General Medical Surgical (Clinical) PDF 2024

General Medical Surgical (Clinical ) Prepared by Staff of Adult Nursing Department Faculty of Nursing Aswan University 2024 1  List of content Content...

General Medical Surgical (Clinical ) Prepared by Staff of Adult Nursing Department Faculty of Nursing Aswan University 2024 1  List of content Content Page 3 IV infusion 8 Blood transfusion 17 Supplying Oxygen Inhalation 24 Chest Physiotherapy 30 Incentive Spirometers 34 Surgical dressing 1. Close 2. Open 46 Nursing care for drain 53 Suture removal 60 Inserting a Nasogastric tube 67 Removing an NG Tube 70 Gastric gavage 76 Ostomy Care (Ileostomy or Colostomy) 83 Paracentasis 88 Port catheter care 2  Intravenous infusion I. Definition It is a medical technique that administers fluids, drug, medications and nutrients directly into a blood stream through a needle or tube inserted into a vein. II. Indications for IV Therapy 1. Fluid and Electrolyte maintenance and balance. 2. Maintain or correct a patient's nutritional state. 3. Replacement therapy in Hemorrhage, low platelets, persistent vomiting and diarrhea. 4. Restoration therapy in Burns , nasogastric tubes and abdominal wounds. III. Preparation for administration Before preparing the solution, inspects the container and determine that: 1. The solution is the one prescribed by the physician. 2. The solution is clear and transparent. 3. The expiration date has not elapsed. 4. No leaks are apparent. 5. A separate label is attached, identifying the type and amount of other drugs added to the commercial solution. I. How To Calculate Flow Rate:- a. To find the number of milliliters to be given per hour: Total solution = –––––––——––––––––– ═ mL hour No. of hours to run 3  b. To find drops per minute: mL /hr × drop factor = ––––––––––––––––––––– ═ d/minute 60 minutes N.B 20 drops\minute 60 drop\m 10 drop\m IV. Equipment 1. IV solution in a bag ( fig 1). 2. Medication administration record 3. Gloves 4. IV tubing ( fig ,2) 5. The spike (see fig 3) 6. The drip chamber ( fig, 4) 7. Roller clamps(fig, 5) ( fig 1) 4  (fig, 2) (fig, 3) (fig, 5) (fig, 4) V. Procedure Steps Rational - Reduces the transmission 1. Wash hands apply gloves microorganisms 2. Removing protective cover from the bag. 3. Inspect the bag for leaks, tears, or cracks - Prevents infusing contaminated or inspect the fluid for clarity and color. outdated solution. Check expiration date. 4. Prepare a label for the IV bag: on the label - To prevent mistaks. ( date, time, and initials). 5. Remove gloves and wash hands. - Prevent infection. 5 6. Hanging the prepared IV (fig,6). (fig,6) 7. Wash hands. - To prevent infection 8. Check patients identification arm band. - To ensures IV solution is given to the correct patient. 9. Make sure the clamp on the tubing is - To decrease rapid flow of solution closed. grasp the port of the IV bag with without air bubbles. non-dominant hand remove the plastic tab covering the port and insert the full length of the spike into the bag's port(fig,7). (fig,7) 10. Compress drip chamber to fill halfway. -prevent air of IV line 11.Open roller clamp, and flush tubing - To remove air from tubing. with solution. 12. Close roller clamp. - To prevent fluid from leaking and maintain sterility of needle. 13. Remove the cap protector from the tubing attach the IV tubing to venipuncture catheter. 14.Open clamp and regulate flow rate. 15. Wash hands. 6 7  Blood Transfusion I. Definition Blood transfusion is the IV administration of a component of blood or whole blood. Component frequently transfused include fresh or frozen plasma, Red blood cells or packed red blood cells and platelet. II. Indications 1. Major surgical operations 2. Anaemia. 3. Accidents. 4. Severe burn victims. 5. Women in childbirth and newborn babies in certain cases. III. Purpose 1. Restore blood volume after hemorrhage. 2. Maintain hemoglobin levels in severe anemia.. 3. Replace specific blood component. IV. Equipment 1. Blood administration set and filters (fig,1). 2. Intravenous solution of 0.9% sodium chloride (normal saline). 3. Disposable gloves. 4. Tape. 5. Blood warmer, if needed. 8  N.B –the blood must be given within 4h after getting from lab. - The time of transfusion 1-3 h. - Double check is important before the blood transfusion. 6. Blood warmer, if needed. (fig,1) V. Procedure Steps Rationale 1. Verify the physicians order for the transfusion. - Blood must be ordered by a physician or qualified practitioner. 2. Explain procedure to the client. - Ensures that client understands procedure and decreases anxiety. - Prompt reporting of a side effect will 3. Review side effects (dyspnea, chills, headache, lead to earlier discontinuation of chest pain, itching) with client and ask them to transfusion and minimize the report to the nurse. reaction. 9 4. Prompt reporting of a side effect will lead to - Some hospitals or agencies earlier discontinuation of transfusion and require the client to sign a consent minimize the reaction and have the client sign form. consent forms. 5. Obtain baseline vital sign. - Allows detection of a reaction by any change in vital signs during the transfusion. 6. Obtain the blood product from the blood bank - To prevents bacterial growth and within 30 minutes of initiation (fig,2). destruction of red blood cells. (fig,2). 10 7. Verify and record the blood product and identify the - Strict verification procedures will client with another nurse (fig,3,4) reduce the risk of administering blood products to the wrong client. (fig.3) A. Clients name, blood group, Rh type. (fig.4) B. Cross-match compatibility. C. Donor blood group and Rh type. D. Unit and hospital number. E. Expiration date and time on blood bag. F. Type of blood product compared with physicians order G. Presence of clots in blood. 8. Instruct client to empty the bladder. - A urine specimen after initiation of the transfusion will be needed if a transfusion reaction occurs. 9. Wash hands and put on gloves. - Reduces risk of transmission of blood borne bacteria. 10. Open blood administration kit and move roller clamps to ―off position 11 11. For Y-tubing set: A. Spike the normal saline bag and open the roller A. The Y-tubing allows the nurse clamp on the Y-tubing connected to the bag. to switch from infusing normal B. Close clamp on unused tubing. saline to blood. C. Squeeze sides of drip chamber and allow filter to B. Correctly filled drip chamber partially fill. (fig.5 ) enables an accurate drip count. C. Removes all air from tubing system D. Prevents waste of IV fluid. D. Open lower roller clamp and allow tubing to fill Equal distribution of cells with normal saline to the hub. prevents clumping, which can E. Close lower clamp. lead to clotting of cells. F. Invert blood bag once or twice. Spike blood bag, open clamps on inlet tube to allow blood to cover E. Prevents blood from flowing the filter completely (fig.6). until tubing is attached to G. Close lower clamp. venous catheter. 12 12. For single-tubing set: A. Attaches tubing to blood unit. A. Spike blood unit. B. Correctly filled drip chamber B. Squeeze drip chamber and allow the filter to enables an accurate drip count. fill with blood (fig.7). (fig.7) C. Open roller clamp and allow tubing to fill with blood to the hub (fig.8). (fig.8) 13. Attach tubing to venous catheter using - Allows the blood product to be sterile precautions and open lower clamp. infused into the clients vein. 14. Infuse the blood at a rate of 2–5 ml/min - Packed red blood cells usually run according to the physicians order. over 11/2–2 hours; whole blood runs over 2–3 hours. 13 15. Remain with client for first 15–30 minutes, - If a reaction occurs, it generally monitoring vital signs every 5 minutes for happens during the first 15–30 15 minutes, then every 15 minutes for 1 minutes. Changes in vital signs can hour, then hourly until 1 hour after the warn of a transfusion reaction. infusion is completed (fig,9). 16. After blood has infused, allow the tubing to - The client will receive all of the clear with normal saline. blood that is left in the tubing. 17. Appropriately dispose of bag, - Reduces transmission of tubing, and gloves. microorganisms. 18. Wash hands. 19. Document the procedure. Blood transfusion reaction Transfusion reactions are adverse events associated with the transfusion of whole blood or one of its components. They range in severity from minor to life- threatening. Reactions can occur during the transfusion (acute transfusion reactions) or days to weeks later (delayed transfusion reactions). 14  I. Types of transfusion reactions A. Acute Transfusion Reactions 1. Mild allergic. 2. Anaphylactic reaction. 3. Febrile non-hemolytic. 4. Septic 5. Acute hemolytic transfusion reactions 6. Transfusion-associated circulatory overload 7. Transfusion-related acute lung injury B. Delayed Transfusion Reactions II. Common signs and symptoms of transfusion reaction 1. Urticaria /Itching 2. flushed skin 3. vomiting 4. Diarrhea 5. Fever/Chills 6. Dyspnea 7. Hypotension 8. Hypothermia III. Nursing management for transfusion reaction 1. Stop the transfusion. Maintain the intravenous line with normal saline solution through new intravenous tubing, administered at a slow rate. 2. Asses the patient carefully, compare the vital sign with those from thebase line assessment. 15 3. Notify the physician of the assessment findings and implement any order obtained. 4. Notify the blood bank that a suspected transfusion reaction has occurred. Send the blood container and tubing to the blood bank for repeat typing and culture, the identifying tag and number are verified. 16  Oxygen therapy I. Definition Method by which oxygen is supplemented at higher percentages than what is available in atmospheric air. II. Purpose 1. To relieve dyspnea. 2. To reduce or prevent hypoxemia and hypoxia. 3. To alleviate associated with struggle to breathe. III. Sources of Oxygen Therapeutic oxygen is available from two sources. 1. Wall Outlets (Central supply). 2. Oxygen cylinders. IV. Oxygen devices Device Advantages Disadvantages Figure Nasal cannula - Comfortable and well - Can cause drying and tolerated. irritation of airways when higher flow rates - Patient can eat, drink and are used. communicate easily. - No risk of rebreathing carbon dioxide. Simple face- - Generally well tolerated - Can cause build-up of mask when used for a short carbon dioxide when period of time (hours used at a flow rate of rather than days).