrared thermometer Steps Rational 1. Identify the patient. To give care to correct patient. 2. Wash hands. Reduces risk of cross infection. 3. Collect equipment. Saves time and energy. 4. Ensure that forehead is dry; wipe with towel Moist skin interferes with thermometer if needed. sensor 5. Remove the cap from the probe of the To prevent infection. thermometer, and disinfect the probe by gently wiping it with an alcohol swab. 6. Place sensor flush on patient’s forehead above Contact avoids measurement of ambient eyebrow. temperature. 7. Press red scan button with your thumb. Scanning for highest temperature Slowly slide thermometer straight across continues until you release scan button. forehead while keeping sensor flush on skin. 8. Keeping scan button pressed, lift sensor from Sensor confirms highest temperature forehead and touch sensor to skin on neck, just behind earlobe. behind earlobe. Peak temperature occurs when clicking sound during scanning stops. Release scan button and note reading. 9. Clean sensor with alcohol swab. Prevents transmission of microorganisms. 10. Return thermometer to charger or Maintains battery charge of thermometer thermometer base. unit. 11. Perform hand hygiene. Reduces transmission of microorganism 12. Document, Report any abnormality To ensure prompt attention. 44  Checklist Temporal artery temperature measurement with electronic infrared thermometer Steps Mark Trail 1 Trail 2 Trail 3 Comment 1. Identify the patient. 2. Wash hands. 3. Collect equipment. 4. Ensure that forehead is dry; wipe with towel if needed. 5. Remove the cap from the probe of the thermometer, and disinfect the probe by gently wiping it with an alcohol swab. 6. Place sensor flush on patient’s forehead above eyebrow. 7. Press red scan button with your thumb. Slowly slide thermometer straight across forehead while keeping sensor flush on skin. 8. Keeping scan button pressed, lift sensor from forehead and touch sensor to skin on neck, just behind earlobe. Peak temperature occurs when clicking sound during scanning stops. Release scan button and note reading. 9. Clean sensor with alcohol swab. 10. Return thermometer to charger. 11. Perform hand hygiene. 12. Document, Report any significant change or abnormality 13. Document, Report any significant change or abnormality 45  F. Temperature Using a Heat-Sensitive Wearable Thermometer Steps Rational 1. Identify the patient. To give care to correct patient. 2. Wash hands. Reduces risk of cross infection. 3. Collect equipment. Saves time and energy. 4. Ensure that forehead is dry; wipe with towel Moist skin interferes with thermometer if needed. sensor 5. Place the thermometer strip on the forehead To measure. and begin timing for 15 seconds. 6. After 15 seconds, read the correct temperature by reading the color changes. 7. Discard the strip in the waste container. Prevents transmission of microorganisms. 8. Perform hand hygiene. Reduces transmission of microorganism 9. Document, Report any abnormality To ensure prompt attention. 46  Checklist Temperature Using a Heat-Sensitive Wearable Thermometer Steps Mark Trail 1 Trail 2 Trail 3 Comment 1. Identify the patient. 2. Wash hands. 3. Collect equipment. 4. Ensure that forehead is dry; wipe with towel if needed. 5. Place the thermometer strip on the forehead and begin timing for 15 seconds. 6. After 15 seconds, read the correct temperature by reading the color changes. 7. Discard the strip in the waste container. 8. Perform hand hygiene. 9. Document, Report any abnormality 47  2- Pulse measurement Objectives: Students will be able to: Define Pulse. List Purpose to pulse measurement. Describe characteristics of pulse rate. Identify factors that affect pulse rate. Identify the nine pulse site locations on the human body. Demonstrate measuring pulse procedure. Definition: Pulse is pressure of blood pushing against wall of artery as heart beats and rests per minute (bpm). The normal pulse rate in adult is (60 – 100 beat/min.). Purpose to pulse measurement: 1. To determine number of heart beats occurring per minute (rate). 2. To gather information about heart rhythm and pattern of beats. 3. To evaluate strength of pulse. 4. To assess heart's ability to deliver blood to distant areas of the blood viz. fingers and lower extremities. 5. To assess response of heart to cardiac medications, activity, blood volume and gas exchange. 6. To assess vascular status of limbs. Characteristics of Pulse (Normal/ Abnormal): 1. Pulse quality: refers to the ‘‘feel’’ of the pulse, its rhythm and forcefulness 2. Pulse rate: is an indirect measurement of cardiac output obtained by counting the number of apical or peripheral pulse waves over a pulse point. 48  - A normal pulse rate for adults is between 60 and 100 beats per minute. - Bradycardia: is a heart rate less than 60 beats per minute in an adult. - Tachycardia: is a heart rate in excess of 100 beats per minute in an adult. 3. Pulse rhythm: is the regularity of the heartbeat. It describes how evenly the heart is beating: - Regular (the beats are evenly spaced). - Irregular (the beats are not evenly spaced). - Dysrhythmia (arrhythmia): is an irregular rhythm caused by an early, late, or missed heartbeat. 4. Pulse volume: is a measurement of the strength or amplitude of force exerted by the ejected blood against the arterial wall with each contraction. - It is described as normal (full, easily palpable). - Weak (49hread and usually rapid), or - Strong (bounding). Factors That Influence Pulse Rate Exercise Activity increases pulse rate. Rate may increase 20–30 bpm, based on the intensity of activity. Age As age increases, pulse rate decreases. Infants and children have a faster pulse rate than adults. Gender Female pulse rate is about 10 bpm higher than a male of the same age. Physical condition Athletes and people in good physical condition have lower pulse rates. Size Pulse rate is proportionate to the size of the body. Heat loss is greater in a small body, resulting in the heart pumping faster to compensate. Disease condition Pulse rate is increased in certain disease conditions such as thyroid disease, fever, and shock. 49 Medication Many medications can either raise or lower the pulse rate. Medications such as digoxin are given to regulate the heartbeat. Caffeine and nicotine can increase the heart rate in certain people. Depression May lower the pulse rate. Fear, Anxiety, Anger May raise the pulse rate. Sites of Taking Pulse Rate: 50  Location of Common Pulse Sites Radial Radial Thumb side of wrist about 1 inch below base of thumb (most frequently used site). Brachial Brachial Inner (antecubital fossa/space) aspect of the elbow (pulse heard when taking BP). Carotid. Carotid At side of neck between larynx and sternocleidomastoid muscle (pulse used in CPR). Temporal. Temporal At side of head just above the ear Femoral. Femoral In groin where femoral artery passes to leg Popliteal. Popliteal Behind the knee; pulse located deeply behind the knee and felt when knee is slightly bent Posterior Tibial. Posterior Tibial On medial surface of ankle near ankle bone Dorsalis Pedis. Dorsalis Pedis On top of foot slightly lateral to midline; helps assess adequate blood circulation to the foot Apical. Apical At apex of heart; left of sternum, 4th or 5th intercostal space below the nipple Measuring Radial / Apical pulse Equipment: Stethoscope (apical pulse only). Wristwatch with second hand or digital display. Pen, vital sign flow sheet, or patient’s electronic health record. Radial pulse N STEPS RATIONALE 1. Identify the patient. To give care to the correct patient. 2. Wash hands. Prevents the risk of cross infection. 3. Prepare the equipment. Saves time and energy and prevents interruption during procedure. 51 4. Explain procedure to patient. Gains cooperation, reduced patient’s anxiety. 5. Place patient in a comfortable position. Relaxed position of lower arm and extension of wrist permits full exposure of artery for palpation. 6. Place tips of first two or middle three Fingers tip are most sensitive parts of fingers of dominant hand over groove hand to palpate arterial pulsation. Thumb along radial or thumb side of patient’s has pulsation that may interfere with inner wrist. accuracy. 7. Lightly compress against radius; press Pulse is more accurately assessed with pulse initially, and then relax pressure so moderate pressure. Too much pressure pulse becomes easily palpable. occludes pulse and impairs blood flow. 8. Using a watch with a second hand, count Sufficient time is necessary to assess the the number of pulsations felt for 1 rate, rhythm and amplitude of the pulse. minute. 9. Assess the pulse, rhythm, and amplitude Irregularity in heart rate may disrupt the while counting rate. cardiac output. Amplitude of pulse indicates the quality of the heart’s contraction. 10. Wash hands. Prevents risk of cross infection. 11. Record pulse rate on flow sheet, site, Promotes continuity of care. rhythm and amplitude in nurse’s notes (if abnormal). 52  Apical pulse N STEP RATIONAL 1 Identify the patient. To give care to the correct patient. 2 Wash hands. Prevents the risk of cross infection. 3 Prepare the equipment. Saves time and energy and prevents interruption during procedure. 4 Explain procedure to patient. Gains cooperation, reduced patient’s anxiety. 5 Clean earpieces and diaphragm of Reduces transmission of stethoscope with alcohol swab. microorganisms. 6 Draw curtain around bed and/or close Maintains privacy door 7 Help patient to supine or sitting position. Provides easy access to pulse sites. Move aside bed linen and gown to expose sternum and left side of chest. 8 Place diaphragm of stethoscope in palm Warming of metal or plastic of hand for 5 to 10 seconds. diaphragm prevents patient from being startled and promotes comfort 9 Place diaphragm of stethoscope over Determine apical site accurately to be apical impulse at fifth intercostal space at able to auscultate sounds clearly. left midclavicular line and auscultate for heart sounds. 10 If apical rate is regular, count for 30 Regular rate is accurate when seconds and multiply by 2. measured for 30 seconds. 11 Note if heart rate is irregular and describe Irregular heart rate indicates pattern or irregularity. dysrhythmia. Regular occurrence of dysrhythmia within 1 minute 53 12 Replace patient’s gown and bed linen; Provides privacy and minimizes help patient return to comfortable embarrassment. position. 13 Clean earpieces and diaphragm of Prevents transmission of stethoscope with alcohol swab routinely microorganisms. after each use. 14 Perform hand hygiene. Perform hand hygiene. Reduces transmission of microorganisms. 15 Record pulse rate on flow sheet, site, Promotes continuity of care. rhythm and amplitude in nurse’s notes (if abnormal). 54  Checklist radial pulse Steps Mark Trail 1 Trail 2 Trail 3 Comment 1. Identify the patient. 2. Wash hands. 3. Prepare the equipment. 4. Explain procedure to patient. 5. Place patient in a comfortable position. 6. Place tips of first two or middle three fingers of dominant hand over groove along radial or thumb side of patient’s inner wrist. 7. Lightly compress against radius; press pulse initially, and then relax pressure. 8. Using a watch with a second hand, count the number of pulsations felt for 1 minute. 9. Assess the pulse, rhythm, and amplitude while counting rate. 10. Wash hands. 11. Record pulse rate on flow sheet, site, rhythm and amplitude in nurse’s notes (if abnormal). 55  Checklist Apical pulse Steps Mark Trail 1 Trail 2 Trail 3 Comment 1. Identify the patient. 2. Wash hands. 3. Prepare the equipment. 4. Explain procedure to patient. 5. Clean earpieces and diaphragm of stethoscope with alcohol swab. 6. close door 7. Help patient to supine or sitting position. Move aside bed linen and gown to expose sternum and left side of chest. 8. Place diaphragm of stethoscope in palm of hand for 5 to 10 seconds. 9. Place diaphragm of stethoscope over apical impulse at fifth intercostal space at left midclavicular line and auscultate for heart sounds. 10. Note if heart rate is irregular and describe pattern or irregularity. 11. Replace patient’s gown and bed linen; help patient return to comfortable position. 12. Clean earpieces and diaphragm of stethoscope with alcohol swab routinely after each use. 13. Perform hand hygiene. 14. Record pulse rate, site, rhythm and amplitude in nurse’s notes (if abnormal). 56  3- RESPIRATION Objectives: Students will be able to: Define respiration. List Purpose to respiration measurement. Describe characteristics of respiration rate. Identify factors that affect respiratory rate. Demonstrate measuring respiration procedure. Definition: Respiration, or the act of breathing, is the process of inhaling oxygen into the body and exhaling carbon dioxide. Respiratory cycle: consists of one expiration (exhalation) and one inspiration (inhalation). Purposes to respiration measurement: 1.To determines number of respirations occurring per minute. 2. To gather information about rhythm and depth. 3. To assess response of patient to any related therapy/ medication. Characteristics of Respiration (Normal/ Abnormal): Respiratory rate: is the number of respirations per minute. The normal respiration rate for healthy adults at rest is 12 to 20 cycles per minute. Tachypnea: is a respiratory rate greater than 20 breaths per minute. Bradypnea: is a respiratory rate of 12 or fewer breaths per minute. Respiratory rhythm: refers to the regular and equal spacing of breaths 57  Regular respiratory rhythm: the cycles of inspiration and expiration have about the same rate and depth. Irregular breathing patterns: the depth and amount of air inhaled and exhaled and the rate of respirations per minute will vary. Respiratory Depth: The depth of respiration is the volume of air that is inhaled and exhaled. It is described as either “shallow” or “deep.” Hyperventilation: is characterized by deep, rapid respirations. Hypoventilation: is characterized by shallow respirations. Respiratory Quality: refers to breathing patterns— both normal and abnormal. Labored breathing refers to respirations that require greater effort from the patient. Factors affecting Respiratory Rate: Increased Rate: - Allergic reactions. - Certain drugs (e.g., epinephrine). - Disease (e.g., asthma, heart disease). – Exercise. - Excitement/anger. – Fever. - Hemorrhage. – Nervousness. - Obstruction of air passage. – Pain. - Shock. Decreased Rate: - Certain drugs (e.g., morphine). - Disease (stroke, coma). - Decrease of CO2 in blood. 58  Measuring respiratory rate Equipment: Wristwatch with second hand or digital display Pen, vital sign flow sheet or record, or electronic health record N STEPS RATIONALE 1. Identify the patient. To give care to the correct patient. 2. Wash hands Prevents the risk of cross infection. 3. Collect equipment. Saves time and energy 4. Be sure client’s chest is visible remove bed linen or gown. 5. Assess patient’s activity prior to checking A patient who has been exercising will respiration. needed to rest for few minutes to permit the accelerated respiratory rate return to normal. 6. Place patient in a comfortable position. 7. Place hand against patient’s chest to feel his Awareness of respiratory rate chest movement or place patient’s arm assessment would cause the patient across the chest and observe the chest voluntarily to alter the respiratory movement while supposedly taking the pattern. radial pulse. 8. Check the respiratory rate, rhythm and depth Accuracy of reading. for 1 minute. 9. Wash hands. Prevents the risk of cross infection. 10. Document in flow sheet and (if required) Promotes continuity of care. nurse’s note, report any abnormality. 59  Checklist respiratory rate measurement Steps Mark Trail 1 Trail 2 Trail 3 Comment 1. Identify the patient. 2.Wash hands 3. Collect equipment. 4. Be sure client’s chest is visible remove bed linen or gown. 5. Assess patient’s activity prior to checking respiration. 6. Place patient in a comfortable position. 7. Place hand against patient’s chest to feel his chest movement or place patient’s arm across the chest and observe the chest movement while supposedly taking the radial pulse. 8. Check the respiratory rate, rhythm and depth for 1 minute. 9. Perform hand hygiene. 10. Record respiration rate, rhythm and report if any abnormality. 60  Blood pressure Objectives: Students will be able to: Define blood pressure. List purposes of measuring blood pressure. Identify factors that affect blood pressure. Differentiate between types of sphygmomanometers Explain phases of Korotkoff Sounds. Demonstrate measuring blood pressure procedure. Definitions: Blood pressure is the force required by the heart to pump blood from the ventricles of the heart into the arteries. It is measured in systolic and diastolic pressure. Systolic pressure: is the highest pressure that occurs as the left ventricle of the heart is contracting. Diastolic blood pressure: is the lowest pressure level that occurs when the heart is relaxed and the ventricle is at rest and refilling with blood. The pulse beat is felt (or heard) at the systolic pressure level and is absent at the diastolic pressure level. Blood pressure is read in millimeters (mm) of mercury (Hg), or “mmHg,” Pulse pressure: is the difference between the systolic and diastolic readings and calculated by subtracting the diastolic reading from the systolic reading. If the blood pressure is 120/80, the pulse pressure is 40. In general, a pulse pressure that is greater than 40 mmHg is considered widened, and one that is less than 30 mmHg is considered to be narrowed. 61 Purpose to measure blood pressure: ▪ To maintain a base line measure of arterial pressure. ▪ To assess the hemodynamic (i.e., the study of movement of blood and the forces concerned) status of a patient. ▪ To monitor response of the circulatory system to various disease conditions and therapies. Blood Pressure Guidelines: Ideally, blood pressure is measured while the patient is seated upright with both feet flat on the floor. Sitting with legs crossed at the knees can elevate blood pressure readings. If warranted by the patient’s condition, blood pressure may be measured while lying on an examination table. A rise or fall in blood pressure is an indication of many medical conditions. 62 Factors affecting blood pressure: 1. Age: in older adults, the diastolic pressure often increases as a result of the reduced compliance of the arteries. 2. Exercise: Physical activities increase both the cardiac output and hence blood pressure, thus, a rest of 20 to 30 minutes following exercise is indicated before the blood pressure can be reliably assessed. 3. Stress: thus, increasing the blood pressure reading. 4. Severe pain: can decrease blood pressure greatly and cause shock. 5. Obesity. 6. Sex: after puberty, females usually have lower blood pressure than males of the same age. After menopause, women generally have higher blood pressure than before. 7. Medications: many medications may increase or decrease the blood pressure. 8. Diseases (Fever, hemorrhage…. etc.). Types of sphygmomanometers: 63 Korotkoff Sounds: Korotkoff sounds are the rhythmic, tapping sounds heard while taking blood pressure as the arterial wall distends under the compression of the cuff. Phases (Korotkoff’s Sounds Correlated to Pressure Dynamics): Phase I: The period initiated by the first faint clear taping sound. These sound gradually become more intense. Phase II: The period during which the sounds have a swishing quality. Phase III: The period during which the sounds are crisper and more intense. Phase IV: The period, during which the sounds become muffled and have a soft, blowing quality. Phase V: The period where the muffled, blowing sound disappear. 64  Measuring blood pressure Equipment: ▪ Sphygmomanometer. ▪ Cloth or disposable vinyl pressure cuff of appropriate size for patient’s extremity. ▪ Stethoscope. ▪ Alcohol swab. ▪ Pen, vital sign flow sheet or record form, or electronic medical record. N STEPS RATIONALE 1. Identify the patient. To give care to the correct patient. 2. Explain procedure to patient. Reduces anxiety and gains cooperation. 3. Collect and check equipment. Ensures proper functioning of apparatus. 4. Have patient in sitting or supine Promotes comfort and relaxes patient. position. Provides accurate reading. 5. Wash hands. Prevents cross infection. 6. Clean the ear piece of stethoscope Prevents transmission of microorganisms. with the spirit swab. 7. Be sure that the manometer is Ensure accurate reading of mercury level. positioned vertically at eye level. 8. Support patients fore-arm at heart Blood pressure increases when the arm is level, with palm turned up. below heart level and decreases when the arm is above heart level. 65 9. Expose patient’s left upper arm by Ensures proper cuff application. Tight removing constricting clothing. sleeves interfere with the ability to hear pulsations and may cause inaccurate readings. 10. Warp the deflated cuff evenly around Even wrapping produces equal pressure. the upper arm by placing the lower Too loose / tight cuff will give inaccurate edge of the cuff 2.5 –5 cm above the reading. The bladder directly over the antecubital space. brachial artery gives accurate reading. 11. Place the stethoscope in your ear and Tapping is done to check whether the sound check the diaphragm by tapping. is audible. 12. Make sure to unlock the mercury column before inflating. 13. Palpate brachial or radial pulse with Indicates approximate systolic pressure one hand. Close the valve of the bulb: (Done if it is the initial examination). inflate the cuff noting the level of mercury where pulse disappears. 14. Deflate cuff quickly and wait for 30 Prevents venous congestion and false high seconds; tighten the valve. reading. 15. Relocate brachial artery and place the Proper stethoscope placement ensures diaphragm of stethoscope over the optimal sound reception. Improper position 66  brachial pulse and hold it in place (Do of diaphragm causes muffled sounds and not let the diaphragm touch the cuff or often results in false low systolic and false patient’s clothing). high diastolic readings. 16. Inflate the cuff to 30 mm Hg above Ensures accurate measurement of systolic where the pulse disappeared. pressure. 17. Slowly release the valve and allow Too rapid or too slow decline of mercury mercury to fall at the rate of 2 – 3 mm level can cause inaccurate readings. Hg per sec. 18. Note point on manometer when first First Korotkoff sound indicates the systolic clear sound is heard. pressure. 19. Continue to deflate cuff gradually This is noted as the diastolic pressure. noting point at which sounds disappear. 20. Deflate cuff rapidly and completely. Prevents arterial occlusion resulting in Remove cuff from patient’s arm. numbness and tingling of patient’s arm. (Lock mercury column unless measurement must be repeated.) 21. Assist patient to a comfortable Ensure patients comfort position. Cover the upper arm. 22. Inform client of B.P reading (depends Promotes participation in care and on patient’s conditions). understanding of health status. 23. Clean stethoscope with spirit swab Prevents spread of microorganisms and and return equipment to appropriate safety of equipment. place. 24. Wash hands. Prevents transmission of microorganisms. 25. Record accurately in the flow sheet Timely documentation ensures accurate according to hospital policy. therapeutic intervention, if needed. 67  Checklist measuring blood pressure Steps Mark Trail 1 Trail 2 Trail 3 Comment 1. Identify the patient. 2. Explain procedure to patient. 3. Collect and check equipment. 4. Have patient in sitting or supine position. 5. Wash hands. 6. Clean the ear piece of stethoscope with the spirit swab. 7. Be sure that the manometer is positioned vertically at eye level. 8.Support patients fore-arm at heart level, with palm turned up. 9. Expose patient’s left upper arm by removing constricting clothing. 10. Warp the deflated cuff evenly around the upper arm by placing the lower edge of the cuff 2.5 –5 cm above the antecubital space. 11. Place the stethoscope in your ear and check the diaphragm by tapping. 12. Make sure to unlock the mercury column before inflating. 13. Palpate brachial or radial pulse with one hand. Close the valve of the bulb: inflate the cuff noting the level of mercury where pulse disappears. 14. Deflate cuff quickly and wait for 30 seconds; tighten the valve. 68 15. Relocate brachial artery and place the diaphragm of stethoscope over the brachial pulse and hold it in place. 16. Inflate the cuff to 30 mm Hg above where the pulse disappeared. 17.Slowly release the valve and allow mercury to fall at the rate of 2 – 3 mm Hg per sec. 18. Note point on manometer when first clear sound is heard. 19. Continue to deflate cuff gradually noting point at which sounds disappear. 20. Deflate cuff rapidly and completely. Remove cuff from patient’s arm. 21. Assist patient to a comfortable position. Cover the upper arm. 22. Clean stethoscope with spirit swab and return equipment to appropriate place. 23. Wash hands. 24. Record accurately in the flow sheet according to hospital policy. 69  Pain assessment Objectives Student will be able to Define pain and Pain assessment. Identify types of pain. Enumerate factors contributing to pain and discomfort. Discuss effects of pain on patients. Demonstrate different methods of pain assessment. Definition of Terms Pain is an unpleasant sensory and emotional experience, associated with, or resembling that associated with, actual or potential tissue damage Pain assessment: is a multidimensional observational assessment of a patients’ experience of pain. Pain measurement tools: are instruments designed to measure pain. Factors Contributing to Pain and Discomfort ❖ Physical Factors Illness and injuries Immobility Wounds Fever or hypothermia Sleep disturbance and deprivation ❖ Psychosocial Factors Anxiety and depression Fear of death Loss of control Separation from family Impaired communication Unfamiliar surroundings Fear of pain 70 ❖ Environmental Factors and routine Continuous noise Continuous light Awakening and physical manipulation every 1 to 2 hours for vital signs or positioning Continuous and frequent invasive procedures Competing priorities in care: unstable vital signs, bleeding, dysrhythmias and poor ventilation may take precedence over pain management. Types of Pain We categorize pain in several ways. Most often, pain is categorized as nociceptive or neuropathic based on underlying pathology. Another useful scheme is to classify pain as acute or chronic ❖ Pain Categorized by Origin (underlying pathology) Nociceptive is the response of our bodies (sensory nervous systems) towards actual or potentially harmful stimuli. Neuropathic pain is described as a nerve injury or nerve impairment that causes a pain response from a stimulus that is non-painful in normal conditions. ❖ Pain Categorized by Nature (cause, course, manifestations, and treatment) Acute pain is defined as pain with sharp well‐defined onset and short duration. It is usually caused by nociceptive or inflammatory cause. Chronic pain is defined as pain that prolongs from three to six months after the onset or the expected period of healing. 71  Acute Chronic Time span Less than 6 months More than 6 months Localized, associated with a specific Location Difficult to pinpoint injury, condition, or disease Often described as sharp, diminishes Often described as dull, Characteristics as healing occurs diffuse, and aching Elevated heart rate Normal vital signs Elevated BP Physiological Normal pupils Elevated respirations signs No diaphoresis May be diaphoretic May have loss of weight Dilated pupils Physical immobility Crying and moaning Hopelessness Rubbing site Listlessness Behavioral Guarding Loss of libido signs Frowning Exhaustion and fatigue Grimacing Expresses pain only when Statement of pain asked Consequences of Pain Patients Unrelieved pain is the most traumatic memory patients. Under treatment of pain leads to harmful physiological and psychological effects. ❖ Physiological Tachypnea. Delayed wound healing. Tachycardia. Infections. increased oxygen demand Hyperglycemia. Ischemic injury. ❖ Psychological Anxiety Depression 72  ❖ Ethical Breakdown of trust Suffering Failure to adhere to responsibility ❖ Financial Increased ventilated days Increased total use of medication Increased length of stay Increase chance of readmission Body System Effect Cardiovascular Tachycardia, Hypertension, Increase cardiac work load Respiratory muscle spasm, Decrease ventilation capacity, Pulmonary Atelectasis, Hypoxia, Increased risk of pulmonary infection Gastrointestinal Postoperative Ileus Renal Increased risk of oliguria and urinary retention Coagulation Increased risk of thromboembolism Immunologic Impaired immune function Muscle weakness, Fatigue, Limited mobility, Increase the risk Muscular of thromboembolism Psychological Anxiety, Fear, Frustration, Poor patient satisfaction Patient Barriers to Pain Assessment Communication Cultural Influences Altered Level of Consciousness Lack of Knowledge Older Patients Methods of pain assessment Pain assessment is an integral part of nursing care. It is a prerequisite for adequate pain control and relief. Pain assessment has two major components: 1) subjective non-observable. 73  2) objective or observable or. A. The Subjective Component Pain is known as a subjective experience. The subjective component of pain assessment refers to the patient’s self-report about his or her sensorial, affective, and cognitive experience of pain. The patient’s self-report of pain can also be obtained by questioning the patient using the mnemonic PQRSTU Provocation Provocative and Palliative or Aggravating Factors: indicates what provokes or causes the patient’s pain what he or she was doing when the pain appeared, and what makes the pain worse or better Quality: characteristics of pain, refers to the quality of the pain or the pain sensation that the patient is experiencing. For instance, the patient may describe the pain as dull, aching, sharp, burning, or stabbing. Region/ Radiation: Where is the pain located? Does the pain radiate? Where? Does it feel like it travels/moves around? Did it start elsewhere and is now localized to one spot? Severity: How severe is the pain on a scale of 0 to 10, Does it interfere with activities? How bad is it at its worst? Timing: When/at what time did the pain start? How long did it last? How often does it occur: hourly? Daily? Weekly? Monthly? Is it sudden or gradual? Understanding: is the patient’s perception of the problem or cognitive experience of pain. 74  Verbal Rating Scale (VRS) Use words to describe pain. Word such as no pain, mild pain, moderate pain & severe pain are used to describe pain levels. Numeric Rating Scale (NRS) A numerical rating scale with the range of 0 to 10 is another type of pain scale that is used. The word “no pain” appear by “0” and “worst pain possible” is found by “10” Patients are asked to choose a number from 0 to 10 that best reflects his/her level of pain. 75  Wong-Baker Faces Pain Rating Scale with the Wong-baker pain scale, six faces are used: Face 0 is a happy face Face 2 is still smiling Face 4 is not smiling Face 6 is starting to frown Face 8 is definitely frowning Face 10 is crying How to use? Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because he doesn't hurt at all. Face 2 hurts just a little bit. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don't have to be crying to feel this bad. Ask the person to choose the face that best describes how he is feeling. 76  B. The Observable or Objective Component When the patient’s self-report is impossible to obtain, nurses can rely on the observation of behavioral indicators, which are strongly emphasized in clinical recommendations and guidelines for pain management in nonverbal patients. Behavioural Pain Scale (BPS) The BPS is composed of 3 subscales: facial expression, movement of the upper limbs, and compliance with mechanical ventilation (MV). Each subscale is scored from 1 (no response) to 4 (full response). A BPS score of 5 or higher is considered to reflect unacceptable pain. Behavioral Pain Scale (BPS) ITEM DESCRIPTION SCORE Relaxed 1 Partially tightened 2 Facial expression (e.g., brow lowering) Fully tightened (e.g., eyelid 3 closing) Grimacing 4 No movement 1 Upper limbs Partially bent 2 Fully bent with finger flexion Permanently 3 retracted 4 Tolerating movement 1 Compliance with Coughing but tolerating ventilation for most 2 ventilation of the time Fighting ventilator 3 Unable to control ventilation 4 Total 3 to 12 From Payen JF, et al. Assessing pain in the critically ill sedated patients by using a behavioral pain scale. Crit Care Med 29:)12( 2258-2263, 2001. 77  Critical-Care Pain Observation Tool (CPOT) It is the most valid and reliable for use in ICU patients who are unable to self-report. The CPOT has 4 components: facial expression, body movements, muscle tension, and compliance with the ventilator for intubated patients or vocalization for extubated patients. Each component is scored from 0 to 2 with a possible total score ranging from 0 to 8. A CPOT ≥ 3 is indicative of significant pain. 78  FLACC - The acronym FLACC stands for Face, Legs, Activity, Cry and CONSOL ability. How to use FLACC Each category (Face, Legs etc) is scored on a 0-2 scale, which results in a total pain score between 0 and 10. The person assessing the child should observe them briefly and then score each category according to the description supplied. FLACC has a high degree of usefulness for cognitively impaired and many critically ill children Key considerations assess pain using a developmentally and cognitively appropriate pain tool reassess pain after interventions given to reduce pain (eg. Analgesia) have had time to work assess pain at rest and on movement investigate higher pain scores from expectation document pain scores use parent/guardian pain behavior knowledge for children with cognitive impairment 79  Oxygen therapy Objectives Student will be able to Define Oxygen therapy. List the Oxygen therapy devices. Enumerate Indications for Oxygen therapy. Demonstrate Oxygen therapy administration procedure for each method ▪ Oxygen therapy is the administration of oxygen, in concentrations greater than those in room air to treat hypoxia. These supplementary oxygen concentrations can vary from 24% (nasal cannula) to 95% (non‐rebreathe oxygen mask) ▪ It is important to select the correct oxygen delivery device for the patient, i.e., how much supplementary oxygen needs to be administered and what the patient can actually tolerate ▪ Oxygen is a colorless, odorless gas that forms about 21% of the earth’s atmosphere and is essential for plant and human life ▪ Tissue oxygenation is dependent upon inspired oxygen, the concentration of hemoglobin, and its ability to saturate with oxygen, as well as the circulation of blood Indications Respiratory compromise Anaphylaxis Shock During anesthesia Post surgery 80  Equipment of oxygen therapy ▪ Oxygen supply: e.g., piped oxygen behind the bed, oxygen cylinder ▪ Flowmeter: to determine oxygen flow rate in liters/minute ▪ Oxygen tubing ▪ Oxygen delivery mechanism: e.g., nasal cannula, face masks, non‐rebreathe oxygen mask ▪ Humidifier: to warm and moisten the oxygen prior to administration. ▪ Face shield as needed for risk of splash ▪ Clean gloves, if secretions are present ▪ Pulse oximeter The oxygen delivery method selected depends on: ▪ Age of the patient ▪ Oxygen requirements/therapeutic goals ▪ Patient tolerance to selected interface ▪ Humidification requirement. Procedure Steps Rational 1. Identify patient using at least two identifiers Ensures correct patient. Complies with (e.g., name and birthday or name and medical The Joint Commission standards and record number) according to agency policy. improves patient safety 2. Perform hand hygiene. Reduces transmission of microorganisms 3. Verify the physician’s or qualified Ensures correct dosage and route. practitioner’s order 4. Explain procedure and hazards to the client. Increases compliance with procedures. 5. If available, note patient’s most recent arterial Objectively documents the patient’s pH, blood gas (ABG) results or pulse oximetry arterial oxygen and arterial carbon dioxide (SpO2) value. concentrations, or arterial oxygen saturation. 81 6. Attach oxygen delivery device (e.g., cannula, Humidity prevents drying of nasal and mask, T tube, tracheostomy collar) to oxygen oral mucous membranes and airway tubing, and attach end of tubing to humidified secretions. oxygen source adjusted to prescribed flow rate. 7. Insert humidifier and flow meter into oxygen For access to oxygen. Many institutions source in wall or portable unit also have compressed air available from outlets very similar in appearance to oxygen outlets. Green always stands for oxygen. Be sure to plug the flow meter into the green outlet. 8. Apply oxygen device: Attach the oxygen tubing and nasal cannula to Rates above 6 liters/min are not the flow meter and turn it on to the prescribed efficacious flow rate (1–5 liters/min). Use extension tubing and can dry the nasal mucosa. for ambulatory clients so they can get up to go to the bathroom. 82 Places the Nasal cannula: in patient’s nares, Keeps delivery system in place so client then places the tubing around each ear. Uses the receives the amount of oxygen ordered slide adjustment device to tighten the cannula under patient’s chin. Apply Simple face mask by placing it over A properly fitting device that does not patient’s mouth and nose. Then bring the straps create pressure on nares or ears is over patient’s head and adjust to form a comfortable, comfortable but tight seal. and patient is more likely to keep it in place; reduces risk for skin breakdown Partial or nonrebreather mask: Mask seals Easily humidifies oxygen and does not dry tightly around mouth. Reservoir fills on mucous membranes. Useful for short-term exhalation and almost collapses on inspiration. therapy of 24 hours or less. Reservoir should not collapse completely. 83 Venturi mask: Apply as regular mask. Select It is used when high-flow device is appropriate flow rate. desired. Face tent: Apply tent under patient’s chin and Excellent source of humidification; over the mouth and nose. It will be loose, and a however, mist is always present. you cannot control oxygen concentrations, and patient who requires high oxygen cannot use this device. High-flow nasal cannula: Fit as for nasal Used when high oxygen delivery is cannula. required. 84 9. Makes sure that the oxygen equipment is set Ensures that client receives proper dose. up correctly and functioning properly before leaving patient’s bedside. 10. Check cannula/mask every 8 hours. Keep Ensures patency of cannula and oxygen humidification container filled at all times. flow. Oxygen is a dry gas; when it is administered via nasal cannula of 4 L/ min or more, you must add humidification so patient inhales humidified oxygen 11. Monitor airway patency, vital signs, oxygen Detects response to or any untoward saturation, and for signs and symptoms of effects hypoxia every 2 hours. Additionally, monitor from therapy. Determines whether tube is breath sounds and tube position every 4 in hours. place. 12. Properly dispose of gloves (if used) and Reduces transmission of microorganisms perform hand hygiene. 85  Procedure Checklist Steps Mark Trial 1 Trial 2 Trial 3 comment 1. Identifies the patient according to agency policy using two identifiers; perform hand hygiene, safety, privacy, body mechanics, and documentation. 2. Attaches the flow meter to the oxygen source. 3. Assembles the oxygen equipment. 4. Attaches the humidifier to the flow meter. Humidification is necessary only for flow rates of greater than 3 L/min.) 5. Turns on the oxygen using the flow meter and adjusts it according to the prescribed flow rate. Variation: Nasal Cannula 6. Attaches the nasal cannula to the humidifier or the adapter. 7. Places the nasal prongs in patient’s nares, then places the tubing around each ear. 8. Uses the slide adjustment device to tighten the cannula under patient’s chin. 9. Makes sure that the oxygen equipment is set up correctly and functioning properly before leaving patient’s bedside. 10. Assesses respiratory status before leaving bedside. 86 Variation: Face Mask 11. Gently places the face mask on patient’s face, applying it from the bridge of the nose to under the chin. 12. Secures the elastic band around the back of patient’s head, making sure the mask fits snugly but comfortably. 13. Makes sure that the oxygen equipment is set up correctly and functioning properly before leaving patient’s bedside. 14. Assesses respiratory status before leaving bedside 15. Gently places the face tent in front of patient’s face, making sure that it fits under the chin. 16. Secures the elastic band around the back of patient’s head. 17. Makes sure that the oxygen equipment is set up correctly and functioning properly before leaving patient’s bedside. 18. Assesses respiratory status before leaving the bedside. 87  Body mechanics Objectives: Students will be able to: Define Body mechanics. List the purpose of Body mechanics. Explain elements of Body Mechanics. Discuss principles of Body Mechanics Differentiate between types of assistive devices. Demonstrate moving a patient up in bed procedure. Demonstrate assisting a patient to a sitting position procedure. Demonstrate moving a patient from bed to stretcher procedure. Demonstrate Bed to wheelchair transfer procedure. Definition of Body mechanics: Body mechanics can be described as the efficient use of one's body to produce motion that is safe, energy conserving and anatomically and physiologically efficient and that leads to the maintenance of a person's body balance and control Purpose of body Mechanics: ▪ Conserve energy. ▪ Reduce stress and strain on body structures. ▪ Reduce the possibility of personal injury. ▪ Produce movements that are safe. Elements of Body Mechanics: Body movement requires coordinated muscle activity and neurological integration. It involves the basic elements of body alignment (posture), balance, 88  and coordinated movement. Body alignment and posture bring body parts into position to promote optimal balance and body function. The diagram in Figure demonstrates (A) a well-aligned person whose balance is maintained and whose line of gravity falls within the base of support. Diagram (B) demonstrates how balance is not maintained when the line of gravity falls outside the base of support, and diagram (C) shows how balance is regained when the line of gravity falls within the base of support. Principles of Body Mechanics: Steps Principles Assess the environment. Assess the weight of the load before lifting and determine if assistance is required. Plan the move. Plan the move; gather all supplies and clear the area of obstacles. Avoid stretching and Avoid stretching, reaching, and twisting, which may place the twisting. line of gravity outside the base of support. 89  Keep stance (feet) shoulder-width apart. Ensure proper body Tighten abdominal, gluteal, and leg muscles in anticipation of stance. the move. Stand up straight to protect the back and provide balance. Place the weight of the object being moved close to your centre of gravity for balance. Equilibrium is maintained as long as the line of gravity passes through its base of support. Stand close to the object being moved. Hold objects close to your centre of gravity Face direction of the Facing the direction prevents abnormal twisting of the spine. movement. Turning, rolling, pivoting, and lev