Nursing Foundations-Basic BSc Nursing 1 Year Short Answers PDF

Page 1 NURSING FOUNDATIONS-BASIC BSc NURSINGI YEAR SHORT ANSWERS 1.Define health? 2.Define illness? A) World Health Organization defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. 3.Define hospital? A) "llness is a condit...

Page 1 NURSING FOUNDATIONS-BASIC BSc NURSINGI YEAR SHORT ANSWERS 1.Define health? 2.Define illness? A) World Health Organization defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. 3.Define hospital? A) "llness is a condition characterized by a deviation from a normal health state which is manifested by physical & psychological symptoms." - Kozier A) Hospital is an institution for the care, cure, and treatment of the sick and wounded, for the study of diseases and for the training doctors and nurses. (Steadman's medical dictionary) 4.List out four risk factors for developing illness? tobaccO use A) The major risk factors include: the harmful use of alcohol QUESTION BANK UNIT I INTRODUCTION physical inactivity raised blood pressure (or hypertension) raised cholesterol. overweightobesity unhealthy diet raised blood glucose. 5.Define immunity? A) Immunity is referred to the resistance exhibited by the host towards injury caused by microorganisms and their products. Page 2 6.Differentiate between active and passive immunity? A) Active immunity is created by the antibodies by the individual's body. Passive immunity, on the other hand, is mediated by antibodies produced outside. Passive can be used to generate a rapid immune response. Antibodies were among the primary tools used to treat specific infectious diseases. At the moment, antibodies play a vital role in fighting infectious diseases. 7.Enlist the healthcare team members? A) The health care team consists of Physicians, nurses, social workers ,auxiliary personnel ,village health guides, trained dais, health assistants, radiologist. 8.Define primary health care? A) Primary healthcare is a term used to describe the first contact a person has with the health system when they have a health problem or issue that is not an emergency. It is the part of the health system that people use most and may be provided, for example, by a general practitioner (GP), physiotherapist or pharmacist. 9.List down any four functions of hospital? 1) Provides quality medical care services to as many out- patient as possible. 2) Provides the widest coverage of quality health care for the people not for curative only. 3) Ensures that health services are always available to the people. 4) Provides health services that is within the financial capability of the people. 10.Mention the levels of prevention? A) 1) Primordial Prevention 2) Primary Prevention 3) Secondary Prevention 4) Tertiary Prevention Page 3 SHORT ESSAYS NURSING AS A PROFESSION 1. Describe characteristics of nursing profession? A) a. specialized education b. body of knowledge C. servicesD.autonomy E. code of ethics F. research orientation UNIT II G. service orientation H. professional organization a) Body of knowledge: - as a profession, nursing is establishing well - defined body of knowledge and expertise. A number of nursing conceptual frameworks contribute to the knowledge base of nursing and give direction to nursing practice, education, and ongoing research. b) Service orientation: -nursing as a tradition of service to others. These services, however, must be guided by certain rules, policies, or code of ethics. Today, nursing is also an important component of the health care delivery system. c) Code of ethics: - ethical code change as the needs and values of society change. Nursing has developed its own code of ethics and is most instances has set up means to monitor the professional behavior of its members. d)Autonomy: -a profession is autonomous if it regulates itself and sets standards for its members. Providing autonomy is one of the purposes for a professional association.to the autonomous, e) A professional group must be granted legal authority to define the scope of it practice, describe it particular function and roles and determine its goals and responsibilities in delivery of its services. Page 4 2. Explain the functions of Nurse? A) a. Care giver - i) as a care giver, the nurse helps the client to regain health through healing process. ii) she preserves dignity of client. i) nurse address the holistic health care needs of client. lv) she accepts client as person not merely as mechanical beings. B. Clinical and ethical decision maker i) nurse use critical thinking skill thought out the nursing process to provide effective Care li) nurse make decision in collaboration with client & family. lii)she also collaborate & be consult with other health professionals. C. Protector i) she provides safe and conductive environment to the clients li) she takes step to prevent injury for client. lii) she asks about any allergy to medicine or food. Iv) she provides immunization against diseases. D. Manager i) as a manager, nurse co- ordinates the activities of other members of health care team. li) she manages the nursing care of not only one client but also of families and in Communities. lii) she delegates the nursing activities to auxiliary worker & worker & another nurse. E. Communicator - i) she covey information verbally as well as through documentation. Page 5 li) nurse communicates verbally at change of shift. lii) she reports while shifting the client from one unit to another. F. Comforter i) as a comforter, nurse provide comfort to the client by considering him as an individual with unique feelings and needs. li) she motivates clients to reach therapeutics goals. lii) she promotes comfort to client by staying near the patient. G. Leader i) nursing leadership is defined as mutual process of interpersonal influence through which nurse helps the client in making decisions for establishing and for achieving the goals. J. Teacher i) she determines that the clients fully understood. li) she also evaluates client's progress in learning. lii) she gives health education on diet, about preventive measure of diseases. 3. Describe qualities of Nurse? A) Nurse should have following qualities: i) Self confidents: A professional nurse have elf confidence. Because of this, i) Humble and Honest: with these qualities, nurse develops rapport and gains trust of the client. ii) Loyal: Nurse aCcept the as he is. she recognizes the client as a person and iv) Co- operative: As an individual, nurse plays many role in hospital. She works cooperatively with health team members as well as with family member. she is able to take decision and provides holistic care. understands empathically his feelings. Page 6 v) Good Listener - This is the best quality of nurse, by which she understands clients view. By active listening, she identifies client's needs provides care accordingly. vi) Keen observer - while dealing with client a nurse, by which she understands vii) Good administration – Because of this quality a professional/ registered nurse executes and evaluates the junior nursing staff. vi) Good supervisor -A professional nurse work works as supervisor to the junior nursing staff as well other employees while performing their duties. ix) Impartial - professional nurse treats each client without any prejudice / x) effectively Capable - A nurse is competent enough and has a capability to give care xi) Advocate - A nurse supports and speaks in favour of client and provide 4. Justify Nursing as Profession? A. professions are those occupation based on specialized intellectual study and training the purpose of which is supply skilled service with ethical components to others, for definite fee or salary. B. Professional is a type of occupation that is meets certain criteria that raise it to a level above that of an occupational C. Nursing is the protection, promotion, and optimization, of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis treatment of human response and advocacy in Carew of individuals, families, communities, and populations. a. The services provided are vital to humanity and the welfare of society. b. There is a special body of knowledge that is continually enlarged through research. C. The services involve intellectual activities; individuals responsibity is a strong feature. client's as nonverbal commands / behavior. personal interest. She provides care fairly to every client. information to client / family for making informed decision. Page 7 d. Practitioners are relatively independent and control their own policies and activities. e. Practitioners are motivated by service and consider their work an important component of their lives. f. There is a code of ethics to guide the decision and conduct of practitioners. g. There is an organization that encourages and supports high standards of practice. 5.Enumerate ethical principles of Nursing? A) Autonomy - It refers to right to make one's own decision. Respect for autonomy means that nurse recognize the individual's uniqueness, the right to be what that person is and the right choose personal goals people may have "inward autonomy" if they have the ability to make choices as well as may have "outward autonomy" if their choices are not limited or imposed by others. Nurses should follow the principle of autonomy and respect a client's right to make decision even when those choices seem not to be client's best interest. Justice- The principle of fairness is the basis for the obligation to treat all clients equally and fairly. Justice is the foundation for decisions about resources allocation throughout the society or a group. Health care system provides care on the basis of medical need rather than ability to pay, social status, race or gender. Non maleficence - non-maleficence is the avoidance of harm or hurt. So, it is an obligation to nerve deliberately harm another. The nurse tries to balance the risk and benefits of plan of care. In health care ethics, it is important to remember that ethical practice involves not only they will do good but also equal commitment not to do harm. Beneficence - It means promoting good or doing good. In others words, refers to taking positive actions to help others. SO, practice of beneficence encourages the urge to do good for other. For example, a child's immunization may cause discomfort during administration, but the benefit of protection from diseases both for the individual and for the society, outweigh the temporary discomfort. Page 8 Fidelity- It means to keep promise. Nurse have an obligation to follow through with nursing care She should avoid abandonment of clients, even when clients goal differs from health care provide goals. For example, pain managenent plan. 6.Classify and explain importance of values in Nursing? A) TYPES OF VALUES We can speak of universal values, because ever since human being have lived in community, they have had to establish principles to guide their behavior towards others. In this sense, honesty, responsibility, truth, solidarity, cooperation, tolerance, respect, and peace, among others are considered universal values. However, in order to understand them better it is useful to classify values acc. To the following criteria : 1. Personal values: these considered essential principles on which we build our life and guide us to relate with other people. They are usually a blend of family values and social cultural values, together with our own individual ones. To our experiences. li. Family values: these are valued ina family and are considered either good or bad. these derive from fundamental beliefs of the parents who, use them to educate their children. They are the basic principles and guidelines of our initial behavior in society, and are conveyed through our behavior in the family, from the simplest to the lii. Social cultural values: these are the prevailing values of our society, which change with time, and either coincide or not with our family or personal values. They constitute a complex mix of different values, and at times they contradiction another, or pose a dilemma. For example, if work is not valued socially as a means of personal fulfillment, then the society is directly fostering anti values' like dishonesty, ly. Material values: these values allow us to survive, and are related to our basic needs as human beings, such as food and clothing and protection from the environment. They are web that is created between personal, family, and social cultural values. most complex. irresponsibility, or crime. Page 9 Spiritual values: they refer to importance we give to non - material aspects in our lives. They are part of our human needs and allow us to feel fulfilled. They add meaning and foundation to our life, as do religious beliefs. V. Vi. Morals values: the attitudes and behaviors that a society considers essential for coexistence, order, and general well. Professional values are the guiding beliefs and principles that influence your work behavior. Your professional: values are usually an extension of your personal values such honesty, generosity, and helpfulness. Nurse professional values are acquired during socialization in nursing from codes of ethics, nursing experiences teacher s and peers. the American association of college of nursing ( acne, 1998) identified five values essential for nursing: li) li) Iv) a. b. altruism C. autonomy d. values in professional nursing: human dignity 7.Describe Professional conduct of a nurse? integrity A) CODE OF PROFESSIONAI CONDUCT FOR NURSES- social justice PROFESSIONAL RESPONSIBILITY AN ACCOUNTABILITY- Carries out responsibility within professional boundaries. Practices healthful behavior. ls responsible for own decision and actions. ls responsible for continuous improvement of current practices. Page 10 i) NURSING PRACTICE- a. Provides care in accordance with set standards of practice Respect's individual and families need to promote healthy practices and discouraging harmful practices. b C. Promotes participation of individuals and significant others in the care. ii) COMMUNICATION AND INTERPERSONAL RELATIONSHIP- a. Establishes and maintains effective interpersonal relationship with individual, families, and communities. b. Co -operates with other health professionals to meet the needs of the individual, families, and communities iv) VALUING HUMAN BEING – a b. Encourage and supports individual in their right to speak for themselves on C. Takes appropriates action to protect individuals from harmful unethical practice. Respect and support choices made by individuals. v) MANAGEMENT- a. participates appropriates allocation and utilization of available resources. b. participates in evaluation of nursing services. 8.Discuss on scope of Nursing? A) Staff nurse: It provides direct patient care to one patient or a group of patients. Assist ward management and supervision. ward. II) Ward sister or nursing supervisor - she is responsible to the nursing superintendent for the nursing care management of ward or unit. Take full charge of issues affecting their health and welfare. Page 11 I) Department supervisor lassistant nursing superindent: she is responsible to the nursing superindent and deputy nursing superindent for the nursing care and management. IV) Deputy nursing superindent: she is responsible to the nursing superintendent and assists in the nursing administration of the hospital. V) Nursing superintendent: she is responsible to medical superintdent for safe and efficient management of hospital nursing services. VI) Director: she is responsitble for both nursing service and nursing education within a nursing teaching hospital. VII) Community health nurse (CHN): services rendered mainly focusing reproductive child health programme. 9.Discuss categories of Nursing Personnel in hospital? A) Types of nursing in hospital- ) A Education requirement: associates degree or Bachelor of Science degree B C. D Registered Nurse (RN) li) A. Expected job growth: 15% increases E. Salary range: $60,000 - $75,900 (RN) Employment locations: Hospitals, residential care facilities, etc. Registered nurse (RN) provides and coordinate patient care, educate patients and the public about various health conditions, and provide advice and emotional support to the patients and their family members. Most registered nurses work team with physician and other health care specialists in various setting. Relevant certificate: State Nursing License Cardiac nurse- Education requirement: associates degree or BSc, registered nursing license Page 12 B C D. One of the leading causes of death in the United States today is heart diseases. The demand for cardiac nurses continues to grow with the rising number affected with heart problems. A. li) Certified registered nurse anesthetist (CRNA)- B Education requirement: master's degree (MSN), registered nurse license (RN) and one year in acute care setting. Expected job growth: 16% increase Employment locations: hospitals, in home care and rehab centers Iv) Salary range: $67,490 medsian annually A certified registered nurse anesthetist (CRNA) is highly trained nurse that specializes A. in assisting with anesthesia during surgeries. CRNA's make up some of the highest B. - paid nurse specialties in the medical field due to high demand of these nurses in surgical setting. C D. Salary -$153,780 Clinical nurse specialist (CNS)- Education requirement: master's degree and sometime a doctoral degree. Expected job growth: 15% (much faster than average) Relevant certification: N/A Salary range: $ 85,723 Clinical nurse specialty are type of advanced practice registered nurse (APRN), who provide direct patients care by working with other nurses and staff to improve the quality care of patient receives. 10.Discuss on contribution of Florence Nightingale in Modern Nursing? A) Florence's nightingale. The era of modern nursing commences with the work of Florence Nightingale in the Crimean war (1854-1856.) She was born on May 12, 1820. She was the second daughter of wealthy English parents. She felt that God had called Page 13 her to fulfil 'mission of Mercy". She thought of nursing or education work. She observed the life of poor and tried to relieve the sick. Nursing contributions - A Appointed resident lady superintendent of an establishment for Gentle women During illness B. C. In 1854 assembled party of 38 nurses to serve in Crimean war D. Founded the Nightingale school and home for nurses at saint Thomas hospital in London. Wrote Notes on nursing, the first textbook for nurse. Page 14 SHORT ANSWERS 1. Expand LAMA HOSPITAL ADMISSION AND DISCHARGE Ans. LAMA: Leave Against Medical Advice. UNIT-III The patient will leave the hospital against the Doctors advice even though after explains patient health condition. Consent for LAMA I am leaving the hospital ward against medical advice. Doctor explained me about my disease condition and ill effects of discharge against medical advice. Doctors and Nursing staffs will not be responsible for any ill effects happening after my departure". 2. Define abscond Ans. ABSCOND: Abscond from Hospital Absconding refers to the departure of patients from hospital wards without permission. The definition of absconding can vary depending on the length of time required for an absence to be considered absconding, and on the method of departure (e.g. leaving a locked ward, leaving the hospital grounds, or failing to return from day leave). Absconding status is influenced by the patient's admission, whether it be voluntary, involuntary, or legally detained. There are significant implications of absconding for patients, carers and family members. 3. Expand MLC Absconding: where patients under an involuntary mental health order leave hospital without permission, can result in patient harm and emotional and professional implications for nursing staff. Patients absconded early in admission. Definition: ANS. Medico-legal cases (MLC) are an integral part of medical practice that is frequently encountered by Medical Officers MLC is defined as "any case of injury or ailment where, the attending doctor after history taking and clinical examination, considers that investigations by law enforcement agencies (and also superior military authorities) are warranted to ascertain circumstances and fix responsibility regarding the said injury or ailment according to the law". Page 15 4. List down the types of discharge Ans. Types of Discharge 1. PLANNED DISCHARGE: Patient completes the initial, actual management in the hospital and now he or she need not to be under direct supervision of that hospital." 2. DAMA/LAMA: Discharge/Leave Against Medical Advice 3. TRANSFER: Transfer to other unit or hospital 4. ABSCOND: Abscond from Hospital 5. REFFERAL: Referred for further management 5. What is the meaning of referral? Ans. Any hospital, including a district hospital, will receive referrals from lower levels of care. Indeed, referral can be defined as any process in which health care providers at lower levels of the health system, who lack the skills, the facilities, or both to manage a given clinical condition, seek the assistance of providers who are better equipped or specially trained to guide them in managing or to take over responsibility for a particular episode of a clinical condition in a patient. The process of directing or redirecting(as a medical case or a patient) to an appropriate specialist or agency for definitive treatment. 2 : an individual that is referred. 6.List down any four medico legal issues in admission of a patient ? Ans. Attempted suicide ✔ Sexual Offences ✔ Burns and Scalds ✔ Poisoning, Alcohol Intoxication ✔ Cases of trauma with suspicion of foul play ✔ Electrical injuries Accidents like Road Traffic Accidents 7. Mention any two responsibilities of a nurse in discharge procedure Ans.. Planning in the beginning. See doctor's written order Teach nursing procedures to be continued at home, get it's practice done. Inform other departments regarding discharge Page 16 Confirm bill paid. Check and receive any hospital property. Hand over personal belongings. Explanations.. Plan for rehabilitation and follow-up need. Arrangement for transport. 8. Enlist medico legal issues in discharge of a patient ans. Police have to be informed before the said patient leaves the hospital.' If the patient is not serious and can take care of himself, he may be discharged on his own request, after taking in writing from him that he has been explained the possible outcome of such a discharge and that he is going on his own against medical advice. Failure to do so renders the doctor liable for "negligence" and "deficiency of service". While discharging or referring the patient, care should be taken to see that he receives the Discharge Card/Referral Letter, complete with the summary of admission, the treatment given in the hospital and the instructions to the patient to be folowed after discharge. It is always better to inform the police through the casualty of the hospital where the medico-legal register is usually maintained and necessary entries can be made in it. Whenever a medico-legal case is discharged, the same should be intimated to the nearest police station at the earliest. 9. Enlist types of referrals? Ans. They are mainly two types of referral systems 1. Internal referral 2. External referral Internal referrals indicates transfer of patient in same hospital from one speciality to another speciality for diagnostic purpose and for treatment External referral indicates transfer from hospital to other higher centers for advanced treatment with good skilled staff and high technology equipped technology. 10. What is planned discharge? Ans. Planned Discharge: Patient completes the initial, actual management in the hospital and now he or she need not to be under direct supervision of that hospital. Patient can go to home with follow up instructions. Page 17 SHORT ANSWERS COMMUNICATION AND NURSE PATIENT RELATIONSHIP 1. Define communication? A) Communication is sending and receiving information between two or more people. The person sending the message is referred to as the sender, while the person receiving the information is called the receiver. The information conveyed can include facts, ideas, concepts, opinions, beliefs, attitudes, instructions and even emotions. 2. Enlist the levels of communication? A) 1. Intrapersonal 2. Interpersonal A) 3. Small Group Communication 4. Public Communication 5. Mass Communication 6. Intrapersonal Communication 3. List down the elements of communication? A) 1. Source 2. Message 3. Channel 4. Receiver 5. Feedback 6. Environment UNIT IV 7. Context 8. Interference 4. Enlist types of communication? Interpersonal communication Intrapersonal communication Group Communication Mass Communication Page 18 Verbal Communication Non-Verbal Communication Meta- Communication Formal communication Informal communication Downward communication Upward communication Horizontal communication Diagonal communication 5. Define empathy? A) Empathy is the ability or practice of imagining or trying to deeply understand what someone else is feeling or what it's like to be in their situation. Empathy is often described as the ability to feel what others are feeling as if you are feeling it yourself. To feel empathy for someone is to empathize. 6. List out the modes of communication? A) There are three modes of communication: Interpretative Communication Presentational Communication Interpersonal Communication 7. Enlist steps of communication process? A) Sender, Message, Encoding, Media, Receiver, Feedback, Noise. 8. List down factors influencing communication. 1. Cultural Diversity. 2. Misunderstanding of Message. 3. Emotional Difference. 4. Past Experiences. 5. Educational and Intellectual Difference. 6. Group Affiliations. 7. Positional Differences among the Personnel. 8. Functional Relationship between Sender and Receiver. Page 19 9. List down any four purposes of patient teaching A) a The system establishes a unit of measure for nursing. a Program costing and formulation of the nursing budget. a Tracking changes in patients care needs. a Determining the values of the productivity equations Determine the quality. 10.Enlist four barriers to effective communication. A) Language Barriers, Psychological Barriers, Physiological Barriers, Attitudinal Barriers, Systematic barriers, Cultural Barriers of Communication, Perceptual Barriers, Technological Barriers & Socio-religious Barriers. Page 20 SHORT ESSAYS Ans. ASSESSMENT 1. Explain ASSESMENT as first step of nursing process THE NURSING PROCESS Definition Assessment is the systematic and continuous collection, organization, validation, and documentation of data (information). 1. Initial nursing assessment UNIT -V Types of assessment: The four different types of assessments are; 2. Problem-focused assessment 3. Emergency assessment 4. Time-lapsed reassessment 1. Initial nursing assessment: Performed within specified time after admission. To establish a complete database for problem identification. Eg: Nursing admission assessment 2. Problem-focused assessment: To determine the status of a specific problem identified in an earlier assessment. Eg: hourly checking of vital signs of fever patient 3. Emergency assessment: During emergency situation to identify any life threatening situation. Eg: Rapid assessment of an individual's airway, breathing status, and circulation during a cardiac arrest. 4. Time-lapsed reassessment: Several months after initial assessment. To compare the client's current health status with the data previously obtained. 2. Explain the types and sources of Data collection Ans. Data collection is the process of gathering information about a client's health status. It includes the health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. Types of Data Two types: subjective data and objective data. Page 21 1. Subjective data, also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person. Itching, pain, and feelings of worry are examples of subjective data. 2. Objective data, also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination. For example, a discoloration of the skin or a blood pressure reading is objective data. Sources of Data collection: Sources of data are primary or secondary. 1. Primary: It is the direct source of information. The client is the primary source of data. 2. Secondary: It is the indirect source of information. AIl sources other than the client are considered secondary sources. Family members, health professionals, records and reports, laboratory and diagnostic results are secondary sources. 3. Describe various methods of the data collection Ans. Methods of the data collection: The methods used to collect data are observation, interview and examination. Interview method: An interview is a planned communication or a conversation with a purpose. There are two approaches to interviewing: directive and nondirective. The directive interview is highly structured and directly ask the questions. And the nurse controls the interview. A nondirective interview, or rapport building interview and the nurse allows the client to control the interview. STAGES OF AN INTERVIEW: An interview has three major stages: 1. The opening or introduction 2. The body or development Page 22 3. The closing Observation Method: It is gathering data by using the senses. Vision, Smell and Hearing are used. Examination Method: The physical examination is a systematic data collection method to detect health problems. To conduct the examination, the nurse uses techniques of inspection, palpation, percussion and auscultation. 4. Differentiate between medical and nursing diagnosis with examples. Ans. Difference between Nursing Diagnosis from Medical Diagnosis Nursing diagnosis A nursing diagnosis is a statement ofA medical diagnosis is made by a nursing judgment that made by nurse, by physician. their education, experience, expertise, are licensed to treat. problem. Nursing diagnoses describe the human Medical diagnoses refer to disease response to an illness or a health processes. Ex: Ineffective breathing pattern Nursing diagnoses may change as theA client's medical diagnosis remains the client's responses change. same for as long as the disease is Activity intolerance Acute pain Disturbed body image and Medical diagnosis Ans. The are 5 steps of nursing care plan: 1. Assessment 2. Nursing diagnosis present. Ex: Asthma Cerebrovascular accident 5. Explain the steps of nursing care plan for the client with suitable examples Appendicitis Amputation Page 23 3. Planning 4. Implementation 5. Evaluation EX. 1: the patient with fever planed the nursing care plan assessment Nursing Subjective client data: the related producing complained evidenced by that he feels body heat out from body. warm and temperature Objective data: Body temperature diagnosis highly Hyperthermia recorded by measuring temperature illness as to recording. Planning Assess the vital signs of the client. > Provide hygienic care. Administer medications like antipyrutics. Give compression for 15 min Provide plenty of fluids. > Educate on cold nutritious diet personal hygiene. rest Encourage sleep and and Implementation > Assessed the Body vital signs oftemperature the cltent. Provided hygienic care. Administered the medication tab. Pct 650 mg. Given compression for 15 min Provided cold plenty of fluids Educated on nutritious diet and personal hygiene > Encouraged to take rest and sleep Reassessed Evaluation the vital signs and recorded. after reduced implementing all measures. Page 24 Ans. The planning process 1. Setting priorities 6. Explain the steps in planning as a part of nursing process 3. Selecting nursing interventions Reassess the 2. Establishing client goals /desired outcome Setting priorities signs. 4. Writing individualized interventions on care plan vital The nurse begin planning by deciding which nursing diagnosis requires attention first, which second, and so on. Nursing interventions Nurses frequently use Maslow's hierarchy of needs when setting priorities. Establishing client goals/desired outcomes After establishing priorities, the nurse set goals for each nursing diagnosis. Goals may be short term or long term. A nursing intervention is any treatment, that a nurse performs to improve patient's health. TYPES OF NURSING INTERVENTIONS 1. Independent interventions are those activities that nurses are licensed to initiate on the basis of their knowledge and skills. 2. Dependent interventions are activities carried out under the orders or supervision of a licensed physician. 3. Collaborative interventions are actions the nurse carries out in collaboration with other health team members Writing lndividualized Nursing Interventions After choosing the appropriate nursing interventions, the nurse writes them on the care plan. Nursing care plan is a written or computerized information about the client's care. 7. Define nursing diagnosis and discuss the types of nursing diagnosis with examples Page 25 Ans. Definition The official NANDA definition of a nursing diagnosis is: "a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community." Status of the Nursing Diagnosis: The status of nursing diagnosis are actual, health promotion and risk. 1. An actual diagnosis is a client problem that is present at the time of the nursing assessment. 2. A health promotion diagnosis relates to clients' preparedness to improve their health condition. A risk nursing diagnosis is a clinical judgement that a problem does not exist, but the presence of risk factors indicates that a problem may develop if adequate care is not given. Components of a NANDA Nursing Diagnosis A nursing diagnosis has three components: (1) The problem and its definition (2) The etiology (3) The defining characteristics. 1. The problem statement describes the client's health problem. 2. The etiology component of a nursing diagnosis identifies causes of the health problem. 3. Defining characteristics are the cluster of signs and symptoms that indicate the presence of health problem. Formulating Diagnostic Statements The basic three-part nursing diagnosis statement is called the PES format and includes the following: 1. Problem (P): statement of the client's health problem (NANDA label) 2. Etiology (E): causes of the health problem 3. Signs and symptoms (S): defining characteristics manifested by the client. Example: Acute pain related to abdominal surgery as evidenced by patient discomfort and pain scale. Page 26 8. Define nursing process. Explain the purpose and importance of nursing procesS Ans. Definition: Nursing process is a critical thinking process that professional nurses use to apply the best available evidence to care giving and promoting human functions and responses to health and illness. Purposes of nursing process To identify a client's health status and actual or potential health care problems or needs. To establish plans to meet the identified needs. To deliver specific nursing interventions to meet those needs. Importance of nursing process: The nursing process is important to ensure quality care and to get the preferred outcome. In the nursing process, critical thinking is used to recognize the issue and come up with a logical solution to solving it. One important aspect of the nursing process is that the plan is not set in stone; it is meant to be manipulated in order to better suit the patient. > Nurses must be able to think critically in order to recognize the issue, develop a way to correct it, and be able to communicate the issue to others. Throughout the nursing process, critical thinking is used to determine the best plan of care for a patient based on their diagnosis. 9. Define nursing intervention and discuss the types of nursing intervention Ans. Health system nursing interventions are actions nurses take as part of a healthcare team to provide a safe medical facility for all patients, such as following procedures to reduce the risk of infection for patients during hospital stays. i)Types of Nurse Intervention: Intensive: is reserved for catastrophic cases where medical recovery is expected to extend over long or indefinite periods of time Moderate: combines both phone calls and face-to-face interaction (Field Nurses). Limited: consists of telephone interaction only (COP Nurses). Page 27 i)Types of nursing interventions I. Independent interventions Activities nurses are licensed to initiate (i.e., physical care, ongoing assessment) II. Dependent interventions Activities carried out under primary care provider's orders or supervision, or according to specified routines III. Collaborative interventions Actions nurse carries out in collaboration with other health team members. 10. Explain the steps of evaluation in nursing process Ans. Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals; in this phase nurse compare the client behavioral responses with predetermined client goals and outcome criteria. 1. Collecting the data related to the desired outcomes 2. Comparing the data with outcomes 3. Relating nursing activities to outcomes 4. Drawing conclusion about problem status 5. Continuing, modifying, or terminating the nursing care plan Collecting the data: The nurse collects the data so that conclusion can be drawn about whether goals have been met. It is usually necessary to collect both subjective & objective data. Data must be recorded concisely and accurately to facilitate the next part of the evaluating process. Comparing the data with outcomes: If the first part of the evaluation process has been carried out effectively, it is relatively simple to determine whether a desired outcome has been met. Both the nurse and client play an active role in comparing the client's actual responses with the desired outcomes. Relating nursing activities to outcomes The third aspect of the evaluating process is determined whether the nursing activities had any relation to the outcome. Page 28 Drawing conclusion about problem status: The nurse uses the judgement about goal achievement to determine whether the care plan was effective in resolving, reducing or preventing client problems. When goals have been met the nurse can draw one the following conclusions about the status of the client's problem. Continuing, modifying , or terminating the nursing care plan: After drawing conclusion about the status of the client's problems, the nurse modifies the care plan as indicated. Whether or not goals were met, a number of decision need to be made about continuing, modifying or terminating nursing care for each problem. Before making individual modification, the nurse must first determine why the plan as a whole was not completely effective. This require a review of the entire plan. Page 29 SHORT ANSWERS DOCUMENTATION AND REPORTING 1. List down types of records in hospital ANS. Types of Records 1) Patients Clinical Record. 2) Individual Staff Records 3) Ward Records UNIT-VI 4) Administrative Records with Educational Value. 2. What is incidental Report Ans. In a health care facility, such as a hospital, nursing home, or assisted living, an incident report or accident report is a form that is filled out in order to record details of an unusual event that occurs at the facility, such as an injury to a patient. The purpose of the incident report is to document the exact details of the occurrence while they are fresh in the minds of those who witnessed the event. This information may be useful in the future when dealing with liability issues stemming from the incident. 3. Differentiate Record and Report Ans. RECORDS A record is a permanent written communication that documents information relevant to a client's health care management, e.g. a client chart is a REPORTS can be compiled daily, weekly, monthly, quarterly and annually. Report summarizes the services of the nurse and/ or the agency. Reports may be in the form of an analysis of some aspect of a service. 4. State four guidelines for Reporting Ans. Provide only essential background data on patient (e.g name, age, gender, diagnosis, and history) Describe objective measurements about patient condition an response of health problem Evaluate results of nursing or medical care measures. T. PAVITHRA M.Sc (N), M.Sc (psy) continuing account of client's health care status and need. Page 30 Be clear on priorities to which oncoming staff must attend. Don't review all routine care and procedure or tasks Don't review all biographical data already available in written form 5. What is transfer Report Ans. Transfer report: Transfer report is given whenever the patient is transferred to other health care unit. It can happen between: Nursing unit-to-nursing unit transfer Nursing unit to diagnostic area. Special settings (operating room, emergency department). Discharge and inter-facility transfer 6. What is progress note Ans. Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. 7. State four guidelines for recording Ans. > Use complete, concise descriptions of care. > A Record all facts and enter only factual data. Correct all errors promptly, to avoid error, avoid rushing to complete charting. Do not write critical comments about client or care by other health care professionals. > Enter only objective description of client's behavior, client comments should be quoted. client. Do not erase, apply correction fluid, or scratch out errors made while recording. So for any error, just strike over it and sign the name or initials. 8. What is the meaning of documentation Ans. Document is described as any written or electronically generated information about a patient status or the care or the service provided to that patient. Nursing documentation is the record of nursing care that is planned and delivered to individual T. PAVITHRA M.Sc (N), M.Sc (psy) A A Page 31 9. What is the meaning of computerized Documentation (CDS) provide for the documentation of patient care using computers. For example, the CDS records the vital signs directly from the cardio-respiratory monitors, while other documentation, such as nursing assessments are entered by the clinician. Ans. Computerized clinical documentation systems 10. List the cases to be included under medico legal records. Ans. Cases that are to be treated as medico legal are: (1) All cases of injuries and burns - the circumstances of which suggest commission of an offense by somebody (irespective of suspicion of foul play): (2) all vehicular, factory, or other unnatural accident cases specially when there is a likelihood of patient's death. T. PAVITHRA M.Sc (N), M.Sc (psy) Page 32 SHORT ESSAY Ans. 1. Define pyrexia. explain nursing care of a client with pyrexia When body temperature rises above 99 degree f. or 37 degree c. It is called pyrexia or fever. OBJECTIVES- Nursing Care of patient With Pyrexia Prevent complication Promoting balance between heat production and heat loss. Reduce heat production UNIT-VII VITAL SIGNS ASSESSMENT- To increase heat lossv Objectives Assess for contributing factors such as dehydration, infection environmental temperature Obtain frequent temperature reading Assess for presence of thirst, malaise Assess skin colour and temperature Obtain all vital signs ldentify physiological response to fever Observe for shivering and diaphoresis Assess clients comfort and wellbeing NURSING INTERVENTION OF FEVER- minimize heat production- reduce the frequency of activities that increases Oxygen demand, such as excessive turing and ambulation, allow rest period, limit physical activity Maximize heat loss-minimize external covering on clients body, keep clothing and bed linen dry, prevent patient from getting draughts. Expose patient to cool air by an electrical fan Maximize heat loss- Administration of cool drinks Application of cold compress and ice bags Cold sponging and cold packs. Cold bath Use of hypothermic blanket Page 33 Prevent shivering-shivering is prevented because it increases metabolic activity Produces heat, increases oxygen demand, and circulation. May cause hyperventilation and respiratory alkalosis. Promote client comfort Encourage oral hygiene, Prevent dehydration Control temperature of environment. Provide complete bed rest The clothing should be light, Ioose, smooth, cotton, non irritating. Satisty supplement for increased metabolic rate- provide supplemental oxygen therapy. Replace fluid lost Provide high caloric diet- because oxygen consumption in body tissues increases. Diet should be easily digestible and palatable Fluid intake upto3000ml. Encourage patient to take plenty of fluid. Maintain intake output chart. Provide small frequent feeds. Make food palatable. Plenty of fluid and fruits will help to evacuate bowel regularly. Maintenance of personal hygiene-Frequent mouth care Care of skin and pressure points. Give sponge bath daily. If temperature remains high cold sponging is given to bring down the temperature. Safety of patient-Never leave a patient alone. Rigor and convulsions may occur at any time constant observation is important Evaluate urine output periodically. 2. Explain characteristics and factors affecting pulse Ans. Pulse is a wave of blood created by the contraction of left ventricle. pulse reflects the heart beat. Characteristics of pulse 1. Pulse rate: It is the number of pulse beats per minute. Normal pulse rate in aduts varies from 72 to 80 beats per minute. 2. Rhythm or regularity: It is the time interval between pulse beats. Normally the time intervals between pulse beats are equal or regular. Page 34 3. Tension: It is degree of compressiblty and depends upon the resistance of the wall of the artery. 4. Strength/volume: It is the fullness of artery. It is force of blood felt at each beat. Factors affecting pulse 1. Age 2. Sex: The normal range of the pulse in an adult is 60 to100 BPM The average pulse rate of an infant ranges from100 to 160 BPM After puberty the average males PR is slightly lower than female Autonomic Nervous system activity Stimulation of the parasympathetic nervous system results in decrease in the PR Stimulation of sympathetic nervous system results in an increased pulse rate Sympathetic nervous system activation occurs on response to a variety of stimuli incduding Pain , anxiety ,Exercise ,Fever Ingestion of caffeinated beverages ✔ Change in intravascular volume 3. Exercise: PR increase with exercise 4. Fever: increases PR in response to the lowered B/P that results from peripheral vasodilatation – increased metabolic rate 5. Heat: increase PR as a compensatory mechanism 6. Stress: increases the sympathetic nerve stimulation 7. Position changes: a sitting or standing position blood usually pools in dependent vessels of the venous system. B/c of decrease in the venous blood return to heart and subsequent decrease in BP increases heart rate 8. Medication Cardiac medication such as digoxin decrease heart rate Medications that decrease intravascular volume such as divretics may increase pulse rate Atropine in habits impasses to the heart from the parasympathetic nervous system, causing increased pulse rate Propranolol blocks sympathetic nervous system action resulting in decreased heart rate sites used for measuring pulse rate. Page 35 3. Explain characteristics and factors affecting respiration. Ans. Respiration is the act of breathing and includes the intake of oxygen and removal of carbon-dioxide. Characteristics The client should be at rest Assessed by watching the movement of the chest or abdomen. Rate: Rate, Rhythm, Depth and special characteristics of respiration are assessed ls described in rate per minute (RPM) Healthy adult RR= 15- 20/ min. is measured for full minute, if regular for 30 seconds As the age decreases the respiratory rate increases Apnea - temporary cessation of breathing Tachypnea - fast breathing Bradypnea- slow respiration Eupnea- normal breathing rate and depth Rhythm: Is the regularity of expiration and inspiration Normal breathing is automatic & effortless. Depth: Described as normal, deep or shallow Deep: a large volume of air inhaled & exhaled, inflates most of the lungs. Shallow: exchange of a small volume of air minimal use of lung tissue. Factors affecting respiration: Medications Narcotics decrease respiratory rate Age Normal growth from infancy to adult hood results in a larger lung capacity. As lung capacity increases, lower respiratory rates are sufficient to exchange Stress or strong emotions increases the rate and depth of respirations Page 36 Exercise increases the rate & depth of respirations Altitude The rate & depth of respirations at higher elevations (altitude) increase to improve the supply of oxygen available to the body tissues Fever increases respiratory rate Gender Men may have a lower respirations rate than women because men normally have a larger rung capacity than women. 4.. Explain characteristics and factors affecting blood pressure Ans. Blood pressure is the force exerted by the blood against the wall of blood vessel Characteristics Cardiac output: It is the amount of blood ejected by heart in 1 minute Stroke volume: It is the amount of blood ejected by heart in 1 cycle. Normally heart eject 70-80 ml blood in 1 cycle Cardiac output = stroke volume X heart rate > Peripheral vascular resistance: It is the resistance to the blood flow determined by the tone of vascular muscle's & the diameter of blood vessels ,smaller the lumen greater the resistance ,ultimately blood pressure raises. That is why vasoconstriction leads to elevation of blood pressure Blood volume : as soon as the blood volume increases, pressure exerted against arterial wall also increases. That is why giving intravenous fluid in hypotension increases the blood pressure.with hemorrhage & bleeding, blood volume decreases & automatically Blood pressure falls Factors affecting blood pressure Age: blood pressure varies throughout the age. As age increases, BP also raises. Infant blood pressure: 65-115/42-80 mm Hg 7 year child: 87-177/48-64 mmHg Normal adult: 120/80 mmHg Older people, systolic pressure rises with decreased elasticity Body size/obesity: It is observed that as the body size increases, BP also fluctuates. Heavier & taller child have higher BP than the smaller child of same age Emotions/stress: anxiety, fear , pain , stress, sympathetic nervous system get activated, causing vasoconstriction , increases heart contraction & ultimately raises blood pressure Gender: After puberty , male have higher blood pressure than females. But after menopause, women tend to have high BP than male of same age Ethnicity: African – Americans have higher incidence of high blood pressure than European- Americans Page 37 Diet: people taking diet rich in salt & unsaturated fatty acids, having higher blood pressure. Cocaine use also increases blood pressure. Caffeine intake also increases blood pressure. Ans. Smoking: due to nicotine blood pressure increases Exercise: Regular exercise, decreases the blood pressure. Helps in keeping BP normal Diurnal variations: usually, person have low BP in early morning & gradually rises & peaks in evening Medications: medications such as opioid analgesics, antihypertensive drugs have greater effect on BP Chemicals: such as epinephrine, ADH, Angiotensin Il cause vasoconstriction , thus elevating BP. Histamine, kinens cause vasodilation , thus decrease BP. 5. Define hypothermia. Discuss nursing measures for hypothermia. 1. Hypothermia occurs when the body temperature drops below 36.5 degree Celsius (97.7 degree F), the lower limit of normal range of 36.5 - 37.5 degree Celsius (97.8-99.5 degree Fahrenheit) 2. If the temperature falls below 95degree f. Or 35 degree c. The condition is called hypothermia. Nursing care for hypothermia Patient is re-warmed by placing him in a warm rOom, with warm blankets and drinks. Prevent a further decrease in body temperature removing wet clothes, replacing them with dry cloth. If possible give hot liquids such as soup. Avoid alcohol and caffeinated fluid. keep the head covered. For a new born: An important objective of appropriate care of the newborn is to avoid hypothermia from the moment of birth, by using procedures that will prevent heat loss and maintain the temperature within the normal range, thus conserving the infant's energy for growth and development. Placing indirect skin-to-skin contact with mother. Covering both (mother & baby) with heavy and clean blanket. Maintain input output chart frequently Promote client comfort Safety of patient-Never leave a patient alone. 6. Discuss on abnormal pulse? Page 38 Ans. Abnormal Findings In Pulse Abnormality can be in the: RATE Rate Rhythm Volume Character Condition of vessel wall Radio femoral delay Tachycardia(Pulse Rate>100 bpm).Bradycardia(Pulse Rate Eupnea : Normal breathing (Eup-knee-a) Orthopnea: Only able to breathe comfortable in upright position (such as sitting in chair), unable to breath laying down, (Or-thop-knee-a) > Dyspnea : Subjective sensation related by patient as to breathing difficulty. Paroxysmal nocturnal dyspnea - attacks of severe shortness of breath that wakes a person from sleep, such that they have to sit up to catch their breath - common in patient's with congestive heart failure. Hyperpnea: Increased volume with or without and increased frequency (RR), normal blood gases present. Hyperventilation: "Over" ventilation - ventilation in excess of the body's need for CO2 elimination.Results in a decreased PaC02, and a respiratory alkalosis. Hypoventilation: Decreased rate (A) or depth (B), or some combination of both. "Under" ventilation - ventilation that is less than needed for CO2 elimination, and inadequate to maintain normal PaCO2. Results in respiratory acidosis. Can be a slow rate with normal tidal volumes such that the total minute ventilation is inadequate. Can be a normal rate but with such low tidal volumes that air exchange is only in the dead space and not effective. > Tachypnea: Increased frequency without blood gas abnormality > Kussmaul's Respiration: Kussmaul's respiration. Increased rate and depth of breathing over a prolonged period of time. In response to metabolic acidosis, the body's attempt to blow off CO2 to buffer a fixed acid such as ketones. Ketoacidosis is seen in diabetics. > Cheyne-Stokes respirations (CSR): Gradual increase in volume and frequency, followed by a gradual decrease in volume and frequency, with apnea periods of 10 - 30 seconds between cycle. Described as a crescendo - decrescendo pattern. Characterized by cyclic waxing and waning ventilation with apnea gradually giving way to hyperpneic breathing. Seen with low cardiac output states (CHF) with compromised cerebral perfusion Page 41 Creates lag of CSF CO2 behind arterial PaCO2 and results in characteristic cycle. Delayed sensitivity to CO2 changes- during apnea the CO2 increase above the threshold for stimulus but the brain is slow to respond, then it over shoots by hyperventilating and the signal to reduce ventilation is slow to be recognized. Biot's respiration: Similar to CSR but Vr is constant except during apneic periods. Short episodes of rapid, deep inspirations followed by 10 - 30 second apneic period. Seen with patients with elevated |CP as seen in meningitis > Apneustic breathing (previously described): Indicates damage to pons > Central neurogenic hyperventilation: Persistent hyperventilation May be caused by head trauma, severe brain hypoxia, or lack of cerebral perfusion Mid brain and upper pons damage > Central neurogenic hypoventilation: Medulla respiratory centers are not responding to appropriate stimuli. Associated with head trauma, cerebral hypoxia, and narcotic suppression > CO2 and Cerebral Blood Flow (CBF): CO2 plays an important role in autoregulation of CBF mediated through its formation of H*. Increased CO2 dilates cerebral vessels and vice versa. In traumatic brain injury (TBI), the brain swells acutely. Head is a fixed volume container - cannot expand. When bleeding or swelling occurs in the brain pressures rapidly increase. Raising ICPs exceed cerebral arterial pressure and brain perfusion stops. Cerebral hypoxia/ischemia - brain death Mechanical hyperventilation can lower PaCO2, which results in vasoconstriction in cerebral vessels, reduction of swelling and ICP. Controversial as reduces O2 and CBF to injured brain. Only effective for the first 24 hours. Current practice is to treat perfusion pressures pharmacologically rather then use hyperventilation. All agree must avoid hypoventilation in TBl patients. 8. Discuss on types of fever Page 42 Ans. Fever: a body temperature abovethe normal ranges 38 Oc – 410 c (100.4 - 105.8 F) Types of fever 1. Intermittent fever: the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperature. 2. Remittent fever: a wide range of temperature fluctuation (more than 2 0c) occurs over the 24 hr period, all of which are above normal 3. Relapsing fever: short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature. 4. Constant fever: the body temperature fluctuates minimally but always remains above normal 9. Classify cold and hot application. Discuss on purpose and indication of both? Ans. Classification of cold and hot applications : Dry cold lce bag Ice collar Ice pack (poultice) Ice cradle Chemical cold packs CLASSIFICATION OF COLD APPLICATIONS LOCAL Moist cold lce to suck Cold compress Evaporating lotion GENERAL Dry cold Hypothermia Moist cold Cold sponging Cold bath -Cold packs Page 43 A Hot water bottles Dry heat Chemical CLASSIFICATION OF HOT APPLICATIONS LOCAL heating bottles AA Infrared rays Ultraviolet rays Short wave diathermy Heating lamps Electric cradles Electric heating pads To anaesthetize an area > To control hemorrhage PURPOSE OF COLD APPLICATION: To prevent gangrene > To prevent edema and moist or dry form, on the surface of the skin; > To reduce inflammation. Moist heat To reduce pain and body temperature AWarm soaks (Local baths) Hot fomentations To control the growth of bacteria (Compresses) Poultices To provide warmth (cataplasm) Stupes (medical fomentations) Paraffin baths Sitz bath Aquathermia pad To promote suppuration PURPOSE OF HOT APPLICATION: > To promote healing > To relive pain and congestion > To soften the exudates. Cold application is the application of a cold agent cooler than skin either in a To decrease muscle tone and Dry heat Sun bath Electric cradles GENERAL Blanket bed Moist heat Hot application is the application of a hot agent, warmer than skin either in a moist or dry form on the surface of the body; Steam baths Hot packs Whirlpool bath (Full immersion bath) A A Page 44 INDICATION OF COLD AND HOT APPLICATION: Ans. > Cold application assists with extra- vasation following canulation of an AV fistula or graft. Heat may relieve muscle cramps that can occur in 20 % of haemo- dialysis treatments, due to rapid fluid shifts. The application of heat is a non-medically prescribed therapy, used with therapeutic intent. Dialysis Unit Therapeutic effects of heat can assist in relieving sore, stiff muscles or joints. 10. Define blood pressure. Explain steps in measuring blood pressure. > Safe heat or cold applications will be provided to patients / residents as part of pain management programs wherever these applications are appropriate and effective. Definition: Blood pressure is the force exerted by the blood against the wall of blood vessel. Two measurements: Systolic blood pressure: is force exerted by arterial walls during systole. It is the maximum pressure during ventricle contraction Diastolic blood pressure: is the force exerted by blood against arterial wall during diastole. It is the maximum pressure when the ventricles are relaxed Unit of measuring blood pressure is (mmHg) millimeters of mercury Normal blood pressure is 120/80 mm of Hg A Here, systolic pressure is 120 mmHg & diastolic pressure is 80 mmHg Pulse pressure is the difference between systolic & diastolic pressure Normally, The pulse pressure is 40 mmHg Steps in measuring blood pressure: Collect all the articles Wash hands Explain procedure to the client. Ex: you are going to monitor his BP Provide comfortable position. Ex: sitting, supine while keeping his upper arm at heart level ,palm up > Ensure that mercury level of sphygmomanometer is at zero Ensure cuff width against client's arm Page 45 > Ensure mercury meniscus is at your eye level A Palpate brachial artery pulse Ensure no air in the cuff & wrap it evenly around client's arm centering arrow over brachial artery Place lower edge of cuff about 1 inch above antecubital fossa > Tuck the end of wrap under cuff > Ensure that connecting tubings are free of each other. Estimate systolic pressure by palpating the artery with finger tips of one hand while inflating cuff, rapidly to pressure 30 mmHg above point when pulse reappears. Deflate cuff fully & wait for 30 secs > Place earpiece of stethoscope in ears & bell/diaphragm on brachial artery Close valve of pressure bulb clockwise until tight > Rapidly inflate cuff to 30mmHg above palpated systolic pressure Slowly release the pressure bulb valve & allow the mercury to fall at rate of 2-3 mmHg/sec Listen & watch mercury level drop. when first clear:"tap tap" (karot koff) Sound is heard, note the systolic blood pressure Continue to deflate the bulb & when sound disappears, note the diastolic blood pressure Listen for 10-20 mmHg after the last sound & then escape air quickly > Remove cuff > Inform client of his BP reading as needed Reposition client comfortably > Record reading immediately > Replace articles: Clean earpiece & bell/diaphragm of stethoscope with alcohol swab. Discard used alcohol swabs. Place articles to their correct place. Wash hands Add on points: As record is a legal document, It protects the hospital as well as client. Nurse must document the reading of vital signs any deviations While documenting vital signs, she should follow organizations policies procedure Vital sign can be documented on graphic sheet notes in case of abnormality detected. Such as elevated temp, tachycardia, shortness of breath. Also document the actions taken for identified problems. Recording vital signs & Vital signs are documented on vital chart as well as graphic sheet. Page 46 SHORT ESSAY Definition 1)Explain the purpose of health assessment A health assessment is a plan of care that identifies the specific needs ofa person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history. It is done to detect diseases early in people that may look and feel well. facility. HEALTH ASSESSMENT Health assessment helps to identify the medical need of patients. Patients health is assessed by conducting physical examination of patient. A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare systenm or skilled nursing Purpose of Health Assessment Establish a data base o strengths/weaknesses UNIT -VIII physiological status o knowledge base motivation support systems & coping ability other factors that may influence health positively or negatively 2) Explain the preparation of patient unit for physical examination? Preparing Patients for Physical Examination: This duty entails the following: Page 47 Escorting patients from the waiting room to the examination roonms Interviewing the patient, including leading a discussion of medical history and recent tests performed Recording the patients' vital signs Measuring the patients' heights and weights Measuring the patients' blood pressure as needed Sight Conducting one's self in a polite and professional manner at all times with patients Purpose of Physical Examination: To understand the physical and mental health of the patient. To detect disease in its early stage. To find out the cause and the extent of disease. To understand the changes in the condition of diseases, any improvement or regression. To define the nature of the treatments or nursing care needed for the patient. To safeguard the patient and his family by noting the early signs especially in case of a communicable disease. 3) Discussion on methods of physical examination physical assessment, will use four techniques: inspection, palpation, percussion, and auscultation. Use them in sequenceunless you're performing abdominal assessment. Palpation and percussion can alter bowel sounds, so you'd inspect, auscultate, percuss, then palpate an abdomen. Inspection an Performed first, inspection is the most repeated of the four physical examination methods. Teaching students about inspection emphasizes using sight and smell to check specific areas for normal color, shape, and consistency. Page 48 Make sure that your students arrange clothing accordingly and use adequate lighting to fully observe the body parts they are inspecting. Smell Because certain infections give off a stench, smell is vital to inspection. You may simulate smell by using a scent-laden cheese to give students real-life experience with smell inspection. Palpation Palpation is the act of touching a patient to feel for abnormalities anywhere in the body. There are two different types: light and deep palpation. Light Palpation As the name suggests, light palpation is soft and gentle. Nurses may find information on skin texture and moisture, masses, fluid, muscle guarding, and superficial tenderness by using light palpation. Deep Palpation Deep palpation explores the body's internal structures to a depth of 4-5 centimeters. This technique can inform nurses about the position of organs and masses, as well as their size, shape, mobility, consistency, and areas of discomfort. Percussion Percussion includes tapping one's hands on a patient's body to produce sound vibrations. The sounds made can confirm the presence of air, fluid, and solids, along with organ size, shape, and position. Percussion can be practiced almost anywhere to analyze the intensity, duration, pitch, frequency, quality, and location of sound. Auscultation The final method is auscultation, which is listening to the heart, lungs, neck, or abdomen to gather information. There are two types of auscultation: direct and indirect. Page 49 Direct Auscultation Listening with the unaided ear. This may include listening to the patient from a distance or right on the patient's skin. Indirect Auscultation Using amplification or a mechanical device, such as a stethoscope. An acoustic stethoscope does not amplify the body sounds but blocks out environmental sounds. 4) Discuss the significance of History collection in Health assessment Plan strategies to encourage continuation of healthy patterns, prevent potential health problems and alleviate or manage existing health problems.D Establish a data base for the clients normal abilities risk factors, and any current alterations in function. Purposes of health assessment 1. To idientify need for health teaching 2. To identify client's strengths To identify the health problems 3. To organize the collected information 4. To determine client's normal function 5. To gather information regarding client's health Formulating conclusion or a problem statement such as a nursing diagnosis. 6. Provide the holistic view of the clients TYPES OF ASSESSMENT INTIAL ASSESSMENT It is performed within specified time after admission to a hospital. The establish a complete data base for problem identification , reference and future comparison. e.g. Nursing admission assessment.e.g. Hourly assessment of client's fluid intake and output chart Purpose The main purpose of ongoing or focused assessment to determine Page 50 the status of a specific and to identify new or overlooked problem D on going or focused assessment is ongoing process integrated with nursing care. FOCUS or ONGOING ASSESSMENT E.g a rapid asessment of person's airway b breathing ,and cirulation during cardiac arrest Purpose. To identify life- threatining problems Emergency assessment is life saving assessment the major purpose of emergency assessment is save the patient or client's life. EMERGENCY ASSESSMENT Purpose. To compare the client's current status to baseline data previously obtained. e.g Reassessment of a client's functional health patterns in a home.D Time lapsed assessment involves assessmnent several days after first initial assessment. 5) Explain the assessment of Gastro intestinal svstem using techniques of physical examination? Inspection The patient is placed supine on an examining table or bed. It is helpful to place a small pillow beneath the knees to relax the abdominal musculature. The head should rest comfortably on a small pillow. The patient's arms should rest comfortably at the sides. Drapes should be placed over the breasts and groins just below the inguinal regions to preserve modesty. The examiner stands on the patient's right. Palpation Palpation of the abdomen involves using the flat of the hand and fingers, not the fingertips to detect palpable organs, abnormal masses, or tenderness. Again, an orderly approach is necessary to prevent oversights. One should begin in the right upper quadrant with palpation of the liver. The flat of the right hand is placed on Page 51 the abdominal wall with the fingertips pointing toward the right shoulder. The fingertips should be 2 to 3 cm below the costal margin The patient is asked to inspire deeply, bringing the liver edge down to the fingertips. One should note the consistency of the liver and whether there is tenderness. It should be noted whether the edge of the liver is sharp, blunted, or nodular. Percussion Percussion of the albdomen is performed to check liver size, spleen size, and any abnormal gas collections. The size of the liver is estimated by determining the span of liver dullness by percussion. This is performed by percussing just below the breast in the midclavicular line. A resonant note should be obtained because of the underlying air Percussion then proceeds caudally from the dome of the liver until dullness is noted. Percussion is then continued caudally until resonance returns, indicating thạt the examiner has reached the hepatic flexure of the colon at the hepatic edge). A normal liver span is 10 to 12 cm. If dullness is absent over the liver, this may be a sign of intra-abdominal gas, as might occur with a perforated viscus. Auscultation In abdominal examination auscultation is performed before palpation, as palpation may alter the bowel sounds. Starting in the right upper quadrant, the examiner listens over the liver for rubs or bruits and over the free abdominal wall for bowel sounds. One moves next to the left upper quadrant, again listening for bowel sounds and then over the spleen to detect rubs or bruits. One should next auscultate in the periumbilical regions for aortic or renal bruits and for bowel sounds and then in the left and right lower quadrants for bowel sounds or iliac bruits. If, during the course of auscultation, no bowel sounds are detected, one should auscultate in the periumbilical region for 3 full minutes before determining that bowel sounds are Page 52 absent. Important points to note on bowel sounds are the pitch, intensity, and duration of the sounds. 6) Explain the assessment of respiratory System using techniques of physical examination? Palpation is the use of physical touch during examination. During palpation, the physician checks for areas of tenderness, abnormalities of the skin, respiratory expansion and fremitus. The four steps of the respiratory exam are inspection, palpation, percussion, and auscultation of respiratory sounds, normally first carried out from the back of the chest Inspection The examiner then estimates the patient's respiratory rate by observing how many times the patient breathes in and out within the span of one minute. This is typically conducted under the pretext of some other exam, so that the patient does not subconsciously change their baseline respiratory rate, as they might do if they were aware of the examiner observing their breathing. Adults normally breathe about 14 to 20 times per minute, while infants may breathe up to 44 times per minute Palpation Palpation is the use of physical touch during examination. During palpation, the physician checks for areas of tenderness, abnormalities of the skin, respiratory expansion and fremitus. Page 53 To assess areas of tenderness, palpate areas of pain, bruises, or lesions on the front and back of the chest. Bruises may indicate a fractured rib, and tenderness between the ribs may indicate inflamed pleura. Palpate any abnormal masses or structures on the front and back of the chest. Abnornal masses or sinus tracts may point to infections. Chest percussion Percussion over different body tissues results in five common "notes". 1. Resonance: Loud and low pitched. Normal lung sound. 2. Dullness: Medium intensity and pitch. Experienced with fluid. A dull, muffled sound may replace resonance in conditions like pneumonia or hemothorax. 3. Hyper-resonance: Very loud, very low pitch, and longer in duration. Abnormal. Hyper-resonance can result from asthma or enphysema 4. Tympany: Loud and high pitched. Common for percussion over gas-filled spaces. o Tympany may result in pneumothorax. Ascultation 5. Flatness: Soft and high pitched. The areas of the lungs that can be listened to using a stethoscope are called the lung fields, and these are the posterior, lateral, and anterior lung fields. The posterior fields can be listened to from the back and include: the lower lobes (taking up three quarters of the posterior fields); the anterior fields taking up the other quarter; and the lateral fields under the axillae, the left axilla for the lingual, the right axilla for the middle right lobe. The anterior fields can also be auscultated from the front Page 54 7) Write in detail regording of physical examination findindgs from head to toe? Definition A head-to-toe assessment refers to a physical examination or health assessment, and it becomes one of the many important components of understanding a patient's needs and problems. The Order of a Head-to-Toe Assessment 1. General Status Vital signs Heart rate Blood pressure Temperature Pulse oximetry Respiratory rate Pain 2. Head, Ears, Eyes, Nose, Throat Observe color of lips and moistness Inspect teeth and gums Assess buccal mucosa and palate Examine Tongue Examine at uvula Examine tonsils Palpate nose and assess symmetry Check Septum and inside nostrils Verify patency of nares Check patient's sense of smell Palpate sinuses Page 55 Assess patient hearing with whisper test Tuning Fork test (Weber's test, Rinne test) Look inside ear Assess ear discharge and tympanic membrane Check conjunctive and sclera Assess eye symmetry PERRLA Check vision with Snellen Chart Check six cardinal positions of the gaze 3. Neck Palpate lymph nodes Observe and palpate trachea and neck Check for Jugular Venous Distention Check neck range of motion Check shoulder shrug with resistance 4. Respiratory Listen to lung sounds front and back Assess respiratory expansion level Ask about coughing Palpate thorax 5. Cardiac Palpate the carotid and temporal pulses bilaterally Listen to heartbeat 6. Abdomen Inspect abdomen Listen to 4 quadrants of abdomen for bowel sounds Palpate 4 quadrants of abdomen for pain/tenderness Page 56 Ask about problems with bowel or bladder 7. Pulses Check pulses in arms/legs/feet including, Radial Femoral o Posterior tibial Dorsalis pedis 8. Extremities 9. Skin Assess range of motion and strength in arms/legs/ankles Assess sharp and dull sensation on arms/legs Check capillary refill on fingernails/toenails Check skin turgor Check for lesions, abrasions, rashes Check for tenderness, lumps, lesions Check ifpatient is pale, clammy, dry, cold, hot, flushed 10, Neurological Oriented x3 Assess gait Check coordination Assess reflexes Check Glasgow Coma Scale score 8) Explain the assessment of cardio vascular system using techniques of physical examination The cardiac examination consists of evaluation of (1) the carotid arterial pulse and auscultation for carotid bruits; (2) the jugular venous Page 57 pulse and auscultation for cervical venous hums; (3) the precordial impulses and palpation for heart sounds and murmurs; and (4) auscultation of the heart. Examination of the Heart Carotid Arteries Begin the cardiovascular examination by assessing the carotid arterial pulses They are ordinarily examined while the patient is breathing normally and reclining with the trunk of the body elevated about 15 to 30 degrees. In order to examine the carotid arteries, the sternocleidomastoid (SCM) muscle should be relaxed and the head rotated slightly toward the examiner. The examiner places the forefinger or thumb, depending on individual preference, slightly over the artery in the groove just lateral to the trachea. Care should be taken always to palpate in the lower half of the neck in order to avoid the area of the carotid bulb, lest a hypersensitive carotid sinus reflex be evoked with resultant bradycardia and hypotension. Jugular Veins The jugular venous pulse is usually examined next. It includes observation of venous wave form, assessment of the response of the venous pressure to abdominal compression, estimation of the central venous pressure (CVP), and auscultation for cervical venous hums. Venous pulsations are examined by inspection of either the external or internal jugular veins, although the latter are generally more reliable Precordial Movements and Thrills The precordial examination, performed next, consists of inspection and palpation of the anterior chest wall. Precordial movements should be evaluated at the apex (left ventricle), lower left parasternal edge (right ventricle), upper left (pulmonary artery) and upper right (aorta) parasternal edges, and epigastric and sternoclavicular areas It is best to examine the precordium with the patient supine because if the patient is turned on the left side, the apical region of the heart is because they more directly reflect right atrial hemodynamics. Page 58 displaced against the lateral chest wall, distorting the chest movements. Inspect the chest wall by positioning yourself on the patient's right side and looking tangentially across the fourth, fifth, and sixth intercostal spaces. Ask the patient to take a deep breath and then to exhale slowly as you look for a discrete area of apical movement. The following are the factors to be considered about any precordial movenment that can be seen or felt: (1) location; (2) amplitude; (3) duration; (4) time of the impulse in the cardiac cycle; and (5) contour. 9) What are the methods of health assessment explain in detail any one method Purpose of health assessment The purpose of health assessment is to get a general understanding of the state of your healt 5 Principles health assessment techniques Accountability.... Performance-Based Assessment.... Evidence-Based Assessment. * Validity and Reliability in Assessment.... Participation and Collaboration. AUSCULTATION The final method is auscultation, which is listening to the heart, lungs, neck, or abdomen to gather information. There are two types of auscultation: direct and indirect. Direct Auscultation Listening with the unaided ear. This may include listening to the patient from a distance or right on the patient's skin. Indirect Auscultation Page 59 Using amplification or a mechanical device, such as a stethoscope. An acoustic stethoscope does not amplify the body sounds but blocks out environmental sounds. 10) Explain methods of palpation with examples Palpation Palpation is the act of touching a patient to feel for abnormalities anywhere in the body. There are two different types: light and deep palpation. Light Palpation As the name suggests, light palpation is soft and gentle. Nurses may find information on skin texture and moisture, masses, fluid, muscle guarding, and superficial tenderness by using light palpation. Deep Palpation Deep palpation explores the body's internal structures to a depth of 4-5 centimeters. This technique can inform nurses about the position of organs and masses, as well as their size, shape, mobility, consistency, and areas of discomfort. Have students role-play using different scenarios to train them to palpate effectively. Encourage short fingernails and warm hands to boost patient comfort during palpation. Page 60 SHORT ANSWER 1. Define inventory MECHINARY, EQUIPMENT, AND LINEN UNIT: 9 ANS: Inventory means all the materials, parts, supplies, expenses, and in process or finished products recorded on the books by an organization and kept in its stocks, warehouse, or plant for some period of time. 2. What is the meaning of indent? ANS: An indent is an official order or requisition for medicine and supplies from the medical store. The nurse acquires the equipment and supplies based on the need estimation, availability, and the budget. 3. Distinguish between disposable and reusable articles. ANS: Disposable articles means the items used only once, discarded after use and new items are used for every patient. On the other hand, Reusable equipment's means the items and equipment's used for a very long time, they are cleaned, disinfected, and sterilized before and after each use. More care should be given to reusable items than disposable items. 4. Mention types of Equipment's. ANS: A. Self-care equipment's (for patients' daily life) B. Electronic equipment's (ECG Monitor, ventilator etc.) C. Diagnostic equipment's (tools used to test) D. Surgical equipment's (stainless steel tools, OT tools) Page 61 E. Acute care equipment's (dressing material etc.) F. Storage and transport equipment's. 5. Mention any four equipment's used in oral care. ANS: Articles needed for conscious patient: a. Face towels b. Toothbrush C. Toothpaste d. Disposable gloves Log of tepid water Articles needed for unconscious patient: a. Face towel b. Disposable gloves C. Artery forceps d. Dissecting forceps e. Tongue depressor 6. Name any dour rubber goods? Ans. The rubber goods in common use are: 1. Mackintosh 2. Hot water bottles 3.Rubber tubes and Clothier 4.Gloves 7. Lost down types of rubber catheter? Ans. There are three types of catheters: Page 62 1. Indwelling catheters (urethral or suprapubic catheters) 2. External catheters (condom catheters) 3. Short- term catheters (intermittent catheters) 8. what is the meaning of condemnation of article? Ans. Condemnation is the act of declaring something awful or evil. If your little brother does, something unspeakably awful, express your condemnation so he will learn not to do it again. 9. Expand CSSD? Ans. CSSD- The central sterile services department (CSSD), also called sterile processing department (SPD), or central supply, is an integrated place I'm hospital and other health care facilities that performs sterilization and other actions on medical devices, equipment and consumable. 10. What is Autoclaving? Ans. Autoclaving- The autoclave is a pressure cooker that sterilizes or kills all microorganisms and their spores. Autoclaves are used in hospital by surgeon's to sterilizes surgical tools. They are also used in medical facilities and dentist's offices in order to sterilize instruments such as speculums, scopes, and scrappers. Page 63 LONG ESSAYS 1. a. Enlist effects of neglected mouth? MEETING NEEDS OF THE PATIENT Ans. Some of the effects of neglected mouth are. *Leading to bad breath. *Gum disease UNIT X *Tooth abscesses and infections *Loss of teeth. Complication of Neglected Mouth care *Halitosis *Stomatitis *Pyorrhea *Root abscess *Tonsillitis *Sinusitis *Parotitis *Glossitis Page 64 1. Small mackintosh 1, *Sores and crust b. Explain the procedure of oral care in an unconscious patient. 2. Towel1, *Inhalation pneumonia Ans. The patient is unconscious, oral care will be needed more frequently. Unconscious patients usually breathe through the mouth, causing secretions to dry. It is a vital aspect of patient care that needs to be carried out consistently by a nurse. The nurse plays an important role in providing effective oral care and promoting oral hygiene of an unconscious patient. Nurses should be aware of risk factors associated with poor oral health and be able to assess and help patients maintain oral hygiene. 3. Kidney tray 2, *Joint disease Supplies and Equipment for Unconscious Patient: *Rheumatic heart disease A tray containing supplies and equipment needed for oral care or mouth care are listed in the following: *Loss of appetite Chloride), 7. Gloves, 4. Gauze piece or cotton balls, 5. Mouth wash solution (0.12% Chlorhexidine or 05% Cetylpyridinium 6. Galipot-1(Denture soaking solution), 8. The aseptic syringe or irigating bulb, Page 65 9. A suction catheter with a suction apparatus, 10.A cotton ball with artery forceps, 11.Gauze padded tongue depressor, 12.Mouth gag (if patients unconscious to open the mouth), 13.Plain water in a mug, 14.Paper bag. Mouth Care Procedure for Unconscious Patient: Oral care procedures are used for patients who are unConscious or who are not able to eat or drink. 1. Arrange all equipment on the bedside cabinet or an overbed table. 2. Set the patient's bed in a comfortable position and lower one side rail. 3. Place a bulb syringe or suction machine with a suction machine nearby. 4. Place the client in a side- lying position and raise the level of the bed on one side so that the patient is in a partial sitting position. 5. Rinse your hands properly with antiseptic soap and lukewarm water. 6. Wear gloves after drying hands. 7. Place towel or waterproof pad under the client's chin and wrap the patient's chest. 8. Keep the kidney tray under the patient's cheek or remove secretions from the mouth by the suction catheter. 9. Use a padded tongue blade to open teeth gently. Never put your fingers in an unconscious patient's mouth. 10.Turn the head of the patient towards you in a very gentle manner. 11.A clean mouth, gums, teeth, and tongue with toothbrush and toothpaste. 12.Use an Asepto syringe or irrigating bulb without a needle to rinse the oral cavity. Swab or use oral suction to remove pooled secretions. 13.Clean immediately after brushing and Suction the saliva and toothpaste from the mouth of the patient. 14.Wipe out the extra water on the mouth with a clean small towel. Page 66 15.Removes basin dries face and mouth and applies water-soluble lip moisturizer. 16.Bring the patient back to a comfortable position. 17.Raise side rail and lower bed position. 18.Dispose of gloves in a paper bag and wash hands properly. 19.Report & documents oral findings and procedure. 2.a. Mention types of bed making. Ans. TypeS of bed making : a) closed bed : Made following discharge of patient purpose to keep clean untill new patient admitted b) open bed: fan fold the tapsheets to foot of bed to convert closed bed to open bed Fanfold means to fold the sheets like accerdian plats done to welcome patient or for patient who are ambulatory or out of the bed c) occupied bed: Purpose: bed is made while patient is in it usually done after morning bath d) admission bed: This bed prepared to receive the newly admitted patient. 1. To welcome patient Page 67 2. To provide the immediate care,safety and comfort 3. To protect the bed linen while giving with on admission. b. Explain preparation of post-operative bed in detail? A) Bed which is prepared for the patient you are in the effect of anesthesia and following surgery. Purpose: 1. To recive patient conveniently 2. To Prevent of shock 3. To prevent Injury. 4. To prevent soiling of the bed 5. To meet an emergency. PROCEDURE: Postoperative bed-making is to permits easy patient transfer from surgery and promotes cleanliness and comfort. To make such a bed takes the following steps: 1. A simple bed is made as per normal procedure making. 2. Strip on the bed and turn the mattress. 3. The upper bedding is fan-folded to one side accurate the stretcher. 4. The top sheet does not tuck at the foot part. (In cold weather the hot water bottle is placed in the middle of the bed and covered with fan-folded top bedding). 5. The temperature of water in a hot water bottle should not exceed 50°C. 6. Fanfold together the top sheet and blanket towards the side away from the door. 7. The small mackintosh sheet COvered with a towel is open side at top of the bed. 8. Place the bath towel over the small mackintosh sheet. 9. Instead of a pillow, place a small protective sheet and a towel on the head end of the bed. Page 68 10.The basin for the collection of vomits is placed on the bed stand. 11.The transfusion stand is kept ready at the bedside. 12.BP instrument, pulse meter can be kept ready at bed stand. 13.Place the necessary articles on the bedside table and the irrigating stand, suction machine, and oxygen set-up adjacent to the bed. 14. Keep the tray on the locker or table nearby and shock blocks on the floor near the foot end of the bed ready in case of necessity. 15.Adjust the height of the bed to the level of the stretcher. 16.After the patient is transferred to the bed, position the pillow for patient comfort. 17.Ensure safety cover by pulling the top point of the sheet and blanket over the patient. 18.Open the folds after covering the patient tuck in the linens at the foot of the bed and miter the corners. 19. Bottom sheet useful to absorb moisture and stop dislocation of the bottom sheet. 20.When the patient is transferred to bed, keep a kidney tray on the bed near the mouth, and pin-up the paper bag with the bottom sheet on the side. 3. Discuss the procedure of bed bath in a bed ridden patient? A) Definition of Bed Bath: Bed Bath Means cleaning Patients Body from Head to toe, or Removing of dirt and Promoting Skin Care and Promote Personal hygiene. Types of Bed Bath Partial Bed Bath Complete Bed Bath Towel Bath Tub Bath Bag Bath PURPOSE OF BED BATH: 1. To remove accumulated waste products and dirt from the skin. 2. To stimulate the functions of the skin. 3. To sooth and refresh the body. 4. To observe and to detect abnormalities. 5. To stimulate circulation of Skin. Page 69 6. To Promote relaxation and comfort EQUIPMENT: Bed Bathing Equipments need for Procedure 1.A tray containing: Spirit or skin lotion Powder Comb Coconut oil Kidney tray with paper bag Sponge bag or wash clothes -2 Soap dish with soap Nail cutter or scissors Nail brush Duster Bath towel Page 70 Equipment for mouth care if needed Paper squares Basin Jugs 2 (One with hot water and other with cold water) Bucket Lotion thermometer Patient clothes and linen for making if required. Bed Bath Nursing Procedure Steps 1. Explain the procedure to the patiernt. 2. Collect articles, take to bed side, and provide privacy. 3. Switch off the fan. 1. Place the patient in comfortable position. 2. Give mouth care if needed. 3. Remove the counter pane, and blanket, fold and place over the foot end of the bed if weather permits. 4. Undress the patient, fold and place it over railing of head end if needed. 5. Take water half full in a basin, test the temperature of water by placing the back of the hand in the water. 6. Place towel on the chest, wash rinse and dry the eyes, face, ears and neck. Place towel under the far arm wash, rinse and dry forearm, upper arm and axilla. 1. Place basin or towel, dip the hand in water wash, rinse, and dry. Repeat the arm nearest to the nurse provide nail care if needed. Page 71 1. Fold the top sheet upto the waist. Cover chest with towel wash. 2. Fold the top sheet up to pubis. Wash rinse and dry abdomen. Replace the sheet. 3. Place the towel under the a leg. Wash rinse and dry the thigh and repeat for the leg nearest to the nurse. 4. Place basin on the towel. Flex the far knee and place the foot in the basin wash with the brush rinse and dry. Repeat for the foot nearest to the nurse. 5. Turn the patient to the side facing away from the nurse. If the assistants available otherwise turn the patient to the side facing towards the nurse. Place the towel to the bed along with side line of the back, wash rinse and dry back and rub with spirit(sacrum to medial area of the back shoulder,, sides and buttocks with circular movements) or skin lotion or powder or oil depending upon condition of the skin and policy of the institution. 6. Make half of the bed. 7. Let the patient wash, rinse and dry the public area. 8. Help the patient to put on clothes. 9. Complete the bed. 10.Assist with the care of hair if needed. 11.Remove screen. 12. Take equipment for cleaning to the dirty area wash dry and replace. Boil the sponge bags. Dry and replace them. 13.Record observation and reactions of the patient. 4. A.What is the meaning of nasogastric tube feeding? A) DEFINITION. Nasogastric tube feeding is defined as the delivery of nutrients from the nasal route into the stomach vein of feeding B.Explain the steps of nasogastric tube feeding PROCEDURE_ NASOGASTRIC INSERTION: Page 72 1. wash hands thoroughly. 2. measure distance of tube from tip of patient's ear lobe to nose to tipoff xiphoid process 3. Mark the distance of the tube. 4. Lubricate the tube of about 6 to 8 inches with the lubricate using a ring pieces or a paper square. 5. Hold the tube coiled in the right hand introduce the tip into the left nostril. 6. Pass the backwards momentary resistance may occur as the tube is passed into the naso pharynx. 7. When the tube reaches to pharynx the patient may gag. Allow him to rest for a movement. 8. Have the patient lake the sips of water on command advance the tube 3 4_inches each Time swallows 9. Make sure tube is in stomach. 10. Once location of NG tube insured close other end of with spigot sec adhesive in T or butter. 5. A.Define urinary catheterization? A) DEFINITION: A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. B.Explain the steps of urinary catheterization in a female patient? A) Place the patient in the supine position with the knees flexed and separated and feet flat on the bed, about 60 cm apart. If this position is uncomfortable, instruct the patient either to flex only one knee and keep the other leg flat on the bed, or to spread her legs as far apart as possible. A lateral position may also be used for elderly or disabled patients. Page 73 With the thumb, middle and index fingers of the non-dominant hand, separate the labia majora and labia minora. Pull slightly upward to locate the urinary meatus. Maintain this position to avoid contamination during the procedure. With your dominant hand, cleanse the urinary meatus, using forceps and chlorhexidine soaked cotton balls. Use each cotton ball for a single downward stroke only. Place the drainage basin containing the catheter between the patient's thighs. Pick up the catheter with your dominant hand. Insert the lubricated tip of the catheter into the urinary meatus. Advance the catheter about 5-5.75 cm, until urine begins to flow then advance the catheter a further 1-2 cm. Note: If the catheter slips into the vagina, leave it there to assist as a landmark. With another lubricated sterile catheter, insert into the urinary meatus until you get urine back. Remove the catheter left in the vagina at this time. Attach the syringe with the sterile water and inflate the balloon. lt is recommended to inflate the 5cc balloon with 7-10cc of sterile water, and to inflate the 30cc balloon with 30-35cc of sterile water. Improperly inflated balloons can cause drainage and leakage difficulties. Gently pull back on the catheter until the balloon engages the bladder neck. 6. A.Define enema : During a cleansing enema, a water-based solution with a small concentration of stool softener, baking soda, or apple cider vinegar is used to stimulate the movement of the large intestine. A cleansing enema should stimulate the bowels to quickly expel both the solution and any impacted fecal matter. Classify enema: Page 74 A Evacuent enema Simple Evacuent enema Medicated Evacuent enema Oil enema Purgative enema Astringent enema Anthelminthic enema Carminative enema Cold enema Retained enema Stimulant enema Nutrient enema Emollient enema Sedative enema Anaesthetic enema These are given to cause the bowel to contrast actively * Purgative Enema & Its acts by their irritating effect on the mucus lining, stimulate peristalsisto evacuate its contents & The stretching of the intestine due to this inflow of fluid causes the intestine to contract cause the evacuation of bowel & leads to the evacuation of bowels Anthelmintic enema & Before the treatment is given the bowel should be cleansed by a soap water enema so that the drug may come in direct contact with the wormsexpel the worms from the intestines & Amount of the solution : 250 ml# Hypertonic saline solution : sodium chloride 60 ml with 600 ml of water Infusion of quassia : 15gms of chips to 600 ml of water o The treatment is given until the worms are destroyed Solution : the lining of the intestine To stimulate defecation & Purpose : Simple evacuant enema & To stimulate uterine contraction & To relieve the retention of urine by reflex stimulation of the bladder a To relieve the gaseous distention by stimulating the peristalsis to treat constipation & To cleanse the bowel prior to x-ray studies, visualization of the bowels (ex: sigmoidoscopy), surgery to hasten the child birth & retention enemas Oil enema These are given to soften faecal matter in case of severe constipation Before the 1st bowel movement after operation on the rectum or perineum. To avoid straining These are given to soften faecal matter in case of severe constipation Oil enema & injury to the sutures & It should then be followed by Page 75 a soapo It should be retained for half an hour to 1 hour to soften the faeces 4WOunds & water enema to open the bowels #Astringent enema & the blood vessels , checks bleeding & inflammation , lessens the amount of mucus discharge & It is usually given in colitis *gives a temporary relief in the inflamed area The solution is allowed to run in slowly* They are usually given in the form of rectal or colonic irrigations dysentery & return quickly to avoid distension , pain & irritation of the Abdominal cramps Hypothermia & Complications : It is given in the form of colonic irrigation a This is given to decrease the body temperature in hyperpyrexia and heat stroke c. Explain the steps with scientific principles in enema 1. The amount of the solution to be administered depends upon the type of the enema and the age} The temperature of the solutions needs to be adjusted according to the purpose of enema } The rectal tube is lubricated with water soluble lubricant} the rectal tube needs to be smooth and flexible} The appropriate size catheter or rectal tube need to be used } General instructions & The height f the can should be adjusted to regulate the flow of the so