Medical Surgical Nursing II Procedures PDF 2024-2025

Medical Surgical Nursing II Procedures Prepared by All staff members in medical surgical nursing department Second year - First term - 2024/2025 Revised by Assist. Prof. Dr...

Medical Surgical Nursing II Procedures Prepared by All staff members in medical surgical nursing department Second year - First term - 2024/2025 Revised by Assist. Prof. Dr/ Samah Elsayed Assist. Prof. Dr/ Eman Sobhy Dr/ Ola Ahmed Dr/ Doaa Mohamed Under supervision Prof. Dr/ Amal said Professor of Medical Surgical Nursing and Head of Department Second year / First term 2024-2025 List of teaching staff members and their assistants in medical surgical nursing department for teaching and practical training Second year - First term - 2024/2025 Prof. Dr/ Aml said Prof. Dr/ Manal Hamed Assist. Prof. Dr/ Hayam Ahmed Assist. Prof. Dr/ Samah Elsayed Assist. Prof. Dr/ Safaa Mohamed Hamed Assist. Prof. Dr/ Eman Sobhy Dr/ Ola Ahmed Dr/ Doaa Mohamed Dr/ Amany Ali Dr / Rehab Rashwan mohammed Dr / Wanesa Mohamed Dr/ Eman Gamal Dr / Rowan Mohamed Dr / Walaa Elsayed Assist. Lecturer /Shaimaa Elsayed Assist. Lecturer / Sara Abdel Samad Assist. Lecturer / Eman Abdel Wahab Assist. Lecturer / Hala Elsayed Assist. Lecturer / Hend Salah Inst / Gehad Mohamed Inst /Shahenda Mohsen Inst/ Shorouk Ahmed Inst/ Eman Khalil Inst/ Amira Eldesoky Inst/ Shorouk Shabaan Inst/ Ayat Rezk Inst/ Maha Abdel Aziz Inst/ Samar Mohamed 4 5 6  2025/2024 ‫نموذج توصيف مقرر دراسى‬ ‫بناء على المعايير األكاديمية المبنية على الكفايات‬ ‫ بنها‬: ‫جامعة‬ 2017 ‫ابريل‬ ‫ التمريض‬: ‫كليــة‬ ‫ جامعه بنها‬-‫ تمريض الباطني الجراحي كليه التمريض‬: ‫قسم‬ 159 ‫ جلسه‬2024/9/11:‫تاريخ اعتماد التوصيف‬ :‫بيانات المقرر‬-1 - ‫ الفرقة‬/ ‫المستوى‬ :‫الرمز الكودي‬ second level / third Medical Surgical Nursing (2):‫اسم المقرر‬ semester )Practical) CLN211 2 ‫التوصيف الميدانى تمريض باطنى جراحى‬ - : ‫التخصص‬ Practice: ‫عدد الساعات التدريسية‬ Bachelor Degree In Nursing (11) hours ×15 weeks=165hours Science 2 - Aim of the course: This course aims to provide nursing students with essential nursing skills in a clinical lab. and hospital areas caring for the adult patients with medical and surgical problems based on scientific knowledge according to competency-based learning 7  3-Course specification based on competency: ‫توصيف المقررالمبنى على الكفايات‬ Domain No.1: Professional and ethical practice Competency Key elements Course Subjects Subjects Objectives Teaching Media used Assessment Methods Methods Competence 1. 1 Urinary Catheter 1.1.2.1 Perform aseptic technique Online learning Power point Practical 1-1 Demonstrates 1.1.2 Apply ethical for patient undergoing urinary presentation & knowledge and professional nursing catheterization. Demonstration clinical understanding & examination responsibility of practice to conduct ethical 1.1.2.2 Prepare patient for urinary Redemonstration the legal decision making. catheterization take into Videos OSCE exam obligation for -Virtual lab ethical nursing consideration the patients privacy training practice. 1.1.2.3 Apply nursing care plan for - OSCE lab training patient with urostomy 1.1.2.4 Perform patient rights during removal of urinary catheter. Cast and traction 1.1.2.5 Apply action plan when Online learning Power point Practical caring for patients with cast and Demonstration presentation & traction & clinical Re demonstration examination 1.1.2.6 Demonstrate the nursing -Virtual lab Videos OSCE exam management of patient with the training - OSCE lab musculoskeletal disorder. training 8  1.2.7Analyze physiological Online learning Power point Practical presentation & Lumber puncture and behavior response of Demonstration clinical & examination Pain Re demonstration Videos OSCE exam 1.1.2.8 Apply patients rights, -Virtual lab autonomy and privacy in training - OSCE lab according with institutional training policies 1.1.2.9 Implement nursing Online learning Power point Practical Eye drop. ointment Demonstration presentation & management of patient with & clinical Ear irrigation Re demonstration Videos examination auditory system disorder. OSCE exam 1.1.2.10 Demonstrate ear irrigation accurately. 1.1.3.10 Administer otic medications with safety 9 Competency Key elements Course Subjects Course objectives Teaching Media used Assessment Methods Methods Competence 1.1 1.1.3 Implement Online learning Demonstration Power point Practical 1-1 Demonstrates ethical policies and procedural 1.1.3.2 Write principles for of & presentation & and professional nursing guidelines in the field medication administration Re demonstration clinical examination knowledge and practice in Eye drop. Videos accordance to legal of nursing practice ointment -Virtual lab training obligations and diversity to excellent, equality and considering  Ear irrigation - OSCE lab training sustainability1. patients/clients rights. Online learning Power point Practical Demonstration presentation & 1.1.3.3 Illustrate Routes of & clinical examination drug administration Re demonstration Videos -Virtual lab training - OSCE lab training 10  Online learning Power point Practical Demonstration presentation & Bandage and 1.1.3.4 Apply patients rights, & clinical examination splints autonomy and privacy in Re demonstration Videos OSCE exam according with institutional -Virtual lab training policies - OSCE lab training 11 Competency Key elements Course Subjects Subjects objectives Teaching Media used Assessment Methods Methods Competence 1.1 1.1.3 Implement Lumber puncture Online learning Power point Practical 1-1 Demonstrates policies and 1.1.3.1 Provide patient safety during Demonstration presentation & & & clinical examination ethical and performing lumber puncture procedural Re demonstration videos OSCE exam professional Procedure. nursing knowledge guidelines in the 1.1.3.2 Apply principles of aseptic -Virtual lab and practice in field of nursing technique for patient undergoing training accordance to legal procedure. - OSCE lab obligations and practice training diversity to considering excellent, equality and sustainability. patients/clients Ear irrigation 1.1.3.4 Implement nursing Online learning Power point Practical management of patient with Demonstration presentation & rights. & & clinical examination auditory system disorder Re demonstration videos OSCE exam 1.1.3.5 Perform ear irrigation 1.1.4 Illustrate accurately. -Virtual lab responsibility and 1.1.3.6 Apply aseptic technique training during ear irrigation. - OSCE lab accountability for training care within the scope 12 Competency Key elements Course Subjects Subjects objectives Teaching Media used Assessment Methods Methods of professional and Audiometry 1.1.3.7 Perform audiometry testing Online learning Power point Practical practical level of accurately. Demonstration presentation & testing & & clinical examination competence 1.1.3.8 Perform ear irrigation. Re demonstration videos OSCE exam 1.1.3.9 Implement nursing - management of patient with auditory system disorder. -Virtual lab training - OSCE lab training 13  Domain 2: Holistic patients/clients care Competency Key elements Course Subjects Subjects objectives Teaching Media used Assessment Methods Methods Competence 2.1 2.1.2 DemonstrateNeurological Online learning Power point Practical Provide a holistic nursing care reflex test 2.1.2.1 Demonstrate neurological Demonstration presentation & reflex test for patient with meningitis. & & clinical examination holistic that addresses Re demonstration videos OSCE exam patients/clients, patients/clients 2.1.2.2 Illustrate safety measure. -Virtual lab training families and 2.1.2.3 Practice appropriate centered care - OSCE lab training communities needs parameters for assessment of patient for individuals, and problems across from head to toes. families and life span. communities to Online learning Power point Practical. 2.1.2.4 Apply aseptic technique Urostomy Demonstration presentation & minimize risks & & clinical examination during care for patient with and harm. Re demonstration videos OSCE exam Urostomy -Virtual lab training - OSCE lab training Online learning Power point Practical Visual acuity test 2.1.1.5-Demonstrate distance visual Demonstration presentation & acuity test effectively. & & clinical examination Re demonstration videos OSCE exam -Virtual lab training - OSCE lab training 14 Competency Key elements Course Subjects Subjects objectives Teaching Media used Assessment Methods Methods Online learning Power point Practical Bandage 1.1.4.6 Demonstrate nursing Demonstration presentation & management of patient with and binder & & clinical examination musculoskeletal system. Re demonstration videos OSCE exam 1.1.4.7 Perform different type of bandage. -Virtual lab training - OSCE lab training Domain 4: Informatics and technology Competency Key elements Course Subjects Subjects objectives Teaching Media used Assessment Methods Methods Competence 4.1.2Use technology 4.1.2.1-Use technology in recording and Online learning Power point Practical and reporting of pertinent patients; Demonstration presentation & 4.1 information concerning fundamentals & & clinical examination informationmanage of nursing practice and skill Re demonstration videos OSCE exam ment tools to Report and support safe care record -Virtual lab and evaluate their training impact on patient - OSCE lab training outcomes 15 Competency Key elements Course Subjects Subjects objectives Teaching Media used Assessment Methods Methods 4.1.2.2 Use the internet and other Online learning Power point Practical electronic sources as a mean of Demonstration presentation & communicates and sources of & & clinical examination information Re demonstration videos OSCE exam -Virtual lab training - OSCE lab training Online learning Power point Practical Demonstration presentation & & & clinical examination Re demonstration videos OSCE exam -Virtual lab training - OSCE lab training 16  Domain 5: Inter-professional communication Competency Key elements Course Subjects objectives Teaching Media used Assessment Subjects Methods Methods Competence 5.1.1 Maintain inter- 4.1.2.1-Use technology in recording and Online learning Power point Practical professional reporting of pertinent patients; Demonstration presentation & 5.1 information concerning fundamentals of & & clinical examination collaboration, in a nursing practice and skills. Re demonstration videos OSCE exam variety of settings to Report and -Virtual lab maximize health record training outcomes for the - OSCE lab patients, families and training communities 4.1.2.2 Use the internet and other Online learning Power point Practical electronic sources as a mean Demonstration presentation & of communicates and sources & & clinical examination of information Re demonstration videos OSCE exam -Virtual lab training - OSCE lab training 17  IV cannula Course : ‫محتوي المقرر‬-4 Bandage & binder Content Cast & traction Audiometry test Ear irrigation Urinary catheterization Urostomy Lumber puncture Neurological reflex Measuring distance visual acuity Modified lecture, small group discussion, (Assessment skills) : ‫أساليب التعليم والتعلم‬-5 Assignment participation Demonstration and re-demonstration in Lab/ Hospital training. Teaching and Learning Role play. Methods Blended learning / online learning/ face to face learning. 18 We do not have students with limited abilities, but there are methods of teaching and learning for defaulting - ‫أأساليب التعليم والتعلم للطالب‬-6 students: ‫ذوي القدرات المحدودة‬Teaching and - Activate academic supervision to solve students’ problem. Learning Methods of Disables - The teaching academic members support the weakened students throgh library hours. - Revision lectures and scientific lessons to all students especially defaulting students. - - Make routine exams to early discover the weakened students. (quizzes). Students Assessment :‫ تقويم الطالب‬-7 ‫االساليب المستخدمة‬-‫أ‬ Semester work. Used Methods Students' assignment. Clinical lab. Evaluation (Observational Checklist) and Hospital Work Evaluation Final practical examination (Observational Checklist). Assignment & Participation through Semester periodical :time ‫التوقيت‬-‫ب‬ Final practical examination 15th week 19  : ‫توزيع الدرجات‬-‫ج‬ Semester work Marks distribution Midterm practical exam 60 Semester work (clinical lab evaluation , assignment and participation through semester , hospital evaluation )1+1 (30+30) 60 final practical examination 80 ▪ Total 200 List of References ‫قائمة الكتب الدراسية والمراجع‬-8 Gaber H., et al. (2021): Hand out for Fundamentals of Nursing, Faculty of Nursing, Benha ‫ مذكرات‬-‫أ‬ University. Course note Clarke, S., & Drozd, M. (Eds.). (2023). Orthopaedic and trauma nursing: An evidence-based ‫كتب ملزمة‬-‫ب‬ approach to musculoskeletal care. 2th ed., John Wiley & Sons, india. Required Books Touhy, T. A., & Jett, K. F. (2022). Toward Healthy Aging-E-Book: Human Needs and Nursing ( Text Books ) Response. 11th ed., Elsevier Health Sciences ,india. Black, B. (2022). Professional nursing-e-book: concepts & challenges. 10th ed, Elsevier Health Sciences,Canada. Rothrock, J. C. (2022). Alexander's care of the patient in surgery-E-Book. Elsevier Health Sciences. ‫كتب مقترحة‬-‫ج‬ india. RecommendedBooks Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M. R., & Zanotti, M. (2019). Nursing diagnosis handbook E-book: An evidence-based guide to planning care. 11th ed., Elsevier Health Sciences, Canada. 20 https://nurseslabs.com/category/nursing-notes/fundamentals-of-nursing/ Periodicals, web sites https://www.practicenursing.com/ http:// www.enursing.com http://www.cdc.gov/ ‫منسق المقرر‬ ‫رئيس القسم‬ 1  Content Items IV cannula Bandage & binder Cast & traction Audiometry test Ear irrigation Urinary catheterization Urostomy Lumber puncture Neurological reflex Measuring distance visual acuity  IV Cannulation Objectives: At the end of this lecture the student will be able to:  Define the cannula  List different types of the cannula.  Enumerate parts of cannula.  List indications for peripheral venous cannulation  List characteristics of good veins  Enumerate inappropriate sites for vein puncture  Illustrate methods of improving access / vein prominence  Demonstrate the procedure of intravenous cannulation  Remove the intravenous cannula  Illustrate Potential complications of the intravenous cannula Outlines: Definition of cannula Administering IV medication directly with syringe Parts of cannula Choosing correct cannula size Indications for peripheral venous cannulation Characteristics of good veins Inappropriate sites for vein puncture Methods of improving access / vein prominence Procedure of intravenous cannulation Removal of the intravenous cannula Potential complications of the cannula Intravenous cannula Definition: Short flexible tube place into a vein to administer medication. Types of Cannula Adopted from (Shalmovitz & Lopez , 2023): Intravenous Cannulation. Various sizes of over-the-needle IV catheters. Avaliable at: https://emedicine.medscape.com/article/1998177- overview?form=fpf. Parts of an I.V Cannula 1- Flashback Chamber 6-Injection Port Cap 2- Needle Grip 7-Catheter Hub + Wings 3- Luer Lock 8- Bushing Plug 4- Luer 9- Catheter Connector 5- Valve 10- Needle Parts of the cannula Adopted from ( Jenna, 2024 : Parts of Cannula: A Comprehensive Guide By Denex International. Available at. :https://www.ivcannula.com/blog/parts-of- cannula  Choosing a correct cannula size Note that the smaller the number the larger the cannula size Color Common Applications code Orange Large volume replacement. Grey Rapid transfusion of whole blood or blood components. Green IV maintenance,. Pink IV analgesia. Blue Pediatrics, elderly, chemotherapy patients. Yellow Paediatrics, neonates. Violet Specific use on paediatric and neonatal patients. Site chosen for intravenous cannulation: 1-Short term intravenous therapy (few hours or few days): a- The vein at the back of the hand b- The superficial veins of the wrist c- Lower arm 2-Long term intravenous therapy (several days or weeks): A long catheter is inserted into the vein Indications for peripheral venous cannulation Administration of intravenous fluids. Administration of parenteral nutrition. Administration of blood and blood products. Drug administration (continuous or intermittent). Prophylactic use before procedures. Prophylactic use in unstable patients. Surgery In case of cardiopulmonary resuscitation (CPR) Characteristics of Good Veins:  Bouncy Soft Refills when depressed Has a large lumen Straight and non-tortuous Easily visible and palpable Well supported. Avoid area of flexion such as wrist and elbow. Inappropriate Sites for Vein puncture: Contraindication for site selection of vein puncture include the following: ❖ Arm on side of mastectomy.  Edematous areas.  Hematomas.  Arm in which blood is being transfused.  Scarred areas.  Arms with fistulas or vascular grafts.  Sites above an IV cannula.  Evidence of localized infection/inflammation.  Preexisting thrombophlebitis.  Limbs with fractures. METHODS OF IMPROVING ACCESS / VEIN PROMINENCE There are a number of methods to improve venous access, for example: ▪ Tourniquet: Application of a tourniquet promotes venous distension, make veins more prominent and easier to puncture due to venous filling. The tourniquet should not be left on for longer than 2 minutes. ▪ Opening and close of fist  ▪ Lowering the arm below the heart level ▪ Milking the vein upward. ▪ Heat In the form of warm pack to encourage vasodilatation and venous filling) Equipments Sterile gloves an alcohol wipe a disposable tourniquet an IV cannula with correct size. a suitable plaster a syringe 5ml saline solution a sharps bin Patient’s chart or record.  Procedure: Action Rational 1Pre procedure: 1 Preparation:-gather equipment 2Preparation 2 of the environment: -Optimize lightening and promote good ventilation -Keeping patient privacy. 3Preparation 3 of the patient: identify the patient and ask for his name. 4Explain4 procedure to patient & take consent. 5 rails Lower side 5Positioning 6 the patient. 7 Hand washing 6Wear clean 8 gloves.  During procedure: 7Select9 a suitable vein for vein puncture. To reach puncture easily. 8Apply1 tourniquet (4-7) inches (8-10 cm) To facilitate flow of blood into above 0the selected vein. – 9Milk vein upward with hands or ask patient to close and open her hand syringe. 10Clean1 the chosen area with alcohol sponge at 1 seconds least 30 To prevent cross infection & to prevent hand contamination. 11Select 1 the suitable size of the cannula. 2  1 12Place 3 thumb over vein & stretch the skin against the direction of insertion. To prevent air embolism. 13Insert 1 the plastic cannula into the vein at a 10-30°4angle &the inner needle is withdrawn once the vein is punctured, allowing blood to flow back. 14Slightly 1 advance the needle into the vein 5 exert any pressure on the needle & do not ,observe flush back. 15Release 1 the tourniquet, apply pressure to the vein at6 the tip of the cannula and remove the needle fully. Remove the cap from the needle and put this on the end of the cannula. 16Secure 1 the cannula by apply an adhesive plaster7& label the cannula to data & time.  17Prepare 1 5ml of normal saline for flushing. 8 18flush1 gently with 5 ml of normal saline and replace9 cap. Post procedure: 19-Discard 1 of sharps into Information in the chart helps other medical sharps9 bin and equipment workers understand what is going on with the into disposal bag. patient. -Ensure the patient is comfortable, and remove gloves. -Wash hands. -Record and /or report the care along with any abnormal findings and ensure your update patient’s care plan. Removal of the intravenous cannula A peripheral intravenous cannula is removed immediately if: 1. Infiltration is evident. 2. Signs of phlebitis i.e. erythema, pain, heat are present. 4. Treatment is discontinued. 5- Usually 3days after insertion. Action Rational 1-Preparation: Self-preparation: -Preparing equipment -Wash hands -put on clean gloves Preparation:-Patient & environment Identify the patient and ask for her name Explain procedure to patient & take consent. Keep patient privacy 2-Close the flow clamp To discontinue 3-Prepare sterile dressings as required 4-Wear sterile gloves To prevent blood borne cross- infection 5-Expose the site of insertion of the cannula, maintaining asepsis 6- Loose tape & withdraw the To stop leakage cannula slowly with the &hematoma dominant hand formation To stop bleeding 7-Apply pressure with a sterile swab using the non-dominant hand 8-Maintaining pressure (until bleeding stop). Post Procedure: 9-Discard of sharps into sharps bin and equipment into disposal bag. -Ensure the patient is comfortable, and remove gloves. -Wash hands. 10-Document nursing notes, 13  including the patient's notes, medications administered, any adverse reactions, date of cannula removal. Nursing Intervention for potential Complications of Intravenous Cannula: Potential complications Intervention 1-Extravasation -Remove cannula *The infiltration of a drug -Elevate affected arm from an -Apply ice pack (early) or I.V. line into surrounding warm compress (late tissue *occurs when a cannula pulls out of the vein causing backflow of the infusate through the puncture site into the surrounding tissues 2-Hematoma -Apply appropriate pressure *Caused by blood leaking bandage into the tissues during or - monitor the site after vein puncture 3-Phlebitis -Remove cannula *Inflammation of the vein -Apply warm compress -Observe for signs of Infection -If phlebitis is advance antibiotics may be required 4-Thrombophlebitis -Remove cannula *Formation of a thrombus - Observe for signs and inflammation in the of infection vein, usually occurs after -Change cannula frequently (48- phlebitis 72hrs) 14 5-Occlusion - Check for kinks in cannula *Slowing or cessation of - Raise IV higher fluid infusion due to Fibrin -Flush the cannula formation in or around the -Remove cannula tip of the cannula *Mechanical occlusion (kink) of the cannula 15 Case Study: Mr Brown, 52 years, attended the emergency department, suffering from severe right iliac pain. You are required to insert intravenous cannulation for Mr Brown. Question one: What characteristics of good vein the nurse would consider when assessing Mr Brown for the procedure. 1- ------------------------------------------------------------------------------------- 2- ------------------------------------------------------------------------------------- 3- ------------------------------------------------------------------------------------- 4- ------------------------------------------------------------------------------------- Question two: Demonstrate IV cannulation procedure steps for Mr Brown 1--------------------------------------------------------------------------------------- 2--------------------------------------------------------------------------------------- 3--------------------------------------------------------------------------------------- 4--------------------------------------------------------------------------------------- 5--------------------------------------------------------------------------------------- 6--------------------------------------------------------------------------------------- 16  Intravenous Infusion Therapy Objectives: At the end of this lecture the student will be able to:  Define intravenous infusion therapy  Enumerate purpose of IV infusion therapy  List the responsibility of the nurse regarding intravenous infusion therapy  Explain complications of intravenous infusion therapy  Differentiate between types of IV Solutions  Administration of intravenous infusion therapy  Monitoring an IV site and infusion  Change an IV solution container Outlines: Definition of intravenous infusion therapy Purpose of IV therapy The responsibility of the nurse in IV therapy Complications of intravenous infusion therapy Types of IV solutions Administration of intravenous infusion therapy Monitoring an IV site and infusion Change an IV solution container 17  Definition of intravenous infusion therapy An intravenous infusion is the introduction of prescribed sterile fluid into the blood circulation. Indications Provide fluid and electrolyte maintenance, restoration, and replacement. – Administer medication and nutritional feedings. – Administer chemotherapy to cancer patients. – Administer patient- controlled analgesics. – Keep a vein open for quick access – Replacement of severe fluid loss for patient who has severe hemorrhage, burn or dehydration by vomiting or diarrhea. The Responsibility of the Nurse in I.V. Therapy 1.Check the infusion container for any obvious contamination. 2.Verify the amount and type of solution to be administered according to doctor order 3.Check solution being used, desired effect and adverse reactions. 4.Perform the administration of a prescribed fluid to the correct patient. 5.Observing whether the Intravenous line remains patent. 6.Inspecting the site of insertion and reporting abnormalities. 7.Adjust the rate of flow as prescribed. 8.Monitoring the condition of the patient and reporting any changes. 9.Document appropriate records. 18  ( Infusion sites) Complications occur during intravenous infusion therapy: 1- Hematoma (Collection of blood within body tissue or cavities due to the rupture of a blood vessel, vein, artery or capillary). *Heamatoma usually occurs due to excessive probing with the needle & The needle is only partially in the vein. 2- Infiltration (The inadvertent administration of non-vesicant solution into surrounding tissues) -It is normally due to the IV catheter being inadequately secured. Thus to avoid this, secure the catheter firm inside the vein. 3- Thrombophlebitis. 4- Air embolism (Entry of air into the circulation system) this may obstruct the pulmonary artery, which in turn may 19  lead to death. To prevent this, proper priming is required as to remove the air bubbles from the solution. 5- Catheter embolism (Entry of pieces of broken catheter in to the circulatory system). 6- Speed shock (The body reaction to substance that is ingected into the circulatory system too rapidly). Intravenous solutions Prepared IV solutions devided into three general categories: 1- Isotonic solution - a solution with the same osmolality as body fluids, such as plasma. An isotonic solution has a total electrolyte content of approximately310mEq/L -0.9%sodium chloride -Lactated ringers solutions -5%dextrose in water 2- Hypotonic solution: Hypotonic – is a solution with lower concentration of solutes than body plasma A hypotonic solution has a total electrolyte content of less than 250 mEq/L : -0.45%sodium chloride -0.3%sodium chloride 20 3- Hypertonic solution: Hypertonic – is a solution with greater concentration of solutes than body plasma. A hypertonic solution has a total electrolyte content of 375 mEq/L or greater: -3%to 5%sodium chloride -5%dextrose in lactated ringers -> 10%dextrose in water -calculating the flow rate of infusion fluids: Formula used for calculation:- Total volume(ml) *drop factor Total time (in minutes) Example: Total volume of fluid = 500ml , Time for completion= 4hours (4×60=240minutes), Drop factor = 15 500×15 = 31.2=30 drops 240 Equipments IV solutions ,as prescribed Alcohol swabs Tourniquet IV infusion set IV pol Sponge Kidney basin Dry cotton 21  Label of infusion set Prefilled2 ml syringe with sterile normal saline Tape Additional PPE,as indicated Disposable gloves (I) Assessment *Review the patient record for baseline data as(Vital signs-Intake and Output- Laboratory values *Determine most desirable accessable vein *Determine accessibility based on patient condition *Do not use the anticubital vein if another vein is available *Do not use vein in the leg of an adult unless other sites are in accessible (II) Nursing diagnosis 1-Risk for Deficient fluid Volume 2- Risk for Shock 3- Risk for Infection (III) Outcome Identification -The expected outcome to achieve when initiating a peripheral venous access IV infusion is that: -The access device is inserted using sterile technique on the first attempt -The patient experiences minimal trauma -The IV solution infuses without difficulty 22 Action Rationale *Check that the cannula is still available To prevent re puncture *Check the iv solution medical order (if there the cannula is available we use *Check patient chart for allergies it to adminster iv solution ) To *Preparing equipment ensure the correct iv solution *Perform hand hygiene and put PPE,if to prevent spread of microorganisms to indicated(wear gloves) prevent hand contamination Preparation:-Patient & environment *Identify the patient and ask for his name To ensure patients privacy *Close the curtains around the bed and close the door *Explain procedure to patient & take To ensure that the patient understands consent. Prepare the IV solution and administration set 2-check the type, concentration ,amount of To be sure that the correct type&amount IV fluid with doctor prescription in the chart 3-check the expire date of the infusion To prevent an ineffective or toxic -prepare the IV set to be ready for use 4 by: compound being administered to the *removing the seal over the bottle patient. *Invert the iv solution container and remove the cap on the entry site 23  *connecting one end of tubing to the infusing bottle and other end to the needle * attach the infusion bottle up side down to the stand *squeezing the drip chamber to fill at least halfway *allow fluid to flow down the tubing in the kidney basin ensuring that no air present in IV line. *screw the rate regulator to stop the infusion *cover the needle with its plastic cover *cover &put it in a safe place (IV) Implementation 6-sellect a suitable vein To reach puncture easily 7-Apply the tourniquet 4-7 inches above the To facilitate flow of blood into syringe selected area 8-milk vein upward with your hands or ask to help in appearing veins patient to close and open his hand 9-clean the chosen area with alcohol sponge at to avoid infection least 30 seconds Not to remove easily 10-Inserting the cannula (Demonstrate the procedure of IV cannulation as before). They may use adhesive tape to hold in place. 11- If the patient have cannula before check that To ensure the cannula is intact the cannula is still available by flushing it with normal saline 24 11- Once the cannula is in place, healthcare professionals will use tubing to connect it to the IV. 12-adjust the rates of flow of solution as ordered. 13-During the infusion, regularly check the cannula to ensure that the IV is flowing properly and there is no pain or swelling in the area. 14-Observe the patient carefully while giving the To prevent any complication or adverse medication effect from medication 15- when the solution has been finished, stop the infusion by clamp press and disconnect the cannula from the tubing and remove it from the vein. 16- If there is no need for cannula again To stop bleeding remove the cannula and apply pressure over the insertion site. may dress the area with a cotton bud and adhesive tape. 17-Document :amount , types of solution , drugs to given, time in &out ,site, reaction and signature 18-Remove the equipment 19-Performe hand hygiene. 25  Monitoring an IV site and infusion Action Rationale *Check the IV solution To ensure the correct iv solution *Check patient chart for allergies *Preparing equipment *Perform hand hygiene and put PPE, if to prevent spread of microorganisms indicated to prevent hand contamination Preparation:-Patient & environment *Identify the patient and ask for his name To ensure patients privacy *Close the curtains around the bed and close the door *Explain procedure to patient & take To ensure that the patient understands consent. Monitoring an IV site and infusion 1-monitor iv infusion every hour To promote safety administration of iv fluids 2-check the drip chamber and timing drops To ensure that the flow rate is correct 3- check tubing for anything that might Any link on tubing may interfere with interfere with the flow the fiow 4-Be sure clamp is open 5-Observe dressing for leakage of IV solution 6- Inspect the site for swelling,coolness,or pallor ,leakage at the site which indicate To promote safety administration of iv infiltration fluids 26 7-check for local manifestation (redness To promote safety administration of iv ,warmth, pus and pain) that may indicate fluids an infection is present at the site 8-Instruct patient to call for assistance if To facilitate patient cooperation any discomfort is noted at the site 9-remove the equipment 10-Decument procedure (Charting For example :11/6/15 1020 IV site : amount, drugs to given, time in &out right forearm/cephalic vein intact , site, reaction and your signature without swelling ,redness or drainage.D5 0.9% NSwith 20 mEq KCL continues to infuse at 110 ml/hour. 19-Perform hand hygiene. to prevent spread of microorganisms to prevent hand contamination 27  Changing an IV Solution Container Action Rationale *Check the iv solution To ensure the correct iv solution *Check patient chart for allergies *Preparing equipment *Perform hand hygiene and put to prevent spread of PPE,if indicated microorganisms to prevent hand contamination Preparation:-Patient & environment *Identify the patient and ask for his name To ensure patients privacy *Close the curtains around the bed and close the door *Explain procedure to patient & take consent. To ensure that the patient understands Change the iv solution container 1-remove the cap of the entry site of the new IV To prevent contamination solution container.(taking care not to touch the entry site) 2-close the clamp of administration set 3- lift empty container off IV pole and invert it.quickly remove the spike from the old IV container 4-discard the old IV container 28 5-Using twisting and pushing motion , insert administration set spike into the entry site of the new IV container 6- Hang container on the IV pole 7-Slowly open the clamp on the administration set and count the drops 8-Observe the patient carefully while you are giving the medication 9-Decument procedure( Charting: amount, drugs to given, time in &out ,site, reaction and your signature 11-Performe hand hygiene. Scenario: Dina, age 35, has been admitted to general surgical ward after sever vomiting for 2 days, she needs Intravenous fluids to become rehydrated -Dina is asking about risks associated with - IV placement What would you tell her about the risks associated with IV infusion? -Demonstrate IV infusion therapy - procedure? 29  Bandage Objectives: At the end of this lecture, all students should be able to: Define bandage. Identify purposes of bandaging. Recognize types and uses of bandages. Explain principles of bandaging. Define the basic turns of bandage. State the basic turns of bandage. Categorize the basic turns of bandage. Describe character of bandage Identify Complication of bandage. Define binders. Illustrate Types of binders. Apply an elastic bandage. Outline: Definition of bandage. Purposes of bandaging. Types and uses of bandages. Principles of bandaging. The basic turns of bandage. Complication of bandage. Definition of binders. Types of binders. How to apply an elastic bandage. 30  Bandage ☆Definition of bandage: Bandage is a piece of soft material used either to support a medical device such as a dressing or splint, or on its own to support a part of the body. ☆Purposes of bandaging: Cover a wound. Support a splint. Secure traction equipment. 31  Correct deformity. Apply pressure to control bleeding. Minimize swelling. Reduce pain. Aid in improving venous circulation e.g. bandaging the leg of patient suffering from varicose vein. ☆Types and uses of bandages: Different types of bandages have been developed with a variety of sizes, shapes and materials including: 1- Roller Bandages: *This is the most common type of medical bandages and also known as Crepe or Gauze bandage. They consist of a woven strip of absorbent material that can come in a variety of sizes. 32 *Uses of Roller Bandages: They can be used for a number of different applications, including: Holding a dressing in place. Medium injury support (e.g. joint immobilization). Compression. 2-Compression Bandages: *Compression bandages, also known as a tensor or elastic bandages, consist of a long strip of stretchable material that is used to support soft tissue injuries by applying pressure to the affected site. *Compression bandages can further be categorized as: A-Short Stretch Compression Bandages: *This type only allows for a modest range of extensibility (stretch). This provides a high resistance against external movement and muscle contraction. These bandages are typically used for the management of swelling. 33 *Uses of Short Stretch Compression Bandages: Short Stretch Compression Bandages are suitable for managing: Lymphedema. Edema (e.g. from a poisonous bite). Venous leg ulcers. B-Long Stretch Compression Bandages: *This type offers far more extensibility than its counterpart. These bandages can easily be applied to the contours of the body and are often used to relieve & support muscles, ligaments and tendons. *Uses of Long Stretch Compression Bandages: Long Stretch Compression Bandages are suitable for: Holding dressings and splints in place. Providing mild compression. Supporting strains and sprains. C-Snake Bite Bandages: 34 *This injury-specific type of compression bandages is intended for use with the Pressure Immobilization Technique. These bandages are unique with special indicator markings that ensure the correct tension is being achieved when applying the bandage. They are used in the treatment of bites and stings that can result from a number of Australian animals. *Uses of Snake Bite Bandages: Snake Bite Bandages obstruct lymph flow thereby preventing the free circulation of venom, making it a suitable treatment for: Snake bites. Funnel Webbed Spider bites. Blue-Ringed Octopus Bites. Cone Shell stings. D-Cohesive bandages: 35 *Cohesive bandages are a type of compression bandages made of self-adhesive material, allowing to securely wrap injured areas without the need for bandage clips or having the bandage stick to hair or skin. These bandages have the unique ability to stick to itself but not to the skin. *Uses of cohesive bandages: The high conformability and elasticity of cohesive bandages make it a suitable option for: Stabilizing joints. Holding dressings in place. Supporting soft tissue injuries. 3-Triangular Bandages: *A triangular bandage, also known as a cravat bandage, is a multi-purpose cloth in the shape of a right-angled triangle. 36 *Uses of Triangular Bandages: Triangular bandages can be used: As a sling (when unfolded) to support injured limbs. As a normal bandage to secure dressings. To splint broken bones. To apply compression to swelling/bleeding wounds. 4-Tubular Bandages: *A tubular bandage, also known as a tube bandage, is an elasticated bandage, woven in a continuous circle so as to provide uniform compression when applied to arms, legs, ankles and wrists. *Uses of Tubular Bandages: 37 A tubular bandage is suitable for providing moderate compression for applications such as: Immobilizing joints. Supporting joints during activity. Holding dressings in place. Reducing swelling. ☆Principles of bandaging: Choose suitable type and size of the bandage. The bandage should be applied with equal pressure to keep proper circulation. Skin surfaces, as toes and fingers, should not be bandaged together; cotton should be placed in between to prevent them from rubbing inside the bandage. Bony prominences over which the bandage is placed should be padded. The bandage should be extended at least one inch beyond both sides of the dressing. If possible, the end of body part should be left exposed so that assessment of circulation can be done. The bandage should be secured in place using bandage clips, safety pins, adhesive tape or self-adhesion property. The circulation in the area below the bandage should be assessed as soon as the bandage is on then frequently. This includes assessing the color & temperature of the skin, capillary refill time, the nearest pulse, motion & sensation of the limb, and presence of swelling. If the circulation below the bandage is poor, the skin may look pale or blue or feel cold. Signs of poor circulation also include numbness and tingling. If the 38  circulation is reduced, loosen the bandage right away. If symptoms continue, get medical care. ☆The basic turns: 1-Circular Turn : Circular turns are used chiefly to anchor and to terminate bandages. Encircle the body part a few times or as needed, each turns directly covering the pervious turn. Secure the end of the bandage with tape, metal clips or a safety pin over an uninjured area. 2-Spiral Turn : 39  Spiral turns are used to bandage cylindrical parts of the body that are fairly uniform in circumference, such as upper arm and upper leg. Make two circular turns to begin the bandage. Continue spiral turns at about a 30-degree angle, each turn overlapping the preceding one by two-thirds the width of the bandage. Terminate the bandage with two circular turns, and secure the end as described for circular turns. 3-Spiral Reverse Turn: Spiral reverse turns are used to bandage cylindrical parts of the body that are not uniform in circumference, such as the lower leg or lower forearm. 40  Begin the bandage with two circular turns, and bring the bandage upward at about a 30-degree angle. Place the thumb of the free hand on the upper edge of the bandage. The thumb will hold the bandage while it is folded on itself. Continue the bandage around the limb, overlapping each previous turn by two-thirds the width of the bandage. Make each bandage turn at the same position on the limb so that the turns of the bandage will be aligned. Terminate the bandage with two circular turns, and secure the end as described for circular turns 4-Figure of Eight Turn: Figure of 8 bandages often used on a knee, ankle, wrist, elbow, or shoulder. The main benefit of using this type of bandage is providing extra stability and support to an injured or weak joint. It also helps limit movement which can reduce pain, swelling and inflammation in an injury or weakened area. Begin the bandage with two circular turns. 41  Carry the bandage above the joint, around it, and then below it, making a figure eight-continue above and below the joint, overlapping the previous turn by two-thirds the width of the bandage. Terminate the bandage above the joint with two circular turns, and secure the end appropriately. 5-Spica: Spica: it is a form of Figure of eight in which one of turn is very much larger than the other. It consists of ascending and descending turns that overlap and cross each other to form an angle. It is useful for bandaging the thumb, the breast, shoulder, groin and the hip 42  Recurrent bandages: It is used for fingers and for the stump of an amputated limb. After a few circular turns to anchor the bandage. The initial end of the bandage is placed in the center of the body part being bandaged. Well back from the tip to cover the body then passed back and forth over the tip, first on the one side and the other side of the center piece of bandage. 6-Four Tailed Bandage A strip of cloth with each end split into two. The tails are used to cover Prominences such as elbow, chin, nose, or knee. 43 7- A triangular Bandage Sling A triangular bandage sling is usually made from a muslin bandage, but any material that does not stretch (such as a fatigue shirt, trousers, poncho, blanket, or shelter-half) can be used. Fold, cut, or tear the material into a triangular shape. Insert the material under the injured arm so that the arm is in the center, the apex of the sling is beyond the elbow, and the top corner of the material is over the shoulder of the injured side. Position the forearm so that the hand is slightly higher than the elbow (about a 10 degree angle). Bring the lower portion of the material over the injured arm so that the bottom corner goes over the shoulder of the uninjured side. -bring the top corner behind the casualty's neck. Tie the two corners together so that the knot will not slip. The knot should fit into the "hollow" at the side of the neck on the uninjured side. B-Triangular Bandage to the Head : 44  Turn the base (longest side) of the bandage up and center its base on center of the forehead, letting the point (apex) fall on the back of the neck. Take the ends behind the head and cross the ends over the apex. Take them over the forehead and tie them. Tuck the apex behind the crossed part of the bandage and/or secure it with a safety pin, if available. Basic bandage turns: 45  Complication of bandage: ❖ If bandage applied tightly, it will lead to impaired circulation. Discolouration of the toes – blue/black/purple or white Swelling Coldness. Cyanosis Pain. (The onset or increase in pain) Numbness., Tingling or pins and needles in the toes ❖ Pressure sores if insufficient padding is applied to bony prominences or between surfaces. ❖ Infection: if bandage become wet and not changed. 46  Binders ☆Definition: Large piece of material and are specially designed for various parts of the body ☆Types of binders: 1-Abdominal binder: 2-Triangular arm binder : 47  3-T bandage: Secure rectal or perineal dressing in place in females. 4-Double T bandage: The same purpose but in male 5-Tailed binder: To secure dressing on chin. Applications an elastic bandage Action Rational 1)Check the order in the chart. To confirm the order. 2)Wash hands. To prevent cross infection. 3)Check the patient identification. To sure the patient. 4)Keep privacy. To support patient's psychological condition. 5)Prepare, arrange supplies and Safe the time and efforts. equipment's. 6)Wash and dry the area to be bandage. Prevent the infection by removing the microorganisms. 7)Elevate the extremity to be bandaged. That encourage venous, prevent swelling and it easier to warp the bandage properly. 8)Stand in front of the patient and Secure the bandaging while the wrapping is unroll the end of the bandage slightly, occurring. anchor in place with the thumb of the non-dominant hand on the anterior part 48 of the extremity. 9)Make two initial circular turns to Securing the bandage end prevents it becoming anchor the bandage in place. loose. 10) Recurrent bandage technique spiral The body part to be bandage will indicate or circular. which style of bandaging is best. 11)Apply bandage smoothly with light To prevent pressure area, adequate tension is to moderate tension. necessary for the bandage to stay in its place. 12)Ensure that there is no wrinkles are wrinkles impair circulation present while performing wrap. 13)Secure the bandage with tape, clips To remain the bandage in its place. or safety pin. Post procedure 1)Assess the bandage for fit and The bandage which applied too tightly will circulation (peripheral pulses) distal to impede circulation and a loose bandage will not the area. be effective. 2)Compare colour, temperature, To ensure the health of the injured party sensation, capillary refill time on affected extremity with unaffected side. 3)Advise patient regarding how often to early discover any deterioration in they should assess themselves circulation in the affected limb including signs/symptoms they should report. 49  CAST & TRACTION Objective Define cast and traction Differentiate between cast and traction List purpose of traction Enumerate complication of cast &traction Discuss indication and contraindication of cast Discriminate between different type of cast and traction Appling nursing care for patient with traction Demonstrate steps of cast application and care of it. Outline: Cast Definition Indication Contraindication Types Procedure of application and care of cast Complication Traction Definition Purpose Indication Type Procedure of care of skeletal traction 50  Complication CAST ❖ Definition of cast A cast is a rigid, temporary, immobilizing and protective external device made of layers of plasters or fiberglass material molded to the body parts that it encases. ❖ Purposes ▪ To immobilize, support and protect the fractured extremity. ▪ To correct and prevent deformities. ▪ To stabilize weakened joints. ▪ To promote healing process. ▪ To promote early mobilization. ▪ To prevent injury in case of osteomyelitis. ❖ Indication ▪ Fracture immobilization. ❖ Contraindication ▪ Skeletal muscle rigidity. ▪ Open wound or draining wounds. ▪ Edema. ▪ Impaired circulation. ▪ Sever spasticity ▪ Sensory problem. ▪ Unstable fracture. ▪ Patients with poor compliance. ▪ Contracture existing for more than 6month. ▪ Active skin disease. 51 ❖ Type of cast: 1- Short-arm cast: Extends from below the elbow to the palm 2- Thump spica or gauntlet cast: extend from below the elbow to the palm and includes the thumb. 3- Long-arm cast: Extends from the axillary fold to the palm with the elbow is usually immobilized at a right angle. 4- Short-leg cast: Extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. 5- Long-leg cast: Extends from the junction of the upper and middle third of the thigh to the base of the toes. 6- Body jacket cast: encase the trunk. 7- spica cast ▪ Shoulder spica cast: A body jacket that encloses the trunk, shoulder and elbow ❖ Casts for extremities (arms &legs) yalmedicalgroup.org 52  ▪ Hip spica cast: Encloses the trunk and a lower extremity. A double hip spica cast includes both legs. Cast materials: ▪ Natural (plaster of Paris). ▪ Synthetic acrylic (fiberglass free, latex free, polymer, hybrid of material. ❖ Complication of cast application Due to tight cast Pain Pressure sores Compartment syndrome: tight cast that restricts swelling Peripheral nerve injury Due to improper application Breakage Loose cast Plaster blisters Due to allergy Allergic dermatitis Others 53  Muscle wasting ، joint stiffness Skin abrasion، laceration Cast application and care Equipment ▪ Cast material ▪ Stockinet, sheet wadding ▪ Plastic bucket or basin filled with warm water ▪ Disposable glove and aprons. ▪ Scissors (cast and bandage) to cut the supplies. ▪ Water proof disposable pads (provide warmth and protect skin from contact with casting material) ▪ Cast saw: to cut the cast ▪ Mackintosh: to protect the bed from wetting Procedure Steps Rationale 1-preparation: A- Prepare equipment To prevent spread of infection Retrieve the necessary equipment and check 54  the casting packages for any air leaks. B-Prepare Self To provide privacy Wash hands and put apron and gloves. c- prepare patient: Identify the patient. Explain the procedure to the patient. Close curtains around bed and close the door. Place the bed at an appropriate and comfortable working height, if necessary. 2- Remove any jewelry on the limb to be casted. To keep limb in the right alignment position 3- Observe the skin on the affected limb. Look for Detected any problem unusual color, wounds, rashes, or irritation. 4- Then, assist the doctor by correctly positioning the To facilitate the procedure patient’s injured limb, as ordered. 5- Apply soft cotton roll or stockinet, sheet wadding and Protect skin from abrasion padding beyond the end of the cast. 6- Decide on cast length. To apply correct size of cast Steps Rationale 7- Assist in immersing plaster of pairs roll in warm For easy application. water 5-6 times until it bubbles and slightly wring 55  water out. don’t remove too much water. 8- Assist in applying casting material 4-5 layers of plaster Fiber glass dries immediately or 3-4 layers of fiber glass. 9- Assist in applying two or three of cotton padding to Padding protects skin and tissue prominence area in spiral fashion 10- Support the limb while the doctor applies stockinet and sheet wadding. Smooth any wrinkles as this wadding are applied. 11- Instruct patient not to move the extremity until the To prevent denting of the cast cast dried fully and avoid using cast dries. development 12- If the cast is on an extremity, elevate the affected area To promote venous return and on pillows covered with waterproof pads. Maintain the reduce edema normal curvatures and angles of the cast 13. Assess the condition of the cast. Be alert for cracks, dents, or the presence of drainage from the cast. 14- Perform skin and neurovascular assessments often as To ensure neurovascular function every 1 to 2 hours. 16- Check: for pain, edema, inability to move body parts To identify and prevent distal to the cast, pallor, pulses, and abnormal sensations. If complication at early stage. the cast is on an extremity. Steps Rationale 56  17-Assess for signs of infection. Monitor the patient’s To identify and prevent temperature. Assess for a foul odor from the cast, increased complication at early stage. pain, or extreme warmth over an area of the cast. 18-Reposition the patient every 2 hours. To promote healing and prevent Provide back&skin care frequently. complication Encourage ring of motion exercise for unaffected joint. Encourage the patient to cough and deep breath 19. Instruct the patient to report pain, odor, drainage, To observe complication at early changes in sensation, abnormal sensation, or the inability to stage move fingers or toes of the affected extremity 20. Remove PPE, if used. Place bed in lowest position and Perform hand hygiene 21- Document: Help in continuing plan of care. - Date, time of cast, application, type of cast, location and patient response to procedure. - Condition of skin circulation and instruction given to patient. - Color and drainage from the cast. 1. – Report immediately abnormal or unusual finding from neurovascular assessment as bluish color to distal part, marked increase in edema or pain, delayed 57 capillary refill, inability to palpate distal peripheral pulse if originally palpable, increase numbness Traction Definition of Traction: Traction is the application of a pulling force on a part of the skeletal system. Purpose of traction: To guide the body part back into place and hold it steady. Traction may be used to: Stabilize and realign bone fractures, such as a broken arm or leg To eliminate muscle spasms. To relieve pressure on nerves, especially spinal nerves To prevent muscle contractures. To prevent or reduce skeletal deformities. To enable immobilization of aseptic joints. ❖ Complication of traction Erythema Muscular atrophy Paralysis 58  Foot drop Venous stasis with DVT Pressure ulcers Edema Complication from immobility especially with long term traction Indication for skin and skeletal traction: ❖ Skin traction: Commonly applied in children and require kg traction Person who needs long term traction and have skin damage requiring dressing e.g., post operative traction (pin traction) ❖ Types of traction 1- Manual traction: it means puling on the body using a person’s hands and muscular strength It most often used briefly to realign a broken bone. It also used to replace a dislocate bone into its original position. 59  2- Skin traction: It means pulling effect on the skeletal system by pulling device such as pelvic belt and a cervical halter to the skin. 3- Skeletal traction: 4- It means pull exerted directly on the skeletal system by attaching wires pins, or tongs into a bone, skeletal traction is applied continuously for extended period 60  Care of skeletal traction Equipment: Sterile tray containing Sterile applicators Cleaning agent according to hospital policy for example povidone- iodine / normal saline / chlorhexidine dressing Sterile gloves Cotton pad Sterile container Antimicrobial ointment gauze, if needed Procedure Steps Rational 1-preparation: a- Prepare necessary equipment b- Prepare my self -Wash hand -Wear personal protective equipment. c- Prepare patient - Explain procedure to patient 2- Assess the pain level using visual analog scale To check the neuro vascular function 3- Administer any pain medication if ordered To relieve pain 61 4- Check whether the weight hangs freely, not Provides correct traction touching the floor and bed frame, the ropes move freely and all knots are tight 5-Assess the pin site for any signs of infection such Pin site provides a possible entry for as redness, elevated body temperature and bending of microorganisms. the pins. 6- provide pin site care ▪ Perform hand hygiene and put on gloves. Sterile technique prevents the ▪ Open the sterile package: pour the cleansing transmission of the microorganisms agent into the sterile container. ▪ Dip the applicator into the solution ▪ Clean pin site starting at the center (insertion of pin) and moving to the periphery (away from the pin site. ▪ Use one applicator for each stroke. ▪ Apply the antimicrobial ointment to pin sites and apply dressing. ▪ Remove gloves and do hand washing To reduce the risk of infection 7-Pad any bony area near the strapping, such as an To prevent pressure over the Bony ankle with cotton padding area 8-Elevate the limb and attach attraction cord to the To improve the venous return spread 9-Wash and replace the article 10- Perform routine assessment 11-remove the strap every 4 hours once as per Relieve pressure and constriction 62 doctors’ order. 12- Check bony prominence frequently for skin Sign indicates constrictive bandage break down, abrasions and pressure signs. and poor circulation 13- Provide bake care and back massage. Prevent development of pressure area 14- Assess the extremity distal to the traction for redness, pain, abnormal sensation, pulse, temperature, capillary refilling time, calf muscle tenderness, sign of deep vein thrombosis. 15- Check the body alignment. Proper body alignment prevents development of contracture 16- Check for weight to hang freely without touching Enhance the effective pulling force the floor and bed frame and rope to move freely through the pulleys. 17- For every 2 hours encourage the patient to do Promotes effective pulmonary breathing and cough exercise and active range of function and promotes muscles motion exercises in the effected limbs. strength 18- Document the date, time, type of traction, the Serves as legal evidence and to amount of weight used, duration and assessment prevent duplication of work finding. Document response to the traction and the neurovascular status of the extremity. 63  Audiometry Testing Objectives: At the end of this lecture every student should be able to: ▪ Describe the anatomy of ear ▪ Define audiometry testing. ▪ List indications for audiometry testing. ▪ Identify the Purpose of audiometry test. ▪ Describe the audiometry test. ▪ Explain how a hearing test work ▪ List types of audiometry testing. ▪ Enumerate precautions required for audiometry testing. ▪ List risks of audiometry testing. ▪ Distinguish between audiometry test results. ▪ Apply procedure of audiometry testing. Outlines: ▪ Anatomy of the ear ▪ Definition of audiometry testing. ▪ Indications for audiometry testing. ▪ Purpose of the audiometry test. ▪ Description the audiometry test. ▪ How does a hearing test work? ▪ Types of audiometry testing. ▪ Precautions required for audiometry testing. ▪ Risks of audiometry testing. ▪ The results of the audiometry test. ▪ Procedure of audiometry testing. 64  Audiometry Testing Anatomy of the ear https://my.clevelandclinic.org/-/scassets/Images/org/health/articles/24048-ear Definition of audiometry testing Audiometry is a painless, noninvasive hearing test that measures a person's ability to hear the different sounds and frequencies. The test is performed with the use of electronic equipment called an audiometer. This testing is usually performed by a trained technician called an audiologist. https://encrypted-tbn0.gstatic.com 65 Prerequisite medical terminology: Audiogram: A chart or graph of the results of a hearing test conducted with audiographic equip ment. The chart reflects the softest (lowest volume) sounds that can be heard at various frequencies. Decibel (DB): A unit of measure for expressing the loudness of a sound. The range of human hearing span 0 to 120 decibel. Normal speech is typically spoken in the range of about 20-50 decibels. Hertz (HZ): describe the frequency range that can be heard by humans. Humans can hear sounds in the frequency or pitch range of 20 to 20,000 Hertz (Hz), but most conversations occur between 300 and 3000 Hz. Otoscope A hand held instrument with a tiny light and a funnel shaped attachment called an ear speculum, which is used to examine the ear canal and eardrum. Indications of audiometry test Establish hearing routine screening for individuals. Performed when hearing loss is suspected. Used when an individual has vertigo or dizziness Patients who have a tumor in or around the ear to determine whether hearing loss has occurred Monitor hearing before and after ear surgery to evaluate whether surgery improves one's hearing. Used to evaluate whether hearing aids improve patient's hearing. 66 Some important notes Audiometric testing is done between 125 and 8000 Hz. The intensity levels or degree of loudness at which sounds can be heard for most adults is between 0 and 20 decibels (db). With correct diagnosis of aperson's specific pattern of hearing impairment, the right type of therapy, which might include: hearing aids, corrective surgery, or speech therapy, can be prescribed. Purpose of audiometry test The primary purpose of audiometry is to determine the frequency and intensity at which sounds can be heard. Description Audiometry testing is usually done in a sound proof testing room by a trained audiologist (a specialist in detecting hearing loss) uses an audiometer. This equipment emits sounds or tones, like musical notes, at various frequencies, or pitches and at differing volumes or levels of loudness. How does a hearing test work? Ears have three distinct parts: the outer, middle, and inner ear. Audiometry tests can detect whether patient have sensorineural hearing loss (damage to the nerve or cochlea) or conductive hearing loss (damage to the eardrum or the tiny ossicle bones). Common types of audiometer 1-Pure-tone audiometry test: The person being tested wears a set of headphones that blocks out other distracting sounds and delivers a test tone ear at a time. At the sound of atone, the patient holds up a hand or finger to indicate that 67 sound is detected. The audiologist lowers the volume and repeats the sound until the patient can no longer detect it. This process is repeated over a wide range of tones or frequencies. Each ear is tested separately. 2-Bone conduction audiometry: Similar to the pure-tone audiometry test, but instead of headphones, a small device is placed behind the ear or on the forehead. Gentle vibrations are sent through the bone to the inner ear to determine how well patient hear. It also tells if there is a problem in outer or middle ear 3-A Speech audiometry This test helps identify neural types of hearing loss. The auditory system is assessed by evaluating the hearing ability. An audiologist talks through a pair of 68 headphones and the listener has to repeat them. An adult with normal hearing will be able to recognize and repeat 90-100% of the words. Precautions Testing with audiometry equipment is simple and painless. No special precautions are required. Risks Audiometry is noninvasive and carries no risk. Results of the audiometry test The results of the audiometry test may be recorded on a grid or graph called an audiogram. Looking at the audiogram graph will see two axes: The horizontal axis (x-axis) represents frequency from lowest to highest. The lowest frequency tested is usually 250 Hertz (Hz), and the highest is usually 8000 Hz. The vertical axis (y-axis) of the audiogram represents the intensity (loudness) of sound in decibels (dB), with the lowest levels at the top of the graph. Although the top left of the chart is labeled -10 dB or 0 dB that does not mean the absence of sound. Zero decibels actually represent the softest level of sound that the average person with normal hearing will hear. The air conduction results for the right ear are marked with a red “O," and the results for the left ear are marked with a blue “X." 69 Normal results A person with normal hearing will be able to recognize and respond to all of the tone frequencies administered at various volumes in both ears by the audiometry test. An adult with normal hearing can detect a range of low and high pitched sounds that are played as softly as between nearly 0-20 decibels. Abnormal results Audiometry test results are considered abnormal if there is a significant or unexpl ained difference between the levels of sound heard between the two ears, or if the person tested is unable to hear in the normal range of frequencies and volume. The results of the hearing test are an indication for the degrees of hearing loss: Normal hearing: -10 to 20 dB 70  Mild hearing loss: 20 to 40 dB higher than normal Moderate hearing loss: 40 to 70 dB higher than normal Severe hearing loss: 70 to 90 dB higher than normal Profound loss: 90 dB or more Using audiometer Assessment Inspect the ear canal and the tympanic membrane before the examination using an otoscope or audioscope with a light. Nursing diagnosis Determin